Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What is your loading dose goal and typical loading regimen for PO amiodarone in patients with atrial fibrillation?
I generally aim for a loading dose of 10 grams. This is a combination of both IV and PO amiodarone administered. For an outpatient, I utilize one of the original dosing schedules consisting of 200 mg TID x 3 weeks, followed by 200 mg daily (although this is a little more than 10 grams). For an inpat...
What is your preferred, first-line class of anti-anginals for MINOCA with proven epicardial coronary vasospasm?
We typically start with long-acting nitrates such as isosorbide mono or dinitrate, but often patients will have adverse effects to nitrates that make long-term use challenging. We have had good results with non-dihydropyridine calcium channel blockers, particularly diltiazem, both as short and long-...
How do you approach revascularization in patients over 75 years with NSTEMI, given recent evidence from the SENIOR-RITA trial that an invasive strategy does not significantly reduce cardiovascular events compared to a conservative strategy?
The Senior-Rita trial was a randomized trial of nstemi patients over the age of 75 randomized to conservative therapy versus an invasive strategy plus optimal medical therapy. Non-fatal MI was more common in the conservative strategy group but overall a primary outcome event occurred in 25-26% in bo...
What are your top takeaways from AHA 2025?
The signal across fields: cardiology is moving toward biology + behavior to prevent and treat disease earlier/better. POLY-HF: A single once-daily polypill (β-blocker + MRA + SGLT2i) in HFrEF improved LVEF, QOL, and cut HF events by ~60% vs usual care → major signal that adherence-first strategies ...
Would you consider overdrive pacing for recurrent torsades des pointes in a patient without an obvious drug causing QTc prolongation or significant electrolyte abnormality?
Overdrive pacing is a guideline-recommended treatment for recurrent torsade de pointes in the setting of prolonged QT interval, particularly for patients with bradycardia exacerbating the QT prolongation. Isoproterenol infusion is another option to treat these patients. In these patients, the overdr...
How soon would you repeat PET/CT in a patient with cardiac sarcoid after starting treatment with infliximab?
Very good question. There is no consensus on this answer, and it is also important to consider the medical burden on a patient to repeat such involved testing. Our approach is to follow the resolution/improvement of patient-reported cardiac-related symptoms and follow less invasive testing such as E...
What type of DES should you opt for if a patient has or is concerned about possible nickel allergy?
For a coronary stent, I would lean toward a Medtronic DES. There are published recommendations for nitinol with a durable polymer. That said, I cannot remember more than one case in 25 years where I thought that a metal allergy may have played a role in a patient receiving a stent and that was prior...
How would you approach warfarin management in patients with mechanical aortic valve and atrial fibrillation, if they develop chemotherapy-related severe thrombocytopenia?
In general, anticoagulants are held once the platelet count drops to < 50K due to excessive bleeding risk. In patients at very high thrombotic risk (i.e, mechanical mitral valve, tilting disk valve), unfractionated heparin can be considered with close PTT monitoring, though most case reports still h...
Do you prefer telmisartan over other ARBs given its longer half life elimination?
When considering a specific medication within a class, I try to take into account: cost, side effects, efficacy, pharmacodynamics, and long-term compliance. In regard to pharmacodynamics, I am trying to maximize the duration of action. This often, but not always, correlates with drug half-life. For ...
What are your thoughts on the results from the AQUATIC trial which showed that the addition of aspirin daily + oral anticoagulation in patients > 6 months from PCI and with high atherothrombotic risk was associated with a higher risk of death, MI, stroke, coronary revascularization and acute limb ischemia, compared to oral anticoagulation alone?
I think AQUATIC is a well-designed definitive trial. It shows that in patients with chronic CAD (at least 6 mo. out from stent) who are also receiving anticoagulation (typically for AFib), the use of anticoag monotherapy is safer (statistically lower risk in terms of a composite endpoint as well as ...