Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What is your preferred monotherapy antiplatelet agent to continue after completion of DAPT post-PCI for patients with stable ischemic heart disease?
For stable CAD that is more extensive, I have been using Plavix monotherapy based on data from HOST-Exam although I have a discussion with the patient. ASA monotherapy is certainly OK if the patient prefers it. However, the downside to clopidogrel monotherapy is when a patient needs a procedure late...
What advice do you typically offer competitive athletes with recently diagnosed myocarditis on when to resume competitive sports, and how do often should outpatient imaging and mobile cardiac telemetry monitoring be performed to aid in this decision?
This is an important question because myocarditis is responsible for ≈ 6% of deaths during exertion in young athletes, but the answer is difficult because we do not have good data on how to manage athletes with myocarditis. Even the diagnosis is difficult. It is probably overdiagnosed in athletes be...
How do the results of the ESPRIT trial, which evaluated the impact of an SBP target of <120 mmHg on preventing major cardiovascular events, influence your blood pressure management goals for hypertensive patients with diabetes or a history of stroke?
The ESPRIT trial largely validates findings from SPRINT in a Chinese population. One major difference is that 38% of ESPRIT participants had diabetes mellitus (DM). A reduction in death from a CV cause drove the significance in the primary outcome (similar to SPRINT), and BP was measured 3x after a ...
Is there a need to bridge a patient with a history of Factor V Leiden on systemic anticoagulation such as a DOAC prior to elective low-rise procedures such as colonoscopy?
The prevalence of Factor V Leiden heterozygous is around 3-5%. Although it does increase the relative risk of thrombosis, the absolute risk is still low; this does not warrant any additional intervention even in patients undergoing major surgery. Colonoscopy is a low-risk procedure anyway. Excellent...
What is your approach to weaning dialysis in a patient with AKI on CKD and CHF who now has resolved AKI but a history of recurrent episodes of decompensated heart failure?
My preference would be to keep them on dialysis. If the serum creatinine is really getting toward the normal range and urine output is good, I would just stop dialysis for a week and give them diuretics to see if they can do without dialysis. However in patients with creatinine levels in the higher ...
Would you consider using Evenity in an elderly patient with rate controlled atrial fibrillation without history of MI or CVA?
The cardiovascular safety profile of Evenity is complex and has been reviewed in several publications. The concern is myocardial infarction and stroke. In general, if there is a history of an MI or stroke I would personally avoid Evenity. Although I do not have access to the safety dataset, I am una...
What factors would influence your decision to use or avoid heparin bridging in patients with mechanical heart valves resuming anticoagulation after intracerebral hemorrhage?
The main conclusion from the publication by Sakusic et al., PMID 39102615 was that withholding anticoagulation for the first seven days after ICH is safe in patients with mechanical heart valves and bridging with intravenous heparin to coumadin upon resumption of anticoagulation should be avoided. T...
Should intervention be considered for an intermediate flow-limiting coronary lesion that does not correlate with perfusion defects on stress testing in a patient with atypical anginal symptoms?
This is a kind of question that gets into the realm of the "art of medicine". There are multiple questions within this single question. I will try to answer each of them. What is an angina and what is atypical angina: I have come across a wide variety of angina syndromes throughout my clinical expe...
How do you approach treatment planning for lung SBRT in a patient with a lesion within 1 cm of a defibrillator?
V-fib requiring defibrillation poses an immediate life-threatening situation. Even if the patient doesn't regularly need their pacemaker, one would need to know that their defibrillator is functioning. In this case, I don't think there's any choice except to move the pacemaker/defibrillator to the o...
How would you counsel a patient on the risk/benefit profile of preventive management such as statin initiation if they have an elevated lipoprotein (a) level, markedly elevated LDL > 200 but a CAC score of 0 without other CV risk factors?
Assuming this patient is over 45 years, and has tried dietary approaches to reduce cholesterol first, I would recommend a initiation of a moderate intensity statin to lower the risk of ASCVD events as the risk equation does not take into account the CAC score.