Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What advice do you typically offer competitive athletes with recently diagnosed myocarditis on when to resume competitive sports, and how do often should outpatient imaging and mobile cardiac telemetry monitoring be performed to aid in this decision?
This is an important question because myocarditis is responsible for ≈ 6% of deaths during exertion in young athletes, but the answer is difficult because we do not have good data on how to manage athletes with myocarditis. Even the diagnosis is difficult. It is probably overdiagnosed in athletes be...
Is there a need to bridge a patient with a history of Factor V Leiden on systemic anticoagulation such as a DOAC prior to elective low-rise procedures such as colonoscopy?
The prevalence of Factor V Leiden heterozygous is around 3-5%. Although it does increase the relative risk of thrombosis, the absolute risk is still low; this does not warrant any additional intervention even in patients undergoing major surgery. Colonoscopy is a low-risk procedure anyway. Excellent...
What is your approach to weaning dialysis in a patient with AKI on CKD and CHF who now has resolved AKI but a history of recurrent episodes of decompensated heart failure?
My preference would be to keep them on dialysis. If the serum creatinine is really getting toward the normal range and urine output is good, I would just stop dialysis for a week and give them diuretics to see if they can do without dialysis. However in patients with creatinine levels in the higher ...
Would you consider using Evenity in an elderly patient with rate controlled atrial fibrillation without history of MI or CVA?
The cardiovascular safety profile of Evenity is complex and has been reviewed in several publications. The concern is myocardial infarction and stroke. In general, if there is a history of an MI or stroke I would personally avoid Evenity. Although I do not have access to the safety dataset, I am una...
Should intervention be considered for an intermediate flow-limiting coronary lesion that does not correlate with perfusion defects on stress testing in a patient with atypical anginal symptoms?
This is a kind of question that gets into the realm of the "art of medicine". There are multiple questions within this single question. I will try to answer each of them. What is an angina and what is atypical angina: I have come across a wide variety of angina syndromes throughout my clinical expe...
How would you counsel a patient on the risk/benefit profile of preventive management such as statin initiation if they have an elevated lipoprotein (a) level, markedly elevated LDL > 200 but a CAC score of 0 without other CV risk factors?
Assuming this patient is over 45 years, and has tried dietary approaches to reduce cholesterol first, I would recommend a initiation of a moderate intensity statin to lower the risk of ASCVD events as the risk equation does not take into account the CAC score.
What is your preferred imaging modality--cMR vs. TTE--to evaluate for myocardial strain if concerned for chemotherapy-induced cardiomyopathies?
Per American guidelines, TTE with strain would be indicated at baseline and then every 3-6 months while on chemotherapy. No cMR per American guidelines for routine screening/follow-up to the best of my knowledge.
How do you approach long-term blood pressure parameters in ischemic stroke patients with severe symptomatic intracranial stenosis?
Every patient is unique and I just try to be as low and slow as possible. 4-6 weeks seems to be where most people do well with others tolerating more (I'm able to get them to under 140 or even 120 during their hospitalization over a few days). In the acute setting, I've found it helpful to make sure...
What would be a reasonable threshold to recommend epicardial CRT-D intra-op in a patient post-ACS with LVEF< 35%, QRS duration > 120, and breakthrough VT undergoing emergent CABG?
In answering this question, one should keep in mind that CRT-D provides 2 primary benefits: resynchronization therapy to treat systolic heart failure in appropriate patients and defibrillation in patients at risk for malignant arrhythmia. We NEVER implant a defibrillator in a patient having active V...
What are some potential etiologies to consider for isolated, mildly elevated BNP levels with normal TTE findings in an asymptomatic, elderly patient?
BNP and pro-BNP both increase with age, especially in women, and must therefore be interpreted in that context. Pro-BNP less than 300 pg/mL indicates low likelihood for acute heart failure at all ages (though there are exceptions). The recommended age-based thresholds for diagnosing heart failure/vo...