Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How would you choose between left bundle pacing and CRT-P in a patient with a new high-degree AV block and pre-existing reduced LVEF, who does not otherwise meet the criteria for CRT-D?
This is a unique population described in the 2018 ACC AHA HRS Bradycardia guidelines - defined as LVEF 35-50% with >40% pacing, essentially what's left when you subtract the 2013 NEJM BLOCK HF trial = LVEF <50% minus all the SCD-HeFT LVEF <35% on GDMT and a small population of MUSTT LVEF <40% induci...
What is your preferred PO afterload-reducing agent immediately after being weaned off inotropic support in cardiogenic shock?
Once inotropic agents have been successfully weaned and hemodynamics support the initiation of oral guideline-directed medical therapy, then I often start with oral afterload-reducing agents, but there is limited data regarding which agent is superior or provides the maximal benefit. Anecdotally, if...
What is your approach to screening for complete heart block in an asymptomatic pregnant patient with negative SSA and positive SSB antibodies?
There are case reports of congenital heart block (CHB) due to anti-RNP antibody in anti-SSA/SSB-negative pregnant women (Izmirly et al., PMID 28709760). However, it is so rare that too many fetal heart monitoring tests would need to be done to identify these rare events. The amount of time and money...
What precautions do you take prior to CABG in a patient with sickle cell trait?
Surgery and anesthesia are safe in sickle cell trait (HbAS) when normal precautions are followed. In patients with HbAS and control subjects, the frequency of anesthetic, surgical, and postoperative complications was similar; however, most patients were young, and few thoracic procedures were includ...
Is there utility in obtaining pericardial fluid autoimmune labs such as ANA or RF in patients with recurrent idiopathic pericardial effusions, but no other clinical or serologic evidence of rheumatic disease?
There seems not to be a consensus literature on this topic, so my answer is based on common sense rather than science. The first step is a detailed history (including family history) and physical examination looking for evidence of inflammatory joint disease with/without other findings that might fo...
When would it be reasonable to consider enhanced external counter-pulsation therapy in patients with refractory angina despite maximally tolerated anti-anginal therapy?
I would exhaust all options for coronary revascularization first.
When would you consider percutaneous mechanical aspiration of vegetation in right-sided endocarditis?
Percutaneous options for right-sided endocarditis is a growing field. We have utilized it at our institution with the AngioVac in complex ACHD (Eilers et al., PMID 36448943); others have utilized Inari (Whitbeck and Chambers, PMID 35880845 and Bisleri et al., PMID 33155779). Some have even ventured ...
How would you manage a patient with CML in chronic phase with a significant cardiac history, such as heart failure with reduced ejection fraction or arrhythmia?
The management of a patient with Chronic Myeloid Leukemia (CML) in the chronic phase who also has a significant cardiac history, such as heart failure with reduced ejection fraction (HFrEF) or arrhythmia, involves a multidisciplinary approach that includes both hematologic and cardiac care (cardio-o...
What is a reasonable atrial fibrillation percentage burden that would benefit from systemic anticoagulation for a patient with an elevated CHA₂DS₂-VASc score?
Patients with implanted devices can have an accurate measure of their AF load which has raised the question of whether ANY AF should be anticoagulated. Healey et al., PMID 22236222 is often erroneously quoted as saying that 6 minutes is all that is needed. That was their cutoff for inclusion as subc...
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...