Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
For asymptomatic, incidentally found Lambl's excrescence, should long-term surveillance imaging be considered and if so, how often should repeat imaging be ordered?
For small Lambl's excrescence (often characterized as less than 10mm) and found incidentally in asymptomatic individuals, there is no data to support repeat imaging or surveillance. For large/giant growths, or those in the setting of cryptogenic or embolic stroke, further imaging with TEE may be nee...
What would be your approach to a patient with new diagnosis of seropositive rheumatoid arthritis manifesting as a constrictive pericarditis with no joint pain complaints?
This is an interesting clinical scenario. It highlights some of the current issues we face as rheumatologists, namely an atypical presentation of one of our more common diseases. This patient is labeled as having seropositive rheumatoid arthritis yet lacks arthritis features. I suspect the diagnosis...
What is your preferred diagnostic approach to suspected immune checkpoint inhibitor cardiotoxicity in patients who are otherwise not clinically stable enough for cMRI?
The initial diagnostic imaging for a patient with suspected ICI myocarditis/myositis that is not clinically stable enough for a cardiac MRI should be transthoracic echocardiography. However, if the patient is clinically unstable to the degree that they are unable to have a cardiac MRI performed, the...
Is there any contraindication to the use of ezetimibe in patients with a history of statin-induced necrotizing myopathy?
These types of questions are always great to discuss. The reality is there is a risk-benefit ratio to be considered. On one hand, there is a concern for the need for lipid-lowering to prevent cardiovascular disease, and some situations are more pressing than others. A diabetic with a known cardiovas...
What is your approach to evaluating a patient with a suspected myocardial contusion?
Echocardiogram and troponin levels...
Should systemic anticoagulation be considered for patients with a less than 1% atrial fibrillation burden on outpatient monitoring with an elevated CHADSVASc score and acceptable bleeding risk?
This is a recurrent question. My policy is to anticoagulate such patients. The cutoff for anticoagulation is still controversial though. I believe that any episodes lasting longer than 5 min deserve anticoagulation. Not so sure what to do with shorter episodes but my philosophy is that prevention of...
What is your outpatient approach to monitoring paroxysmal atrial fibrillation (i.e. mobile cardiac telemetry, decision to anticoagulate if high likelihood of recurrence) in young adults with CHADsVASC score of 0, in light of potential remodeling and increased Afib burden as they age?
This is an important question, especially in light of the most recent data suggesting that early maintenance of sinus rhythm is beneficial in patients. If the patient truly has a CHADsVASC score of zero, they have lone atrial fibrillation, low stroke risk, and our major concern is prevention of remo...
How do you determine the feasibility of doing a valve-in-valve for patients requiring AVR with index surgical aortic valve replacement?
The feasibility of doing a valve-in-valve TAVR for patients with preexisting SAVR all rests on a high-quality CT pre-planning analysis. a good high-quality study will reveal important information regarding the primary access approach for the TAVR, coronary heights, sinus widths, valve-to-coronary di...
For patients over 90 years old, is there any foreseeable benefit to undergoing left atrial appendage occlusion over permanent cessation of anticoagulation, particularly for those at high risk for major bleeding?
I would have no qualms about referring a 90+ year-old patient with a-fib and high bleeding risk for an LAA occlusion device. However, this requires a shared decision-making process whereby the risks and benefits of the various treatment options are discussed with the patient and, when appropriate, t...
When would you consider initiating patients with CAD and aortic stenosis on PCSK9 inhibitors (as an adjunct to statin therapy), given favorable findings in the FOURIER trial?
There are limited data to support PCSK9 inhibitors in the treatment of aortic stenosis, and in fact, most is theoretical. Elevation of lipoprotein (a) levels independently increases the risk of in early-onset CAD and calcific aortic stenosis. Lp(a) levels are lowered by PCSK9 inhibitors by ~20-30%, ...