Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What steroid sparing agent do you use for treatment of cardiac sarcoidosis?
Recognizing that corticosteroids will be needed to acutely stabilize cardiac sarcoidosis, a steroid sparing agent is usually a reasonable choice early. My choice of secondary agents depends on the other manifestations of sarcoidosis present at the time of diagnosis. I have rarely seen cardiac sarcoi...
Would you change an elderly, frail patient with atrial fibrillation who is already on a NOAC to VKA treatment?
I wouldn't on the basis of this study. Aside from the other limitations of the FRAIL-AF trial, this study only addressed the utility of switching a stable patient from VKA to NOAC and not vice versa. A patient who is doing well on an appropriately dosed NOAC may experience difficulty achieving adequ...
How do you choose between spironolactone and finerenone for patients with proteinuric diabetic kidney disease and heart failure?
Although finerenone may be easier to use due to its lower incidence of sexual side effects and hyperkalemia, it is more expensive than spironolactone and may be more difficult to prescribe. Many prescription drug plans require prior authorization for finerenone and documentation that the patient has...
When would you consider proceeding with antiarrhythmic drug load concurrently with DCCV as opposed to DCCV alone in patients with new-onset atrial fibrillation?
There is no expert consensus. If we are dealing with a first episode of AF, and we know that the arrhythmia has a short duration and the anatomic substrate is not severe, I would proceed with cardioversion alone. After all, we learned from AFFIRM that many patients randomized to "rate control" after...
What techniques do you use in the lab to reduce the amount of contrast that needs to be used in patients with CKD?
Avoid LV angiogram. Use ECHO instead to assess LV function.
What is a reasonable inpatient imaging modality alternative to evaluate for infective endocarditis in a morbidly obese patient with poor acoustic windows on TTE and persistent bacteremia if TEE is not feasible or contraindicated?
This is an excellent question. Retrospectively gated cardiac CTA especially with the newer generations (Siemens Somatom force or Naetom alpha) are probably your best alternative. This would need careful planning and tube setting adjustments depending on the patient's body habitus as scattered and no...
Do you recommend increasing dietary potassium intake for blood pressure management in non-CKD patients with hypertension?
Yes! The AHA guidelines from 2017 list a heart-healthy diet like the DASH diet (which has natural sources of potassium from fruits and vegetables) as strong recommendation (class I) supported by the highest level of evidence (level A). It is even recommended to use potassium supplements if not contr...
Following left main bifurcation stenting, do you routinely proceed with kissing balloon inflation of the side branch, either LCx or LAD?
It depends on the technique used; most crush based techniques require kissing balloon inflation.
Do you recommend bedtime administration of antihypertensives in patients who exhibit nondipping on ambulatory blood pressure monitoring?
Most of the effective anti-hypertensive medications are long-acting, with therapeutic levels maintained for up to 72 hours between doses. From a pharmacokinetic perspective, dosing these meds (like amlodipine and chlorthalidone) at night would not make a difference. Data supporting nocturnal dosing ...
How can hepatic venous pressure gradients in patients with cirrhosis be used to differentiate between cardiac cirrhosis and portopulmonary hypertension?
HVPG is a measure that quantifies the increase in sinusoidal resistance to blood flow and can be obtained in a minimally invasive way compared to portal venous sampling directly which may be more invasive. HVPG is the pressure difference between hepatic vein wedge pressure (HVWP) & hepatic vein free...