Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Would you consider PPM implantation for patients during their hospital stay following TAVR if they were to develop lengthening PR intervals and widening LBBB QRS duration exceeding 150ms afterwards?
Would do an EP study to guide me further.
Would you consider adding niacin to the lipid lowering regimen in statin-intolerant patients who cannot afford PCSK9i or bempedoic acid?
Yes, in a patient who absolutely cannot take a statin or other common alternatives such as ezetimibe, PCSK9 inhibitors, or Bempedoic acid, Niacin for ASCVD risk reduction is still a reasonable choice. While the combination of statin and niacin has been shown to be unhelpful (and possibly of greater ...
Among patients with recovered LVEF on GDMT with a reversible cause for heart failure (i.e., tachycardia-mediated or alcohol-mediated cardiomyopathy), would you consider de-escalation of GDMT?
There are several cardiomyopathies wherein complete recovery in LV function is observed, especially those associated with tachycardia or thyroid disease, with alcohol cardiomyopathy ranking second. However, discerning whether the improvement in function stems from the biology of the disease or the u...
How do you identify the subset of heart failure patients who are likely to benefit from cardiac resynchronization therapy in the setting of an RBBB pattern?
There are no good criteria to delineate which patients with RBBB will benefit from traditional CRT. The best contemporary strategy is to consider CRT if a patient has an RBBB > 150 ms, an atypical morphology (suggesting an underlying delay in the LBBB or an IVCD), and Class III-IV HF symptoms. One m...
Would you consider a short duration of dual antiplatelet therapy following plain old balloon angioplasty (POBA) to a femoropopliteal bypass graft
Aspirin alone is sufficient after plain old balloon angioplasty, particularly in a high bleeding risk patient.
Following completion of antiplatelet monotherapy (i.e., Plavix) plus oral anticoagulation in patients with AFib post-PCI, would you favor continuing antiplatelet therapy + OAC, switching from Plavix to aspirin and continuing OAC, or stopping antiplatelet therapy and continuing OAC?
My practice has always been to continue ASA in addition to anticoagulation but I'm starting to change this practice and remove antiplatelet therapy and continue OAC alone, especially in higher bleeding risk patients. There have been a couple of studies (AFIRE and OAC-ALONE) that would seem to suppor...
What would be your index of suspicion for AL amyloidosis with cardiac involvement in a patient with MGUS to prompt further imaging (and which modality would be preferred)?
In short, we will usually be concerned for potential underlying AL cardiomyopathy (AL-CM) in a patient with MGUS if they have symptoms/signs of heart failure. NT Pro BNP is very sensitive for detecting cardiac involvement of amyloid (Zhang et al., PMID 33283202) and troponin can also help. While the...
Would testing for ATTR cardiac amyloidosis be considered in an older patient with bilateral carpal tunnel surgeries and multiple spinal stenosis surgeries, but no obvious cardiac symptoms?
I would not look for ATTR-CM in the absence of cardiac findings such as abnormal echo (increased LV thickness) or conduction abnormalities that are suggestive. Only 10% of patients with bilateral CTS have ATTR-CM. I would do an echo if not done and review ECG. As much as we are concerned about under...
With the FDA recently approving acoramidis for ATTR cardiac amyloidosis, how should we decide on optimal drug therapy and options for our patients?
Both tafamidis and acoramidis are stabilizers of transthyretin (TTR) and both have been shown in clinical trials to lessen hospital admissions for CHF and to reduce death in TTR cardiomyopathy compared to placebo. Although acoramidis is said to produce "near complete stabilization" of TTR, and is re...
What are high-risk clinical and echocardiographic features in pregnant patients with congenital heart disease?
The most commonly used risk stratification tool available has been the mWHO maternal cardiovascular risk classification which places women into different categories (I-IV) based on diagnosis/ residual lesions. Class IV patients are considered very high risk for cardiovascular events (bleeding, throm...