Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What are some device parameters and clinical scenarios in which recommendations should be made to deactivate the LV lead in patients with an existing CRT-D device following LVAD implantation?
In the context of LV lead deactivation in patients with existing CRT-D devices following LVAD implantation, I will outline a framework based on current knowledge and clinical rationale that should be considered in the context of recent advances and expert opinion in the field along with the recent l...
Is it sufficient to maintain patients with atrial fibrillation and established PAD on a DOAC or VKA alone, or is there an additional benefit to adding an antiplatelet agent for CVD benefit?
If they have medically managed PAD with no recent intervention/revascularization, anticoagulation alone should be sufficient especially if their bleeding risk is not low. In general, most patients on anticoagulation for AF do not need to also be on anti-platelet agents for secondary prevention. Exc...
How do you decide between administering or deferring upstream P2Y12 inhibitor treatment until patient is in the lab for NSTEMI or STEMI cases with unknown coronary anatomy?
Unless you are using clopidogrel there’s no need to consider upstream use in STEMI. In NSTEMI, you can use heparin/lovenox or a P2Y12 no need for both. If you don’t know the anatomy you’re gambling to give upstream P2Y12. In ACS administration of a P2Y12 inhibitor before assessment of coronary anato...
When would be your threshold to consider obtaining an exercise RHC for undifferentiated dyspnea to help diagnose HFpEF?
When to Consider Exercise Right Heart Catheterization (RHC) for Diagnosing HFpEF in Patients with Undifferentiated Dyspnea: Persistent, Unexplained Dyspnea: Clinical Context: Exercise RHC is indicated in patients with persistent dyspnea not explained by common conditions such as chronic obstructiv...
In light of the NOAH-AFNET6 and ARTESiA trials, how would you approach the decision regarding anticoagulation for patients with incidentally-detected AF <24 hrs on pacemakers/defibrillators?
Finding the right answer for subclinical atrial fibrillation is sometimes hard to tease out the subtleties. The 2023 ACC/AHA/HRS atrial fibrillation guidelines were published in Jan 2024 (Joglar et al., PMID 38033089) and a section (6.4.1) is dedicated to patients with CIED without prior atrial fibr...
Should all kidney transplant patients be started on statin therapy post operatively given their increased risk of CVD?
A kidney transplant is not an indication for statin therapy per se. The 2018 cholesterol guidelines list CKD (but not ESRD or Transplant) as a risk-enhancing factor. I would guide the decision to use statin therapy based on the patient's risk as assessed for non-transplant patients. Having said that...
How do you risk stratify patients with different WHO groups of pulmonary hypertension prior to non-cardiac surgeries?
First, I would direct the audience to recent AHA guidelines on the perioperative management of PH in non-cardiac surgery. Rajagopal et al., PMID 36924225In general, the severity of pulmonary hypertension and relevant comorbidities are likely more important than the WHO group. In patients with CTEPH,...
What is your approach to GDMT uptitration (particularly dosing for ARBs/ARNIs/MRA) if there is further evidence of renal dysfunction, especially in situations with worsening AKI on CKD?
Titration of RAAS inhibitors in the setting of AKI on CKD is challenging. First, look at the patient: if they have an increase in Cr after an increase in the RAAS inhibitor but no/stable HF symptoms and appear euvolemic on examination, then I will decrease diuretic therapy and see if the Cr improves...
What is the optimal approach to treat isolated diastolic hypertension?
Isolated diastolic hypertension occurs less commonly in the adult population, where the majority of the outcome trials in hypertension have been conducted. Much of the treatment of hypertension in younger patients is extrapolated from these trials. In my practice, I look more closely for secondary c...
Would you consider switching choice of P2Y12 inhibitor for patients with ISR (non-ACS presentation), with acceptable bleeding risk?
There is no need to change P2Y12 inhibitor in case of ISR without ACS. There are no studies that suggest such approach is indicated or can be helpful. Also, patients are taking their current P2Y12 inhibitor for a while and they are used to the medications. Changing the medication can raise cost with...