Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Is it safe to use statins in IIM patients if HMGCR antibodies are negative?
Absolutely, yes. Statins are a very important drug for patients with cardiovascular disease and should be given to most patients with myositis except patients with known immune-mediated statin myopathy or HMGCR Positive antibody. I would monitor CK levels before and 3 and 6 months post statin, as we...
Would you modify your initial treatment for a patient with de novo metastatic HR- HER2+ breast CA who has cardiomyopathy at baseline (EF < 35)?
Fortunately, the incidence of cardiotoxicity with the combination of a taxane, trastuzumab, and pertuzumab is very low, and thus I would be comfortable starting with this treatment (preferably with weekly paclitaxel) and monitoring her with periodic echocardiograms (every 4-6 cycles, in the absence ...
When is it necessary to monitor the QTc interval in patients on hydroxychloroquine?
The answer to this question is not straightforward mainly because there are limited data in this area. Hydroxychloroquine and Chloroquine directly affect cardiac repolarization and are associated with QT prolongation. Given this, there is an argument for getting a baseline ECG for patients initiatin...
For a patient with cardiac sarcoma, is there a minimum ejection fraction to proceed with adjuvant radiation therapy?
Adjuvant radiation therapy is often indicated for cardiac sarcoma because tumor resections are often incomplete or done with close margins. However, cardiotoxicity is a major issue, especially since patients will often receive doxorubicin-based chemotherapy, which has inherent cardiotoxicity. That b...
How does evidence of cerebral amyloid angiopathy/microbleeds affect choices for secondary stroke prevention in patients with a history of ischemic stroke and atrial fibrillation?
This is a discussion I have with the patient, mentioning that the positive predictive value of cortically based cerebral microhemorrhages is not absolute, especially when there is a small number of them and there are no other signs of small vessel disease (such as FLAIR changes or enlarged peri-vasc...
What is your approach to CLL in patients with atrial fibrillation and/or on anticoagulation?
Before the availability of venetoclax, the only approved targeted oral therapy for patients with CLL was ibrutinib. Given the lack of alternative options, patients with atrial fibrillation and/or patients on anticoagulation were treated with ibrutinib. Use of anticoagulation with ibrutinib can incre...
How do you counsel patients regarding the cardiovascular risk of febuxostat?
We understand that gout is a very inflammatory state and in general that inflammatory states can be a risk factor for cardiovascular disease. Although studies such as this have shown an increased all cause and cardiovascular mortality in febuxostat group compared to allopurinol group, it is importan...
Given the "LDL Paradox", in which RA patients with the highest levels of inflammation can have ultra-low levels of LDL (<70), how do you approach initiation of statin therapy in these patients?
Evaluate lipids at the time of remission/low disease activity and if elevated and the patient is a good candidate for statin therapy, initiate a statin using criteria for the general population.
Do you consider 10MV beams safe in a patient with an implantable cardiac device?
I follow the AAPM TG-203 which considers beams up to 10 MV photons to be non-neutron producing. For example, in a lung, abdominal, or pelvis tumor, I find the reduction in total body dose worthwhile to use 10 MV.
What are your considerations for peri-operative anticoagulation in patients with a mechanical heart valve undergoing a major noncardiac surgery?
For a patient with a modern (e.g St Jude bi-leaflet) mechanical valve (with or without AF) and who does NOT have a h/o of stroke or TIA, the available evidence suggests that "bridging" may have more risk than benefit: See Kovacs et al., PMID 34108229 and Siegal et al., PMID 22912386. Based on this e...