Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What is your approach when a patient has concomitant acute decompensated heart failure and rapid atrial fibrillation?
Is the patient stable? If not stable, then I would move towards immediate cardioversion. If stable (good BP) but poor oxygenation, then diuretic with consideration of metoprolol, digoxin, or amiodarone. If unable to tolerate BB due to lower BP, then would lean towards amiodarone or digoxin. Anticoa...
For which stroke patients, if any, do you recommend implantable loop recorder for long-term cardiac monitoring and why?
Fantastic and pertinent question! I won't pretend that I have an answer, but do have a few thoughts that may help frame further discussion: We derive our evidence for the efficacy of anticoagulation in stroke prevention from older trials designed to answer that specific question (SPAF, etc.). In the...
What is your typical approach to the use of beta blockers in the setting of recent cocaine use amongst patients presenting with cocaine-related MI, arrhythmias, or new-onset heart failure?
I favor using or continuing non-selective beta-blockers in patients presenting with acute cardiac manifestations of recent cocaine use. My preferred agent in this setting is carvedilol.
How do you balance the risks and benefits of stimulant treatment in patients with poorly controlled hypertension?
The short answer is that there are no clear cutoffs to clearly guide management, and often decisions are guided by shared decision making with patients and relevant specialties (psychiatry, primary care, cardiology).Clinical factors which may prompt you to stop or reduce stimulants: Elevated BP that...
How do you decide between obtaining routine, outpatient ETT versus stress TTE when screening for CAD, especially given insurance company preference on ETTs?
Before getting into the opinion on the above question, it has to be said that the practice of utilizing any stress test to "screen" for coronary artery disease is currently frowned upon, and it is recommended that proceeding with a diagnostic workup should be based on the patient being both at risk ...
What should the LDL target be in patients with prediabetes and high lipoprotein (a) with family history of coronary artery disease?
I don’t think that using Lp(a) to guide treatment is quite ready for prime time yet. It’s an independent predictor of risk compared to the rest of the lipid panel, but as far as I am aware, we do not yet have data that treating people based on it makes a difference. What I may do in this scenario is...
What is a reasonable minimal duration of DAPT following drug coated balloon angioplasty for ISR lesions?
A reasonable duration of dual antiplatelet therapy (DAPT) following drug-coated balloon (DCB) angioplasty for in-stent restenosis (ISR) is at least one month. A JAMA Cardiology review (2025) suggests a minimum of 30 days of DAPT. A JACC review (2022) recommends the following durations: stable corona...
In what scenario could brachytherapy be favored over CABG for recurrent ISR lesions with two layers of stent refractory to cutting balloon or laser, provided the patient is a good surgical candidate?
This is a very interesting question that is nuanced by the specific situation. Knowing the specific anatomy is important. Whether this is single- or multivessel disease, and whether it is focal or diffuse, will influence the decision, as will patient preference.I approach this using the information ...
Besides anticoagulation, how would you approach the management of a large LV thrombus newly seen on TTE in patients on VA-ECMO?
This is a highly morbid condition due to coexisting high bleeding and thromboembolic risk in acutely ill patients. No guidelines exist to direct the best strategies.In addition to optimizing or changing anticoagulation strategy and depending on the location of the thrombus and co-morbidities, the fo...
Do you prefer a loading dose of 300mg or 600mg plavix for patients presenting with NSTEMI or unstable angina about to undergo LHC?
Interesting question! As a rule of thumb, 600mg loads faster than 300mg. Therefore, it is more important when you anticipate your ballooning/stenting happening sooner rather than later (within minutes/hours). Per guidelines, Plavix is preferred over prasugrel/brilinta for stable angina (which was no...