Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How do you decide between using a self-expanding supraannular valve and a balloon-expandable valve for TAVR in patients with severe aortic stenosis and a small aortic annulus?
A supra-annular design intuitively allows for lower gradients on echo, so this endpoint was expected. But overall, the data thus far does indeed make a SEP an attractive choice as compared to a BEP, in patients with a small annulus. This is a fairly large subset of patients with AS. The risk of need...
With the recent trials such as SELECT and STEP-HFpEF demonstrating benefits of GLP1-agonists in terms of CV risk reduction and improved exercise function, have you begun to incorporate this class of medications into routine CV health maintenance for patients with HFpEF and/or pre-existing CAD?
I would strongly support the use of this medication. The biggest challenge is insurance coverage. When would it be approved by insurance and how many hoops we will need to jump before they approve it?
Does the presence and location of cerebral microbleeds affect your decision for antithrombotic treatment in patients with atrial fibrillation?
That is a great question. Agree, the data is observational and no firm conclusions can be made. My practice is to consider left atrial appendage occlusion in patients with suspected CAA. In patients with hypertensive microbleeds, both resuming anticoagulation and left atrial appendage occlusion are ...
What would be your threshold to offer coronary angiography for patients presenting with atypical chest pain features and Wellens syndrome on EKG without a troponin elevation or dynamic EKG changes?
In three words- very low threshold. Wellens syndrome typically presents with T-wave inversion in V 2, 3, but can be across the precordium. The patient may be asymptomatic at the time of presentation, but Wellen probably represents a pre-infarction state representing proximal LAD thrombus. The propos...
What are some device parameters and clinical scenarios in which recommendations should be made to deactivate the LV lead in patients with an existing CRT-D device following LVAD implantation?
In the context of LV lead deactivation in patients with existing CRT-D devices following LVAD implantation, I will outline a framework based on current knowledge and clinical rationale that should be considered in the context of recent advances and expert opinion in the field along with the recent l...
Is it sufficient to maintain patients with atrial fibrillation and established PAD on a DOAC or VKA alone, or is there an additional benefit to adding an antiplatelet agent for CVD benefit?
If they have medically managed PAD with no recent intervention/revascularization, anticoagulation alone should be sufficient especially if their bleeding risk is not low. In general, most patients on anticoagulation for AF do not need to also be on anti-platelet agents for secondary prevention. Exc...
How do you decide between administering or deferring upstream P2Y12 inhibitor treatment until patient is in the lab for NSTEMI or STEMI cases with unknown coronary anatomy?
Unless you are using clopidogrel there’s no need to consider upstream use in STEMI. In NSTEMI, you can use heparin/lovenox or a P2Y12 no need for both. If you don’t know the anatomy you’re gambling to give upstream P2Y12. In ACS administration of a P2Y12 inhibitor before assessment of coronary anato...
When would be your threshold to consider obtaining an exercise RHC for undifferentiated dyspnea to help diagnose HFpEF?
When to Consider Exercise Right Heart Catheterization (RHC) for Diagnosing HFpEF in Patients with Undifferentiated Dyspnea: Persistent, Unexplained Dyspnea: Clinical Context: Exercise RHC is indicated in patients with persistent dyspnea not explained by common conditions such as chronic obstructiv...
In light of the NOAH-AFNET6 and ARTESiA trials, how would you approach the decision regarding anticoagulation for patients with incidentally-detected AF <24 hrs on pacemakers/defibrillators?
Finding the right answer for subclinical atrial fibrillation is sometimes hard to tease out the subtleties. The 2023 ACC/AHA/HRS atrial fibrillation guidelines were published in Jan 2024 (Joglar et al., PMID 38033089) and a section (6.4.1) is dedicated to patients with CIED without prior atrial fibr...
Should all kidney transplant patients be started on statin therapy post operatively given their increased risk of CVD?
A kidney transplant is not an indication for statin therapy per se. The 2018 cholesterol guidelines list CKD (but not ESRD or Transplant) as a risk-enhancing factor. I would guide the decision to use statin therapy based on the patient's risk as assessed for non-transplant patients. Having said that...