Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
When would you consider using acetazolamide to augment diuresis in patients with ADHF?
The ADVOR trial suggested that the addition of acetazolamide to a loop diuretic "upfront" in congested patients with heart failure achieves greater decongestion at 72 hours and discharge. While most would not use such a combination in "all" patients, this strategy is optimal in those demonstrating s...
In male patients in their 60s who had a single episode of PAF (24 hours, terminated spontaneously or with beta-blockers) without recurrence on 30-day monitoring, and without reversible triggers (such as OSA), should lifelong anticoagulation be started when they turn 65, thereby, increasing the CHA2DS2 VASc score to 1?
NO-score of 1 based on age alone coupled with a very low burden of AF=risks of anticoagulation likely greater than no anticoagulation. A reasonable option is PRN anticoagulation for an episode lasting longer than 6 hours-12 hours-certainly 24 hours-keeps options are open for doing cardioversion IF t...
Should bare metal stents be favored over drug eluting stents for pregnant patients presenting with acute coronary syndrome?
This is a great question. There is limited data that supports the safe use of DES in pregnant patients requiring revascularization (Regitz-Zagrosek et al., PMID 30165544). New-generation DES has a lower risk of stent thrombosis with shorter or even very short duration (28 days) of dual antiplatelet ...
Can sotalol initiation for atrial fibrillation be performed safely outpatient, and if so, what would be a reasonable protocol for implementing this?
In my opinion, sotalol (and Tikosyn) should never be initiated as an outpatient. We have all seen cases of torsades at some point in our careers related to sotalol initiation and QT prolongation, even when resuming a dose that was previously tolerated. There is a nice review article published in JAC...
Given recent trials for the management of atrial fibrillation with an early ablation strategy (for example, EAST-AFNET 4, EARLY-AF, PROGRESSIVE-AF, STOP-AF), what is your approach to determining the appropriate timing for ablation in patients with atrial fibrillation?
I agree with Dr. @Dr. First Last. I also usually start with an antiarrhythmic drug and then offer ablation if the drug is not tolerated or is ineffectual. This is a shared decision-making process - some patients want nothing to do with drugs and prefer ablation and others want to try multiple drugs ...
What is your preferred monotherapy antiplatelet agent to continue after completion of DAPT post-PCI for patients with stable ischemic heart disease?
For stable CAD that is more extensive, I have been using Plavix monotherapy based on data from HOST-Exam although I have a discussion with the patient. ASA monotherapy is certainly OK if the patient prefers it. However, the downside to clopidogrel monotherapy is when a patient needs a procedure late...
What advice do you typically offer competitive athletes with recently diagnosed myocarditis on when to resume competitive sports, and how do often should outpatient imaging and mobile cardiac telemetry monitoring be performed to aid in this decision?
This is an important question because myocarditis is responsible for ≈ 6% of deaths during exertion in young athletes, but the answer is difficult because we do not have good data on how to manage athletes with myocarditis. Even the diagnosis is difficult. It is probably overdiagnosed in athletes be...
How do the results of the ESPRIT trial, which evaluated the impact of an SBP target of <120 mmHg on preventing major cardiovascular events, influence your blood pressure management goals for hypertensive patients with diabetes or a history of stroke?
The ESPRIT trial largely validates findings from SPRINT in a Chinese population. One major difference is that 38% of ESPRIT participants had diabetes mellitus (DM). A reduction in death from a CV cause drove the significance in the primary outcome (similar to SPRINT), and BP was measured 3x after a ...
Is there a need to bridge a patient with a history of Factor V Leiden on systemic anticoagulation such as a DOAC prior to elective low-rise procedures such as colonoscopy?
The prevalence of Factor V Leiden heterozygous is around 3-5%. Although it does increase the relative risk of thrombosis, the absolute risk is still low; this does not warrant any additional intervention even in patients undergoing major surgery. Colonoscopy is a low-risk procedure anyway. Excellent...
What is your approach to weaning dialysis in a patient with AKI on CKD and CHF who now has resolved AKI but a history of recurrent episodes of decompensated heart failure?
My preference would be to keep them on dialysis. If the serum creatinine is really getting toward the normal range and urine output is good, I would just stop dialysis for a week and give them diuretics to see if they can do without dialysis. However in patients with creatinine levels in the higher ...