Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How do you approach a patient with atrial fibrillation on apixaban who has a new cardioembolic stroke?
Assuming that the apixaban dose was 5 mg bid, I would switch to warfarin and aim for INR 2.5-3.5.
How do you approach mitral valve endocarditis associated with a large vegetation size and severe mitral regurgitation, but without any heart failure, hemodynamic instability or valve destruction?
This is a great question and it poses the risk-benefit of the situation nicely. This stems off the 2012 NEJM (Kang et al., PMID 22738096) paper linked in the question, comparing Early (<48 hr) vs Conventional/Abx treatment for large vegetation (>10 mm) without major stroke yet. Summary: this was pre...
When would you consider using Ibutilide for rapid pharmacologic cardioversion of atrial fibrillation?
Someone already on anti-coagulation for paroxysmal or persistent atrial fibrillation. As well as someone with very recent onset atrial fibrillation/flutter in less than 24 hours. (Some may like less than 12 hours others less than 48 hours) Someone I planned on electrical cardioversion that day, how...
How do you approach inpatient DVT prophylaxis in patients already on low dose rivaroxaban 2.5 mg BID for PAD?
I suspect that the approach to this situation may vary by provider given the lack of definitive evidence. ASH 2018 guidelines provide recommendations for inpatient thromboprophylaxis in acutely or critically ill patients. Generally, prophylactic LMWH is recommended over DOACs, but guidelines acknowl...
How would you decide between conservative management vs. ILR or pacemaker for asymptomatic nocturnal bradycardia/pauses (as an example rates in the 30s, pauses ranging 4-12 seconds) in the absence of bradyarrhythmias during the day and ECG with normal intervals, and not otherwise on medications to slow down HR?
The guidelines are clear in stating that patients with symptomatic bradycardia or higher degree heart block during waking hours would benefit from pacing, but determining symptom-rhythm correlation is not always easy. In sinus node dysfunction, there is no established minimal HR or length of pause t...
What are reasonable alternatives to invasive angiography for CAV surveillance in patients who are a few years out from cardiac transplant with impaired renal function?
In our practice, we move to PET-CT on Year 3 if the prior 2 angiograms with IVUS did not show accelerating disease. The issue with CAV is that there is not much to do about it reactively. The best you can do, is switch to an mTORi regimen early and optimize lipids. IVUS is useful for that reason. Be...
What are your top takeaways from ACC 2024?
In the field of critical care cardiology, DanGer Shock stands out as a key trial presented at ACC 2024 and simultaneously published in NEJM (Møller et al., PMID 38587239). The “splash” of DanGer Shock comes as it is the first randomized controlled trial to demonstrate a mortality benefit from a temp...
How do you decide the right time for MitraClip intervention in patients with symptomatic heart failure and severe mitral regurgitation who are on maximally tolerated GDMT?
When evaluating these patients, it is always important to consider a multidisciplinary approach inclusive of general cardiologists, imaging experts for MR quantification, and most importantly, heart failure and electrophysiology colleagues. I ensure that the patient is seen by our HF colleagues to t...
How long should patients with atrial fibrillation who are already on systemic anticoagulation and are status post TAVR and PCI 6 months ago remain on Plavix?
If PCI was done for a plaque rupture event I.e. ACS, then DOAC + plavix for a year is the current SOC. For non ACS PCI, DOAC + plavix for 6 months, followed by DOAC mono Rx is a reasonable option.
Which class(es) of antihypertensives do you recommend for first-line therapy for hypertension in severe aortic stenosis?
Most beneficial data on ACE inhibitors.B blockers are to be avoided if associated AR but prior apparent contradiction is no longer valid and some benefit in outcomes based on their effects. Exact Aortic Stenosis substrate and comorbidities to determine which drugs to benefit. ARB's role is probably ...