Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How do you approach prescribing statins in patients with an ASCVD <7.5% but have a strong family history and/or elevated LDL (but <190)?
When considering statin therapy for patients with an ASCVD risk of less than 7.5%, but with a strong family history of cardiovascular disease or elevated LDL cholesterol levels, the decision is nuanced. Here’s how I approach this situation: Shared Decision-Making: Involve patients in the discussion...
Would the diagnostic yield for ABIs or peripheral arterial duplex doppler in a patient with metal rods in both legs be similar or acceptable in comparison to those tests in a patient without metal rods?
Ankle-brachial index(ABI) relies on the compression of upper and lower extremity arteries with blood pressure cuffs and measuring the ratio of blood pressure between them. While I am not aware of specific studies in those with metallic rod fixation, ABI measurements should have similar utility as lo...
How does the presence of myositis alter your interpretation of cardiac enzymes when evaluating acute chest pain?
Troponin T and CK-MB are not reliable for cardiac issues in myositis as regenerating muscles produce these enzymes. This is especially true if the patient has an active disease with weakness and CK elevation. Troponin I is not much affected by muscle enzymes and should be used as a parameter to eval...
Do you continue beta-blocker therapy beyond 1 year after myocardial infarction in a stable patient with normal LV systolic function when the only remaining indication is mildly elevated blood pressure that could be managed with an alternative agent?
In 1982, a landmark study, the Beta-Blocker Heart Attack Trial, BHAT showed that significant mortality reductions were achieved when propanolol was prescribed post-MI for an average follow-up period of 25 months. This was followed by a Norwegian study and the Stockholm Metoprolol study, which confir...
What class(es) of antihypertensives should be considered next for refractory hypertension in a patient compliant with high doses of Entresto, chlorthalidone, amlodipine, clonidine, and spironolactone if they previously did not have any improvement on beta blocker or hydralazine and work-up for secondary causes were unremarkable?
Minoxidil remains a rarely used but potent option.
Are there data to support full-dose anticoagulation added to an antiplatelet in recurrent peripheral arterial thrombosis requiring revascularization and stenting?
This question comes up frequently at our institution. I previously consulted with our vascular surgery team who referred me to this trial of Edoxaban with SAPT, trying to avert what may be limb loss if the bypass graft/stent fails. We've often promoted rivaroxaban 2.5 mg po BID per VOYAGER PAD if we...
How do the results of CREST-2 influence your recommendations on screening for asymptomatic carotid stenosis?
Agree with the prior comment. One important nuance is what “medical management” actually meant in CREST-2. This was centralized, protocol-driven care with structured lifestyle counseling and medication escalation, including access to PCSK9 inhibitors with costs covered. Even in that highly organized...
What is the clinical significance of a paradoxical decrease in HDL cholesterol after starting statin therapy?
I agree that the modest/minimal changes in HDL upon starting statin Rx are likely clinically meaningless. During the "statin-wars" that were all we heard about from different pharma sources, but it is probably related to a large drop in total cholesterol flux through the circulation - maybe CETP is ...
Is moderate-intensity statin plus ezetimibe just as effective as high-intensity statin monotherapy in preventing major cardiovascular events?
The secondary stroke prevention trial showed that high/moderate-intensity statin therapy combined with ezetimibe and titrated to achieve LDLc <70 were equally effective (compared to goal LDLc <100). Overall, the most important determinant of risk reduction is the achieved LDLc, and so moderate inten...
What are your thoughts on the results of the ALONE-AF trial and the safety profile of discontinuing anticoagulation post-ablation, provided there is no atrial arrhythmia recurrence?
ALONE-AF is another recent trial to challenge the current dogma. The 2023 ACC/AHA/HRS guidelines for AF recommend "In patients who have undergone catheter ablation of AF, continuation of longer-term oral anticoagulation should be dictated according to the patients’ stroke risk (e.g., CHA2DS2-VASc sc...