Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
For pregnant patients in their first trimester presenting with acute MI with plan for emergent angiogram, who then subsequently have resolution of chest pain and EKG changes following initiation of heparin gtt, DAPT, would you still consider proceeding with LHC or treat medically with presumptive diagnosis of SCAD?
Great question and a highly debatable topic. I would consider a coronary angiogram to define the coronary anatomy as there are many differentials for pregnancy-associated acute myocardial infarction with ST elevation and treatment can differ accordingly. A conservative approach is acceptable for a l...
What has been your approach to minimizing the risk of vascular complications when placing Impella support devices?
I am assuming that you're question is specific for Impella CP (as Impella 5.5 is typically implanted surgically via a subclavian artery graft). As with obtaining any form of large vessel arterial access, minimizing complications will be based on a combination of patient/vessel selection and techniqu...
What is your standard approach (i.e. choice of medication, type of sheath) in the cath lab to reduce the likelihood of radial artery spasm?
Adrenaline is the key vasoconstrictor here, especially in patients with vessels prone to repetitive nicotine-induced constriction, so conscious sedation helps blunt the ‘fright/flight/constrict’ of adrenaline, while a CCB vasodilator (verapamil or nicardipine) addresses local vasoconstriction. A sma...
What are alternate approaches to medical therapy and/or interventions to consider in patients with refractory, severe coronary vasospasm despite short-acting nitrates, calcium channel blockers, L-arginine, and clonidine?
Angina caused by coronary vasospasm is relatively rare. I have come across very few cases of severe coronary vasospasm in my 15 years of career. The most common thread seems to be smoking and drug abuse (amphetamines, cocaine). Smoking cessation and stopping drug abuse are the most important interve...
Can Droxidopa be used for augmenting orthostatic hypotension treatment in patients who are already on midodrine and/or fludrocortisone?
I routinely combine droxidopa with fludrocortisone just as I would midodrine and fludrocortisone when orthostatic hypotension is refractory to tolerated doses of monotherapy. The use of droxidopa and midodrine is something I do less commonly, or frankly just rarely. They compete for the same recept...
Do you favor Sotagliflozin over SGLT2i alone for cardiovascular risk reduction in patients with Type 2 diabetes and chronic kidney disease?
The use of Sotagliflozin rather than SGLT2i alone is reasonable based on the results of the SCORED trial (Aggarwal et al., PMID 39961315). Although this trial compared sotagliflozin to placebo, rather than to SGLT2i, it did show a reduction in both MI and stroke in patients who have type 2 diabetes ...
How do you approach management of recurrent idiopathic pleuropericarditis?
The first line is colchicine and NSAIDs until the pain resolves, CRP normalizes, etc… After this, if the CRP tracks with the symptoms, fluid reaccumulation, and/or cMRI evidence of the pericarditis, I find il-1 inhibitors work very well.
What is a reasonable class of antihypertensive to start in patients with HCM who remain hypertensive and symptomatic in spite of maximal doses of beta blockade or calcium channel blockers?
My answer is based on the experience and not the research data per se in HCM: I will add low-dose HCTZ (12.5 mg daily). It won't cause dehydration or hypokalemia and might do wonders in managing HTN in these patients. One of the cheapest and most effective! Or I would consider Spironolactone instea...
Does oral semaglutide provide similar cardiovascular risk reduction benefits as injectable semaglutide?
Novo Nordisk, the manufacturer of oral and injectable semaglutide, just released positive topline results in its SOUL cardiovascular outcomes trial (n=9,650) for its oral semaglutide in people with T2D and established CVD and/or CKD. The trial met the primary endpoint demonstrating a statistically s...
What is the optimal anti-platelet/anticoagulant strategy and duration following a left atrial appendage occlusion with a watchmen device and is a CTA good enough to assess if the device is well seated and without any peri device leaks?
There is no guideline based answer. Based on observation: High bleeding risk patients: half dose apixaban for 45 days, then confirmation of LAA successful closure with TEE/CTA (depending on centers preference), followed by antiplatelet monotherapy (usually ASA or clopidogrel).