Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What has been your approach to using contrast enhancement agent in the echo lab in pregnant patients if there is concern for LV thrombus or poor imaging windows for LVEF/valvular disease assessment?
This is a quote from a recent ACC article: "The use of agitated saline for evaluation of intracardiac shunting is not recommended in the setting of pregnancy. There are no empirical safety data on the use of ultrasound-enhancing agents (perflutren, sulfur hexafluoride) in pregnancy, although data fr...
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...
For isolated and very high lipoprotein (a) levels (LDL of > 140, has an Lp(a) > 100) in a patient with no cardiac symptoms or risk factors, would you start lipid lowering treatment, such as with a PCSK9i if they develop statin intolerance?
There are a number of trials going on for reduction of Lp(a) with both IM and PO meds. We know that lifestyle modification does not help for reduction of this very atherogenic protein. If calc scores are high, I would look into entering one of the trials. If the score is low (unlikely), I would wait...
What are some immunosuppression regimens to consider in a patient with refractory cardiac sarcoidosis?
Unfortunately, there is no high quality data at this point to directly answer this question but here are some options. For patients who have only been treated with oral steroids, I would first consider the addition of weekly methotrexate at a dose of between 10 - 20 mg WEEKLY with supplemental folic...
When would you consider referring a patient with suspected cardiac sarcoidosis based on PET and MRI for endomyocardial biopsy given degree of patchy involvement, as opposed to initiating empiric immunosuppressive therapies?
I would avoid initiating empiric immunosuppressive therapies without a firm diagnosis of sarcoidosis. I will mention however that the latest Japanese Circulation Society criteria for the diagnosis of sarcoidosis do include criterion for the non-invasive diagnosis of likely cardiac sarcoidosis based ...
What are your top 5 reasons to choose between a TAVI valve Edwards SAPIEN 3 (Edwards Lifesciences) vs an Evolut FX (Medtronic) and what favors one over the other?
Considering the SMART trial, for patients with a small annulus I favor Medtronic. However, evaluating other studies comparing hemodynamics and EOA, I favor Medtronic for most patients (FAVORS MEDTRONIC). If patients have lower coronaries, especially with the history of coronary artery disease, prev...
What is your approach to determining the safety, appropriateness, and timing of SPECT or PET MPI in patients admitted with NSTEMI and who remain chest pain-free and hemodynamically stable?
Patients with NSTEMI who are stable should have a coronary angiogram as soon as possible. If an angiogram is not available or may be higher risk due to renal failure then a stress test is reasonable but it should be also be done as soon as possible. The goal is to revascularize a vulnerable plaque b...
How frequently do you opt to use IVUS as opposed to OCT or invasive hemodynamic assessment when evaluating coronary lesions?
For questions of lesion significance, I rely on FFR. But I use IVUS on nearly all PCI's for vessel sizing, plaque characteristics, and then stent results. Tend to favor IVUS over OCT because will often do 2-3 IVUS runs (or more) for stent optimization and want to avoid multiple contrast boluses. Are...
How do you manage patients with central sleep apnea due to heart failure with reduced ejection fraction?
I assume you are referring to CSA with Cheyne-Stokes respiration. Several possibilities, but first ask yourself what your treatment goal is. If the patient does NOT have symptoms (frequent awakenings, daytime sleepiness, etc.) I contend that you don't need to treat at all. We already know that there...
What are some practical ways to incorporate cardiac POCUS in the primary care setting?
In the primary care setting, I find cardiac POCUS most helpful for triage of undifferentiated patients and for monitoring of changes such as volume status, keeping in mind: Cardiac POCUS has a wide spectrum of accessibility for novice users, from systolic function and chamber sizes (attainable) thro...