Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
When should we consider screening patients with systemic sarcoidosis for cardiac involvement using cardiac MRI or PET given their high risk for sudden cardiac death and discrepancies between reported cardiac symptoms (2-5%) and evidence of cardiac inflammation on advanced imaging and autopsy findings (>25% of cases)?
The current guideline recommendations are only to pursue advanced imaging in patients who have symptoms, EKG abnormalities or abnormal echocardiogram. In our experience, we have been able to capture patients with strict assessment of these criteria. However, it certainly can be challenging in patien...
When should cardiac MRI be obtained alongside standard echocardiography for outpatient monitoring of the progression of chronic aortic regurgitation?
Aortic regurgitation impacts left ventricle with pressure and volume overload. In a patient with chronic, particularly moderate to severe or severe aortic regurgitation, the drop in left ventricular ejection fraction, increasing left ventricular dilation, and patient developing symptoms dictate the ...
Which molecular biomarkers do you favor to risk stratify patients (without CV risk factors) before and after undergoing treatment with cardiotoxic cancer treatments?
In general, troponin, NTproBNP or BNP, and lipid panel are the main biomarkers I use for CV risk stratification prior to cancer therapy. Baseline troponin and NTproBNP are primarily useful for cancer therapies that may cause cardiomyopathy or myocarditis (i.e. anthracyclines, anti-HER2 therapies, VE...
Is there a validated risk prediction model you favor to risk stratify patients for cardiotoxicity prior to initiation of chemotherapy?
I would recommend the HFA-ICOS risk calculator as recommended by the 2022 ESC/ICOS Cardio-Oncology guidelines. There is a great discussion here:Strategies for risk stratification and cardiovascular toxicity prevention in patients with cancerAnd there is an easy-to-use version online and on the ESC P...
Would you consider starting an ACE inhibitor on a patient without CVD or heart failure prior to initiation of anthracyclines to reduce the overall risk of myocardial toxicity?
Even though the patient does not have CVD or heart failure history, there are still factors to consider if they are at higher risk for anthracycline cardiac toxicity: Lower EF at baseline, significant valvular heart disease, prehypertension/hypertension, diabetes, obesity, advanced age, any subclini...
Among asymptomatic patients with structurally normal TTE undergoing treatment with anthracyclines or alkylating agents that develop mildly elevated BNP and/or troponin levels, would you consider referring them for cardiac MRI to evaluate for subclinical cardiotoxicity?
If TTE images are adequate and the echo is entirely normal, but BNP and/or troponin levels are mildly elevated after anthracyclines or alkylating agents, differential diagnosis includes HFPEF, ischemia, or subclinical cardiotoxicity. If Echo shows unexplained significant LVH, CMR is reasonable to ru...
Would you empirically elective to anticoagulate patients with a remote (i.e. >10 year) history of paroxysmal atrial fibrillation presenting with newly diagnosed CVA, presumed cardioembolic in etiology, without any documented recurrence of AF?
Yes, I would, especially if the etiology is suspicious for being cardio-embolic. As per the ACC/AHA/HRS 2019 Updated Guidelines for AF management, patients with non-sex-related CHA2DS2-VASc score of >/=1 should be offered oral anticoagulation. For this particular patient, that score would be 2.
Would you start an amiodarone load for new onset atrial fibrillation with RVR intermittently in normal sinus rhythm to further suppress AF recurrence in the acute setting?
The answer to this question really depends on the clinical scenario. Does the patient have a structurally normal heart? Is this a post-op setting where the AF is expected to settle down with time? Age of patient? Co-morbidities? Candidacy for less toxic drugs or ablation? If this were a post-op pati...
When would you consider discharging post-TAVR patients on outpatient mobile cardiac telemetry with baseline right bundle branch block without further signs of conduction abnormalities 24-48 hours after the procedure, given risk of developing later-onset conduction abnormalities?
I agree with Dr. @Dr. First Last's comments. Preexisting RBBB is one of the most potent predictors for need development of significant AVB warranting a pacemaker post-TAVR and this represents roughly 10% of patients undergoing the procedure. Though there have been expert panel recommendations (Rodés...
What is your preferred pharmacologic agent for recurrent VT suppression in arrhythmogenic right ventricular cardiomyopathy?
In general, I like VT/PVC-focused beta-blockers which tend to be nadolol and propranolol (for example in CPVT, nadolol bested other BBs - Heart Rhythm 2016 Leren et al and propranolol over metoprolol in VT storm - JACC 2018 Chatzidou et al). According to the 2019 HRS expert consensus statement on ar...