Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How do you risk stratify patients with different WHO groups of pulmonary hypertension prior to non-cardiac surgeries?
First, I would direct the audience to recent AHA guidelines on the perioperative management of PH in non-cardiac surgery. Rajagopal et al., PMID 36924225In general, the severity of pulmonary hypertension and relevant comorbidities are likely more important than the WHO group. In patients with CTEPH,...
What is your approach to GDMT uptitration (particularly dosing for ARBs/ARNIs/MRA) if there is further evidence of renal dysfunction, especially in situations with worsening AKI on CKD?
Titration of RAAS inhibitors in the setting of AKI on CKD is challenging. First, look at the patient: if they have an increase in Cr after an increase in the RAAS inhibitor but no/stable HF symptoms and appear euvolemic on examination, then I will decrease diuretic therapy and see if the Cr improves...
What is the optimal approach to treat isolated diastolic hypertension?
Isolated diastolic hypertension occurs less commonly in the adult population, where the majority of the outcome trials in hypertension have been conducted. Much of the treatment of hypertension in younger patients is extrapolated from these trials. In my practice, I look more closely for secondary c...
Would you consider switching choice of P2Y12 inhibitor for patients with ISR (non-ACS presentation), with acceptable bleeding risk?
There is no need to change P2Y12 inhibitor in case of ISR without ACS. There are no studies that suggest such approach is indicated or can be helpful. Also, patients are taking their current P2Y12 inhibitor for a while and they are used to the medications. Changing the medication can raise cost with...
When would you consider obtaining a cardiac CT in lieu of standard TEE for the detection of a left atrial appendage thrombus in atrial fibrillation?
TEE is still the gold standard for the evaluation of left atrial appendage thrombus. That being said, there is certainly a role for cardiac CT as well, especially in patients with esophageal pathology or other conditions that increase the risk or contraindicate the use of TEE such as significant thr...
Would you recommend normal saline for pre- and post-LHC hydration in patients with CKD stage III to IV with reduced LV systolic function, and if so, what is a reasonable amount of volume?
The POSEIDON trial, or Prevention of Contrast Renal Injury with Different Hydration Strategies, was a randomized controlled trial that found a personalized hydration strategy can reduce the risk of contrast-induced acute kidney injury (CI-AKI) in patients undergoing cardiac catheterization. The tria...
Is it reasonable to consider the use of DOACs for LV thrombus management instead of coumadin?
I have no qualms whatsoever at using a DOAC instead of Vitamin K antagonist in this situation, provided that the patient doesn't have a mechanical valve. Endothelium is endothelium, so mechanistically I don't see much of a difference between using a DOAC to prevent/treat an LAA thrombus versus an LV...
Would you recommend cardiac radiotherapy for malignant pericardial effusion refractory to pericardial fenestration?
Yes. I have done this several times and have gotten some reasonable palliative responses. Typically one cannot determine the exact source for the malignant cells, and one presumes that there are tumor deposits throughout the pericardium, in which case the target is the whole heart. This then limits ...
What are first-line choices for vasopressors/inotropes to use in hypotensive patients with Eisenmenger Syndrome?
The answer is that it all depends on the etiology... However, a common issue with Eisenmenger syndrome (ES) is that routine pharmacological treatments that cause peripheral vasodilatation may worsen the right to left shunting and further shock. My first patient with ES was a gentleman recovering fro...
Would you consider lifelong versus short-term (i.e. several months) course of anticoagulation for patients with elevated CHADSVASc score presenting with newly diagnosed paroxysmal atrial fibrillation triggered in the setting of acute illness (i.e. tachyarrhythmias with COVID-19 or bacterial pneumonia)?
AF during an acute illness could result from the stress of an infection, however, these patients do seem to be at higher risk of recurrence. It might also simply represent the first time that AF has been recognized in a patient who is at risk for atrial arrhythmias. Anticoagulation is indicated in t...