Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What is your approach to medical management and echocardiographic surveillance for pregnant patients with severe aortic stenosis during the first, second, and third trimesters?
There is no need for routine echocardiographic surveillance during pregnancy if the patient is asymptomatic and there is no change in the level of BNP. The echo can be helpful for the assessment of pulmonary pressure in patient who develops symptoms .Change in the BNPlevel and echocardiographic PA p...
If a patient has potential arrhythmic-sounding syncope and a noninducible type 2 or 3 Brugada ECG pattern, have we excluded Brugada syndrome as the etiology for their syncope?
This is a complex question with a few nuanced components. The first component is qualifying an arrhythmic versus non arrhythmic cause of syncope. I would stress that this is based on generalization as there are no features that will provide absolute certainty for the nature of a single syncopal even...
Is there any data to support the use of bivalirudin over heparin in patients on VA-ECMO without ongoing concerns for HIT?
Multiple recent meta-analyses and retrospective studies suggest that bivalirudin may reduce the risk of circuit thrombosis, major bleeding, and in-hospital mortality compared to heparin in VA-ECMO patients, even in the absence of HIT.[1][2][3][4][5][6][7][8] Some studies also report improved time in...
Would you recommend PFO closure in patients >60 years old with presumed paradoxical embolism as their mechanism of stroke?
Technically, based on the available clinical trial evidence, PFO closure is not indicated for patients over age 60 or for patients whose stroke was > 6 months ago. However, we frequently need to extrapolate from clinical trial populations to manage the patients we see in practice. Also, presumably, ...
For patients with hypertension who have normal filling pressures following right cardiac catheterization, can hypertension still be attributed to volume overload?
I do not think of chronic hypertension as a disease of volume overload. Loop diuretics are indeed very poor antihypertensive agents. I agree that cardiac loading conditions are dynamic, but in a patient with normal filling pressures and hypertension, I would think of inappropriately increased periph...
How frequently should outpatient mobile cardiac telemetry be ordered following resolution of post-CABG-related atrial fibrillation for patients off anticoagulation?
I am not a big user of MCOTs in general so I would say that I rarely use them in the postoperative setting. I very much like MCOT monitors but the struggle with reimbursement often makes it a challenge. we do routinely get atrial fibrillation burden with our standard event monitor which certainly im...
What is your approach to risk stratification of asymptomatic patients with pre-excitation syndrome?
When addressing pre-excitation on EKG, some good references include: ACC online expert analysis 2012 PACES/HRS expert consensus statement Editorial on the 2012 PACES guidelines about the challenges of being more aggressive In general, I agree with Dr. @Dr. First Last and the ACC expert analysis that...
Is there any difference in the cardiovascular risk reduction profile of brand name Vascepa versus generic icosapent ethyl for patients with hypertriglyceridemia?
The major clinical trial data (Bhatt et al., PMID 30415628) showing benefit for Icosapent Ethyl were with medication provided by the company that ultimately branded the medication. That is no different from the clinical trials showing the benefit of statins or anti-hyperglycemic medications. We do n...
How do you counsel patients with non-statin associated inflammatory myopathies about statin use?
Patients with non-HMGCR-associated myositis could try statins, keeping in mind that they could develop statin-associated muscle symptoms (SAMS). Therefore, would start with fluvastatin/pravastatin/pitavastatin (that are less likely to cause SAMS) at a low dose and slowly escalate if there are no sid...
In a patient with severe TR, when is the best time to start thinking about T-TEER?
When tricuspid regurgitation is symptomatic and is refractory to optimal medical therapy. Prior to irreversible RV dysfunction and hepatic dysfunction. In patients deemed too high-risk for surgical intervention.