Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
When would be the appropriate time to refer an asymptomatic young adult with unicuspid AV s/p valvuloplasty during adolescence for AVR following exercise stress TTE findings demonstrating increase in aortic valve mean gradient from 40mmHg to 70mmHg (achieving 15 METS)?
Great question and the correct answer is: ALWAYS feel free to refer a complex case like this to advanced pedi/ACHD centers. In terms of whether the patient will need or get a prompt AVR… it DEPENDS!First, we need to prove severe aortic stenosis (mean of 70 mmHg seems legit). As is often the case in ...
For which patients do you prioritize ambulatory blood pressure monitoring over self-measured blood pressure?
Self-measured blood pressure can be useful for anyone who has been diagnosed with hypertension or is found to have office blood pressures (BPs) above normal (120/80 mm Hg).1 Correctly measured home BPs inform my decision on when to start antihypertensive medications or when to adjust antihypertensiv...
Do you routinely use vasopressin in the management of RV failure leading to shock state in the absence of an obvious treatable cause such as infarction or PE?
It seems that there is a vasopressin dose-dependent effect on PA pressures. The doses we usually use for septic shock (0.03 or less) have some degree of pulmonary vasodilation (for example, Tsuneyoshi et al., PMID 11373409). Higher doses may have the opposite effect (Leather et al., PMID 12441768). ...
Would you consider a primary prevention ICD in a patient with hypertrophic cardiomyopathy and non-sustained ventricular tachycardia, in the absence of any other high risk predictors for sudden cardiac death?
Nonsustained ventricular tachycardia in hypertrophic cardiomyopathy without major risk factors (IIa primary prevention risk factors in 2020 ACC AHA HCM guidelines – max wall thickness >3 cm, FH SCD, LVEF <50%, unexplained syncope, LV apical aneurysm) remains a minor risk factor in adults (IIb consid...
How would you approach the management of a patient with a new diagnosis of cardiomyopathy in pregnancy without clinical signs of heart failure?
This is a great question. I think the timing of the cardiomyopathy and if it was incidental (although not sure why you would check an echo if there were no symptoms).Peripartum CM is a difficult entity to manage. In some cases, the optimization of patients with GDMT is limited due to post-partum bre...
When would you consider tapering glucocorticoids in a patient with ICI-associated myocarditis?
Once troponins start to decrease, I start the steroid taper and follow troponin levels. If they rise, I slow the taper. I also get serial ECGs, esp if there were arrhythmia manifestations of myocarditis. Don't forget to assess for the need for PJP prophylaxis with Bactrim or pentamidine and PPI sinc...
How would you choose between left bundle pacing and CRT-P in a patient with a new high-degree AV block and pre-existing reduced LVEF, who does not otherwise meet the criteria for CRT-D?
This is a unique population described in the 2018 ACC AHA HRS Bradycardia guidelines - defined as LVEF 35-50% with >40% pacing, essentially what's left when you subtract the 2013 NEJM BLOCK HF trial = LVEF <50% minus all the SCD-HeFT LVEF <35% on GDMT and a small population of MUSTT LVEF <40% induci...
What is your preferred PO afterload-reducing agent immediately after being weaned off inotropic support in cardiogenic shock?
Once inotropic agents have been successfully weaned and hemodynamics support the initiation of oral guideline-directed medical therapy, then I often start with oral afterload-reducing agents, but there is limited data regarding which agent is superior or provides the maximal benefit. Anecdotally, if...
What is your approach to screening for complete heart block in an asymptomatic pregnant patient with negative SSA and positive SSB antibodies?
There are case reports of congenital heart block (CHB) due to anti-RNP antibody in anti-SSA/SSB-negative pregnant women (Izmirly et al., PMID 28709760). However, it is so rare that too many fetal heart monitoring tests would need to be done to identify these rare events. The amount of time and money...
What precautions do you take prior to CABG in a patient with sickle cell trait?
Surgery and anesthesia are safe in sickle cell trait (HbAS) when normal precautions are followed. In patients with HbAS and control subjects, the frequency of anesthetic, surgical, and postoperative complications was similar; however, most patients were young, and few thoracic procedures were includ...