Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Which factors favor extended dual antiplatelet therapy beyond one year in ACS patients with low bleeding risk?
Selecting an optimal duration of dual antiplatelet therapy (DAPT) for a given patient (whether "extended" or "short" in comparison to one year) must be personalized, with a calculus that considers an individual's competing risks of bleeding and thrombosis as a function of time.Accordingly, without b...
What are reasonable next steps in the work-up of suspected ATTR amyloidosis if the PYP scan is equivocal, in light of the potential risks of endomyocardial biopsy?
Before addressing the next move after an equivocal PYP scan, some comments on PYP scan reporting are in order. Unfortunately, despite the relative simplicity of obtaining a high quality PYP scam, around 10 -20% of the ones that we see done at outside institutions (including teaching institutions) ar...
Do you think that home INR monitoring is a feasible option for elderly, frail patients with atrial fibrillation on VKA treatment, given variations in socioeconomic status and access to care?
Whenever possible, I prescribe home INR monitoring with appropriate equipment. This allows me to monitor my patients on a weekly basis, rather than on a monthly basis at best. Unfortunately, insurance reimbursement is not standard for this equipment, and many patients are unable to obtain it. The ab...
Would you recommend statin initiation in a young adult patient (age < 40) with type 1 diabetes mellitus and LDL cholesterol levels greater than 100 without any cardiovascular risk factors?
The recommendations are to start statins in young adults with type 1 DM if duration of diabetes is over 20 years.
What is a reasonable surveillance strategy in terms of preferred imaging modality and frequency of monitoring for suspected AV bioprosthetic stenosis in patients status post SAVR?
Echocardiography is the best way to monitor the valve. Obtain baseline images in the first year after implantation. If baseline function is normal and access to care is good, it is not necessary to image every year in the first 5-7 years. The exception to this would be young individuals in whom the ...
Is there any benefit to supervised PAD exercise programs in the presence of collaterals seen on angiography for patients with severe claudication and significant lesions?
Yes, exercise benefits for claudication are more about muscle training and metabolism and general physical conditioning than building of collateral circulation.
Would you favor stopping low-dose aspirin and continuing OAC alone in a patient with atrial fibrillation and mild coronary artery calcification seen on routine chest imaging?
Absolutely, most of the patients that I would treat with dual-antithrombotics (as opposed to dual antiplatelet plus/minus anticoagulant), have had clinical events. Most commonly MI and/ or stent plus atrial fibrillation. Your patient has one clinical event (AF) and another "subclinical" condition.
What are your management strategies for malignant pericardial effusion with a high risk of spontaneous hemorrhage, particularly in patients requiring anticoagulation for chronic atrial fibrillation?
We have many patients with malignant pericardial effusion who tolerate anticoagulation for DVT/PE/afib. In those patients, when AC is restarted (for example after pericardiocentesis), close monitoring with serial echo in a few days would be performed to see if effusion reaccumulates faster. Also, th...
What is your target or goal lipoprotein (a) level for patients on PCSK9 inhibitors for either primary or secondary prevention?
Let me compliment the clinician who submitted the question because he/she measured lipoprotein (a) [Lp(a)] in the first place. Lp(a) was first described in 1964, but its contribution to atherosclerotic vascular disease risk has only recently attracted widespread attention. Part of that attention is ...
Would you recommend hospitalization for surgery for a large papillary fibroelastoma or atrial myxoma discovered on an outpatient echocardiogram?
NOT necessarily to hospitalize if incidental finding given that both of these lesions are typically present for years prior to diagnosis (unless of course you are concerned about getting sued if a bad outcome occurs). If these lesions are found in the context of a recent neurological syndrome then c...