Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What treatments options may be considered in patients with POTS who also need daily diuretics to treat heart failure and are already wearing compression garments?
Given the epidemiology of POTS and congestive heart failure, you are far more likely to see a patient with neurogenic orthostatic hypotension and CHF than POTS and CHF. I have an article on NOH and CHF in Autonomic Neuroscience 2020. The principals are basically the same however because the managem...
When do you consider pacing in arrhythmogenic epilepsy?
I have seen only rare cases of it. They all had tonic-clonic seizures triggered by profound bradycardia (sinus as well as AV block). In turn, the bradyarrhythmia was triggered by EEG-documented temporal lobe absence seizures. They all resolved long-term with pacing. Regardless of the un...
Is it worth getting a calcium score on a patient who is already on statin therapy?
Plaque, usually TCFA (thin-capped fibroatheroma), benefits immensely from statin Rx. TCFAs are vulnerable plaques that are highly prone to rupture. The pleiotropic effects of statin Rx allow for plaque stabilization and reduce the vulnerability of the plaque to rupture. Calcification of plaque is a ...
Do you continue beta-blocker therapy beyond 1 year after myocardial infarction in a stable patient with normal LV systolic function when the only remaining indication is mildly elevated blood pressure that could be managed with an alternative agent?
In 1982, a landmark study, the Beta-Blocker Heart Attack Trial, BHAT showed that significant mortality reductions were achieved when propanolol was prescribed post-MI for an average follow-up period of 25 months. This was followed by a Norwegian study and the Stockholm Metoprolol study, which confir...
How do you determine personalized blood pressure targets after ischemic stroke?
This is an excellent question and really takes careful consideration of individual patient characteristics. This also requires detailed discussions with your Neuro-Interventional Radiology Team so that you can best understand what happened during thrombectomy and how successful reperfusion therapy w...
What is your preferred duration for triple therapy post-PCI in patients on systemic anticoagulation?
Most practitioners extrapolate data from the AUGUSTUS and PIONEER-AF trials to answer this question.These trial used apixaban and rivaroxaban, respectively, along with use of DAPT with clopidogrel 75mg qd and ASA 81mg qd. From these 2 trial, Augustus demonstrated lower bleeding risk compared to trip...
What types of cardiac conduction abnormalities would lead you to avoid using tricyclic antidepressants?
I wouldn’t say it is a definite contraindication. But, I would want to be sure it is a longstanding patient and they are seeing a cardiologist regularly. Then, if the QTc were within reason, I would consider it; but it wouldn’t be high on my list of options.
How many days prior to surgery do you recommend stopping SGLT2 inhibitors and when is it safe to resume therapy?
SGLT2-inhibitors have been known to precipitate episodes of diabetic ketoacidosis(DKA) with glucose levels far lower than are usually seen in DKA. This has been called euglycemic DKA. SGLT-2 inhibitors cause an increase in the glucagon to insulin ratio, which promotes ketosis, as well as fluid loss ...
How should a CAC score of 350 influence risk stratification in an asymptomatic primary‑prevention patient with borderline‑to‑intermediate ASCVD risk?
I really appreciate this question because it occurs often in real-life clinical practice. Let's establish some basic grounds here: [1] Elevated coronary artery calcium (CAC) scores are predictive of high atherosclerotic cardiovascular disease (ASCVD) outcomes and major adverse cardiovascular events ...
Do you pursue stress testing before discharge for a patient admitted with chest pain who has negative serial high-sensitivity troponins and a low HEART score?
I usually do not since the HEART score (0-3) has such a low incidence of cardiac events in 6 weeks, and in the study, those patients were discharged. That being said, I would ensure the patient has a follow-up within a week to set up any testing that you feel is necessary to work up the chest pain.