Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
For SVG graft stenting, do you consider routinely embolic protection devices (EPD), and do you factor lesion location (prox vs distal) for decision making?
I would prefer to use an embolic protection device, provided it can be easily deployed and the lesion is suitable for it. Avoid, if the lesion is a very distal graft or attachment site. In most cases, I prefer to do direct stenting of the SVG graft to avoid any embolization even with a protection de...
Would you perform a diagnostic paracentesis for first-time ascites in a patient with established CHF or pulmonary hypertension, but without apparent liver or other intra-abdominal disease?
Great question. Yes, we should perform a diagnostic paracentesis for first-time ascites, even in patients with established CHF or pulmonary hypertension, unless there is an obvious alternative explanation and the procedure is unsafe or technically not feasible. After the etiology is established, rep...
Do you routinely check digoxin levels, and if so, when would you consider using Digibind in chronic digoxin use patients?
The subanalysis of the DIG trial gave some insight into the value of keeping digoxin levels below 1.0. If HF patients, I tend to look at the levels for that reason. I rarely use digoxin for AF as there is little evidence of benefit with some evidence of harm. Re: use of digibind, I limit this if t...
For older adults undergoing intermediate-risk non-cardiac surgery, do you routinely check pre-operative pro-BNP levels for risk stratification based on emerging data and updated Canadian guidelines?
Pre-operative NT-proBNP and BNP levels have been featured, not just in the cited Canadian guidelines but also in the 2024 update of the AHA/ACC preoperative evaluation guidelines. (Thompson et al., PMID 39316661). Those guidelines recommend evaluating a pre-op NT-proBNP level if the results will cha...
Should low-intensity statins be favored to minimize the risk of diabetes onset while still offering cardiovascular benefit for patients with prediabetes where a statin is indicated?
While higher-intensity statins are associated with a slightly higher incidence of diabetes, it would not be recommended to start with low-intensity statins as there are no data to support this. Essentially, all of the CV outcomes trials with statins have been with moderate and high-intensity statins...
Can cardioversion be safely performed for recurrent atrial fibrillation in patients who have undergone left atrial appendage clipping during CABG, if they are not on chronic anticoagulation anymore?
Based upon the LAAOS III trial, we know that patients with left atrial appendage ligation at the time of cardiac surgery have a lower risk of stroke compared to those who did not when anticoagulation is continued in both groups. The data is much less clear for complete cessation of anticoagulation a...
How do you determine which atrial fibrillation patients with a high thromboembolic risk and a contraindication for oral anticoagulation should undergo left atrial appendage occlusion?
If the contraindication is absolute, all high risk patients need to be informed about the availability of LAAO devices. If the patient cannot take an anticoagulant or antiplatelet for a short period after implant, an epicardial approach could be considered.
Will TRYNGOLZA (olezarsen), recently approved for familial chylomicronemia syndrome, also lower triglycerides due to other genetic causes of hypertriglyceridemia?
Yes, olezarsen does lower triglycerides due to other causes of hypertriglyceridemia. It is currently in trials in patients with severe hypertriglyceridemia without Familial Chylomicronemia Syndrome (FCS).
How will you decide between using paclitaxel-coated balloons versus conventional uncoated balloons for managing in-stent restenosis?
Recent data (AGENT IDE trial) have suggested that target vessel failure rates are significantly lower in paclitaxel-coated balloons versus conventional balloon angioplasties when used to treat in-stent restenosis (ISR). The drug-coated balloon for managing in-stent restenosis is a major step forward...
When you identify new atrial fibrillation in a hospitalized patient that spontaneously converts to sinus rhythm within 24–48 hours, and the patient has a CHA₂DS₂-VASc score of 2–3, how do you decide whether to initiate anticoagulation and/or discharge with a wearable cardiac monitor?
This is a tough one. I think the easier part is who should get a wearable cardiac monitor? I think the answer is pretty much everyone since the recurrence rate is around 30% in one year - and if it recurs, it predisposes to strokes, and I'd likely provide anticoagulation per AHA/ACC based on CHA₂DS₂...