Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What factors would influence your decision to use or avoid heparin bridging in patients with mechanical heart valves resuming anticoagulation after intracerebral hemorrhage?
The main conclusion from the publication by Sakusic et al., PMID 39102615 was that withholding anticoagulation for the first seven days after ICH is safe in patients with mechanical heart valves and bridging with intravenous heparin to coumadin upon resumption of anticoagulation should be avoided. T...
Should intervention be considered for an intermediate flow-limiting coronary lesion that does not correlate with perfusion defects on stress testing in a patient with atypical anginal symptoms?
This is a kind of question that gets into the realm of the "art of medicine". There are multiple questions within this single question. I will try to answer each of them. What is an angina and what is atypical angina: I have come across a wide variety of angina syndromes throughout my clinical expe...
How do you approach treatment planning for lung SBRT in a patient with a lesion within 1 cm of a defibrillator?
V-fib requiring defibrillation poses an immediate life-threatening situation. Even if the patient doesn't regularly need their pacemaker, one would need to know that their defibrillator is functioning. In this case, I don't think there's any choice except to move the pacemaker/defibrillator to the o...
How would you counsel a patient on the risk/benefit profile of preventive management such as statin initiation if they have an elevated lipoprotein (a) level, markedly elevated LDL > 200 but a CAC score of 0 without other CV risk factors?
Assuming this patient is over 45 years, and has tried dietary approaches to reduce cholesterol first, I would recommend a initiation of a moderate intensity statin to lower the risk of ASCVD events as the risk equation does not take into account the CAC score.
What is your preferred beta blocker for management of arrhythmias and/or HTN during pregnancy?
Per ACOG guidelines, labetalol is the main beta-blocker for the treatment of hypertension and other cardiovascular indications in pregnancy.
What is your preferred imaging modality--cMR vs. TTE--to evaluate for myocardial strain if concerned for chemotherapy-induced cardiomyopathies?
Per American guidelines, TTE with strain would be indicated at baseline and then every 3-6 months while on chemotherapy. No cMR per American guidelines for routine screening/follow-up to the best of my knowledge.
How do you approach long-term blood pressure parameters in ischemic stroke patients with severe symptomatic intracranial stenosis?
Every patient is unique and I just try to be as low and slow as possible. 4-6 weeks seems to be where most people do well with others tolerating more (I'm able to get them to under 140 or even 120 during their hospitalization over a few days). In the acute setting, I've found it helpful to make sure...
What would be a reasonable threshold to recommend epicardial CRT-D intra-op in a patient post-ACS with LVEF< 35%, QRS duration > 120, and breakthrough VT undergoing emergent CABG?
In answering this question, one should keep in mind that CRT-D provides 2 primary benefits: resynchronization therapy to treat systolic heart failure in appropriate patients and defibrillation in patients at risk for malignant arrhythmia. We NEVER implant a defibrillator in a patient having active V...
What is your surveillance approach for outpatient monitoring of ICI myocarditis?
Screening and surveillance strategies for outpatient monitoring of ICI myocarditis are not well-defined. The best surveillance approach would be based on clinical risk assessment, followed by biomarker and imaging data. The risk factors for ICI myocarditis remain to be clarified, but the most valida...
What are some potential etiologies to consider for isolated, mildly elevated BNP levels with normal TTE findings in an asymptomatic, elderly patient?
BNP and pro-BNP both increase with age, especially in women, and must therefore be interpreted in that context. Pro-BNP less than 300 pg/mL indicates low likelihood for acute heart failure at all ages (though there are exceptions). The recommended age-based thresholds for diagnosing heart failure/vo...