Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
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...
Do you recommend routine use of protamine for hemostasis at the end of a transfemoral TAVI?
Always, in order to guarantee hemostasis of the femoral site and minimize femoral access complications. Dose is weight based, anegdotically lots of institutions give half the recommended dose as they still see some of the positive effects. Warning: ask about history of allergy/anaphylaxis. Protramin...
What is your approach to diagnosis and evaluation of nonbacterial thrombotic endocarditis (Libman-Sacks)?
Nonbacterial thrombotic endocarditis (NBTE), also known as Libman-Sacks endocarditis, is a form of endocarditis characterized by the presence of sterile vegetations on cardiac valves. It is most commonly associated with systemic autoimmune conditions, notably systemic lupus erythematosus (SLE) and a...
For CLL patients with high-risk cytogenetics on ibrutinib who develop a cardiac event such as an MI, would you continue ibrutinib?
It depends on the cardiac event (and the CLL status). After any serious event, if the CLL is under good control (clinical CR), I think it is very acceptable to stop the ibrutinib and wait until clinical progression occurs - which can be a while for some patients (median 2 years from the E1912 study)...
How do you approach the decision of when to perform left heart catheterization in a patient with an NSTEMI who recently had an acute ischemic stroke?
This is a complicated question. Most acute CVA patients have non-MI troponin elevations, and I generally treat them medically. If there is a true NSTEMI associated with CVA, it requires a thoughtful approach. I generally divide my NSTEMI patients into high-risk and non-high-risk. I will perform a di...
How do you decide between opting for semi-elective outpatient versus inpatient TAVR for patients with severe critical AS?
Most patients undergo semi-elective procedures, which are more favorable for hospital reimbursement and reduce the risk of acute kidney injury. However, in a small subset of patients (<20%) with critical aortic stenosis (AS) and severe symptoms, particularly syncope, inpatient management is required...
What factors should be prioritized when deciding the timing of CIED extraction in patients with high surgical risk or multiple comorbidities?
I'll do my best to respond, though the question isn’t entirely clear to me. If the intent is to determine which patients should be prioritized for CIED extraction, the key consideration is whether the benefits outweigh the risks. The most straightforward case is persistent bacteremia, especially in ...