Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How frequently and when should lipoprotein A levels be monitored?
Lp(a) levels are fairly stable throughout a person's life, which is why the Europeans recommend checking Lp(a) in everyone at least once. Some conditions can increase the level like CKD and hypothyroidism; it’s also an acute phase reactant. Menopause can increase it as well, so one might want to rec...
Given that there are a fair number of myocarditis cases without a troponin elevation, how do you clinically approach the diagnosis of myocarditis?
If clinical suspicion for myocarditis is not based on elevated troponin there needs to be some objective evidence for it. These would be CRP/sed rate/cardiac MR/biopsy. Unlikely to pursue the last step if the first three are all normal.
How do you decide when to refer patients with obstructive hypertrophic cardiomyopathy for alcohol septal ablation versus septal myectomy?
If a patient with obstructive HCM remains severely symptomatic despite being on maximal standard-of-care medical therapy, (beta blockers, non-dihydropyridine calcium channel blockers, addition of disopyramide for combination therapy, or a cardiac myosin inhibitor if appropriate), septal reduction th...
What are your outpatient surveillance strategies (biomarkers, imaging, symptoms) to monitor response to treatment for ATTR amyloidosis with cardiac involvement?
I continue it indefinitely. Limited survival data shows a beneficial effect for at least 5 years with survival on the drug of 55% compared to 37% on placebo.Elliot et al., PMID 34923848However, if patients deteriorate dramatically on therapy and are class IV NYHA, I discuss with patients and family ...
How do you re-stratify patients with a primary prevention ICD in need of a generator change if their LVEF has improved to >40% and they have not previously required any device therapies?
This is an important question on which there remains a lack of consensus. We had tried to address this through an observational study which was published a few years back:(Appropriateness of primary prevention implantable cardioverter-defibrillators at the time of generator replacement: are indicati...
For patients on immune checkpoint inhibitors presenting with chest pain, dyspnea, fatigue, and troponin elevation, would you recommend early initiation of high dose steroids for empiric treatment of ICI myocarditis while pursuing workup with coronary angiogram, echocardiogram, and/or cardiac MRI, or wait until alternative etiologies have been ruled out?
This question raises an important point that the clinical presentation of ICI-associated myocarditis often overlaps with other cardiovascular disorders, including acute coronary syndrome, chronic CAD, congestive heart failure, and other nonischemic cardiomyopathies. Therefore, prompt initiation of w...
How do you manage patients blood pressures while on anti-angiogenic TKIs?
Advise patients to take BP daily, and inform us if the BP is high.
Should all patients with a remote history of immunotherapy, chemotherapy and/or radiation therapy have a baseline TTE regardless of ASCVD risk?
The current ASCVD risk assessment calculators we have available do not contain cancer-specific parameters and thus are inadequate for accurate assessment of a cancer survivor's risk of developing CHF and ischemic heart disease. If patients have received mediastinal radiation therapy or high-dose ant...
What is your approach to considering geriatric patients for complex PCI given their overall frailty and increased risk of complications such as bleeding and stroke?
I would do everything I could with respect to medical and lifestyle therapy for such a patient. They are at very high risk for a bad outcome in the cath lab.
When would you consider initiating GDMT for new onset HF in the geriatric population?
I would always treat with GDMT but would start low and slowly advance watching for AE's.