Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
When do you start anticoagulation for secondary prevention in patients with HFrEF and history of embolic strokes?
Current guidelines consider anticoagulation in patients with reduced EF as class III (no benefit and possibility of harm), which has not changed significantly since WARCEF was published. The most recent randomized large trial, COMMANDER HF, looked at primary stroke prevention (among other thrombotic...
How do you determine the timing of anticoagulation for patients with large MCA strokes secondary to atrial fibrillation?
Timing for anticoagulation initiation depends on the size of the stroke and whether a thrombus is present outside the cerebral vasculature. In general, between 4-14 days is standard practice, with early initiation in smaller strokes (to prevent recurrent stroke) and later in larger strokes (to preve...
Would you give anthracycline chemotherapy to a patient with HR+, HER2 negative inflammatory breast cancer who has history of cardiomyopathy with LVH and moderately reduced EF but most recent echo shows improvement to normal or near normal ejection fraction?
This is a tricky one. The main question is not what the current LVEF is, in my opinion. While it is reassuring to have a normal EF, comorbidities and/or prior cardiac disease is where the permanent damage of anthracyclines come into picture. Therefore, how safely can we give anthracycline based regi...
Do you recommend continuing SGLT2 inhibitors in patients with diabetic kidney disease and congestive heart failure who have been taking the medication for several years and later develop end stage kidney disease?
The very premise on which SGLT2i is supposed to work does not exist, if the patient does not have meaningful GFR; in fact most would not use/start SGLT2i once eGFR is <20-25 range. Studies have excluded patients with advanced CKD and any benefit with low GFR seems very doubtful. Zinman et al., PMID...
Do you recommend noninvasive testing or coronary angiography as the initial test for pre-kidney transplant evaluation of an asymptomatic patient older than 50 years of age with ESKD secondary to diabetic nephropathy and no known history of CAD?
There is no evidence that revascularization of asymptomatic patients reduces the risk of transplant. obviously patient should have all relevant risk factors treated. the problem with routine angiography is that inevitably any lesion found is treated with stenting which actually exposes the patient t...
Following cardiac MRI, what imaging modality would you consider to further evaluate mild aortic regurgitation (regurgitant fraction on cardiac MRI of 26%) and mild to moderate mitral regurgitation secondary to mild bi-leaflet mitral valve prolapse (RF 30%) with low-normal LVEF and incomplete RBBB?
Consider an exercise echo if the patient is asymptomatic and continue to follow with echo-Doppler.
Do you ever utilize lacosimide in patients with atrial fibrillation?
Yes. I would get screening ECG to look for P-R interval if there is history of conduction abnormalities such as bradycardia, fainting, cardiomyopathy etc.
What criteria do you use on echocardiogram and PFT to determine who needs further evaluation for CTD-associated pulmonary hypertension?
PFTs are often obtained in patients with systemic sclerosis to evaluate for interstitial lung disease. Low DLCO on PFTs can signify an increased probability of PH, but it is by no means specific. Echocardiograms are readily available, offer additional information about possible causes of PH (e.g. LV...
What are your criteria for deciding if a patient who had VF arrest in the setting of subacute myocarditis requires ICD or long term WCD?
This is a complex question with multiple variables. In general, if the patient had a VF arrest, then we are no longer talking about primary prevention, this would be a secondary prevention indication. For me, I would want to identify a reversible cause with reasonable expectation that the VF episode...
How long would you treat a patient with recent history of TAVR presenting with E faecalis bacteremia with unclear source with TEE showing thickened valves but no obvious vegetation?
Treatment duration depends on other additional factors.TEE showed leaflet thickening- a non-specific finding, not a feature per Duke's major imaging criteria. Another feature to consider would be an associated new-onset valvular insufficiency that might increase the likelihood of IE. In such cases, ...