Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What are your top takeaways from ACC 2023?
My “top 3” takeaways from ACC23 are; CLEAR Outcomes trial which demonstrated that bempedoic acid reduced LDL by about 20% and improves long-term CV outcomes compared with placebo among patients with established ASCVD or high risk for it, and intolerance to statin therapy (though a minority of patien...
How do you manage anticoagulation bridging for outpatient ESKD patients given concerns for bleeding risk with enoxaparin in this population?
I don't think we know what is the best route to take. Personally I still usually give lower doses of enoxaparin but it all depends on the circumstances. Why the patient needs anticoagulation? Does the risk of hospitalization out way the risk of increased bleeding from enoxaparin? Can the patient get...
What would be the utility of calcium scoring for the evaluation of low-flow low-gradient aortic stenosis, and what cut-off values typically fall within the severe range?
Echo findings can be equivocal in as many as 40% of patients. Multiple studies have demonstrated a good correlation of calcium score and the severity of AS. A calcium score of 1300 in females and 2000 in men are defined cutoffs. In low flow low gradient AS with diminished EF a dobutamine echo should...
What structural features preclude a transcatheter edge-to-edge repair in a patient with severe symptomatic tricuspid regurgitation?
Evidence of severe calcification in the annulus or subvalvular apparatus Evidence of moderate to severe calcification in the grasping area Excessive chordae structure in the grasping area Presence of perforation in the grasping area Leaflet length < 8 mm Septolateral coaptation gap > 10 mm Severe l...
What is your approach to abbreviated DAPT in post-PCI patients (ACS and non-ACS) with high bleeding risk?
Current guidelines suggest dual antiplatelet therapy (DAPT) for a minimum of 6 months after PCI for patients undergoing PCI for stable CAD (non-ACS) and 1 year of DAPT after PCI for patients undergoing PCI for ACS. Patients at higher bleeding risk (HBR) after PCI, however, may not be able to tolerat...
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...