Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Do you pursue a cardiac evaluation in all patients with an excised cutaneous myxoma?
I'm a dermatopathologist, not a clinician, but would note the following data points: Many things are called myxomas. Those associated with Carney complex, in which atrial myxomas also occur, are a specific variant, superficial angiomyxomas. They usually have inactivation of protein kinase regulator...
Is ABI (Ankle Brachial index) lower limb arterial doppler not recommended if patient already has arterial stents in the legs, and if so, what other imaging modality would you consider as first-line?
ABI is still helpful in follow-up of patients with arterial stents but only gives a sense of global perfusion to the distal limb and may not be helpful in patients with calcified non-compressible vessels, (e.g. CKD, diabetics), so a better assessment is arterial duplex that can visualize the entire ...
Given that high coronary calcium scores portend significantly increased cardiac mortality rates over 5-6 years, is there any data to support performing coronary angiography when the score is very high, e.g. over 1000, even in asymptomatic patients with no objective evidence of ischemia?
The question is; is coronary angiography necessary in asymptomatic folks with extensive CAD on EBCT? Will it tell us more than what we already know; that the patient has extensive CAD? Will it make an asymptomatic patient feel better? Will the information obtained from coronary angiography allow for...
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 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.