Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What is a reasonable approach to monitoring mechanical valve function if systemic anticoagulation needs to be held in the setting of an acute intracranial hemorrhage?
Most modern mechanical aortic valves can tolerate being off anticoagulants for up to 2 weeks. The mitral valves however are more of a concern and I generally recommend an echocardiogram at 1 week and then reassess the risk of rebleed versus valve thrombosis.
Do you use tolvaptan for management of hyponatremia related to heart failure given the side effect profile and lack of mortality benefit seen in a previous trial?
In general, I have not found this to be helpful even though the trials showed a small benefit for sodium levels during the hospitalization only (none at longer-term follow-up). The trials did not show mortality benefit as stated in the question stem - nor did they show benefit for other meaningful o...
When you send for molecular studies for polycythemia vera, what are the mutations that predict increased cardiovascular risk?
This is a very prescient question since arterial and venous thrombosis are frequent events in MPN patients who have polycythemia vera (PV) and these events can precede the diagnosis of PV by several years. Most importantly, we also now know that just having a JAK2 V617F mutation without any clinical...
What are your diagnostic and management approaches beyond statin therapy for hyperlipidemia in young adults with significantly elevated LDL levels in isolation (i.e. reasonable calcium score, normal lipoprotein A levels)?
It depends on other factors such as the presence of diabetes and a family history of early CAD. If either of these is present, I push hard with statins and possibly add Zetia to get the LDL down to 60-70. I also push for lifestyle changes such as moderate daily exercise, weight loss, and reducing li...
Can CAR T cell therapy be considered for heart transplant recipients with concurrent lymphoproliferative disorders?
The short version of my answer is: Possibly Yes. There is a very limited evidence from the literature in this topic, however, I will base my explanation on the following case reports: McKenna et l., PMID 37129856, Dang et al., PMID 33002249, Portuguese et al., PMID 36575360.The provided case reports...
Given recent studies investigating ICI myocarditis biomarkers such as Temra CD8+ cells, is there now a growing selection of clinical biomarkers, besides BNP and troponin, being measured routinely in ICI myocarditis cases?
At this time, Temra CD8+ cells have been shown in research experience only and not measured routinely. We hope that in the near future, we will have better, more specific biomarkers than troponin and BNP for the diagnosis of ICI myocarditis given how difficult it is. Diagnosis of ICI myocarditis is ...
Should patients with co-existing moderate-severe valvular disease (particularly AS and MS) and malignancy requiring radiation therapy undergo more frequent surveillance surface echocardiograms?
The answer is yes, for some patients with baseline moderate to severe valvular heart disease receiving radiation, with the heart in the radiation field (i.e. left breast, lung, esophageal cancers), they should have more frequent surveillance echocardiograms.The 2020 ACC/AHA valve guidelines recommen...
For patients maintained on antiplatelet monotherapy post-DAPT following PCI, what is your recommendation for holding antiplatelet therapy prior to non-cardiac surgery?
As clopidogrel recently has gained traction as a preferred long-term monotherapy to aspirin but is generally not allowed to be administered for a week prior to surgery I have “bridged” with 81 mg aspirin.
For patients presenting with spontaneous coronary artery dissection, what other non-cardiac/vascular work-up can be considered to further risk stratify them as a predictor for any future cardiovascular events?
Our general practice has been to do a CTA head to pelvis to evaluate for FMD and/or aneurysmal disease.
Is there emerging and compelling enough evidence to maintain patients on P2Y12i monotherapy (in lieu of aspirin) following completion of DAPT?
Yes, a recent meta-analysis favors clopidogrel over aspirin for long-term therapy.Also, studies are coming out suggesting a shorter duration of DAPT.Here's one:Choi et al., PMID 36169938