Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What are your preferred femoral vascular closure devices for severely calcified femoral artery vessels following PCI, especially with higher sticks, and why?
One should not have high sticks. The femoral access should be methodical. One should make sure to mark the inferior border of the inguinal ligament and stay below the ligament. I always use a micropuncture needle and obtain fluoroscopy to assess the position of the needle in relation to the femoral ...
For patients admitted with acute decompensated heart failure, do you wait until the patient is euvolemic before ordering a TTE?
For patients with newly diagnosed CHF, I always get a TTE prior to discharge to establish a baseline study. It would help me identify valvular disease and pulmonary hypertension, or other structural problems. If a TTE would help you distinguish CHF from other volume overload conditions, then I would...
Is there any role for adjusting how long to hold anticoagulation perioperatively based on DOAC dose?
The PAUSE trial evaluated perioperative management of DOACs. However, only 20% and 16% of patients were on prophylactic doses of apixaban and rivaroxaban, respectively. It was suggested to hold the drugs for two days, and one day before high-risk and low-risk procedures. A useful review of this appr...
What would be the minimum duration of IL-1 therapy you would recommend for chronic pericarditis?
There is no great data. In my experience, it depends on the reason for IL-1 initiation, the severity of cMRI findings, and how chronic the pericarditis was prior to initiation.. If this is used as a steroid-sparing strategy or steroid weaning, probably 1-2 years minimum. In Rhapsody, the majority fl...
What would be a reasonable next-step approach to the evaluation of mild LV systolic dysfunction with regional wall motion abnormalities on TTE in a patient receiving carboplatin/paclitaxel for ovarian cancer without any cardiac symptoms?
Given the regional abnormalities observed, I would obtain stress testing to determine if an ischemic component may be contributing. If stress testing is negative, I would start low-dose GDMT for presumed non-ischemic cardiomyopathy.
What is a reasonable stepwise approach to diagnostic imaging when there is ongoing concern for cardiac amyloidosis?
Abnormalities on CMR are not diagnostic of cardiac Amyloidosis. Although LGE, abnormal ECV, and abnormal T1 are findings commonly seen in Cardiac amyloidosis, the absence of one or more does not rule out amyloid. In the setting of increased LV thickness and clinical suspicion of amyloid, I would hav...
How long do you recommend waiting after variceal bleeding and banding before a transesophageal echocardiogram can be performed safely?
In the exact wording of this question, the scenario that is being presented is that the patient has had a variceal hemorrhage (VH) recently and urgent banding has already been performed to stop the VH (so that the concern would be of the TEE probe knocking off a band that is actively treating an eso...
Do you consider bleeding risk in elderly, frail patients with atrial fibrillation to be similar for all NOACs?
I believe that apixaban carries a lower risk of bleeding, with particular reference to GI bleed, when compared to rivaroxaban and dabigatran. This is true in the population of AF patients at large and most probably in frail patients as well.
Is there any evidence to support further uptitration of dobutamine beyond 5mcg/kg/min for patients with advanced HF and/or cardiogenic shock, or should further investigation into potential MCS be considered at that point?
When a patient with acutely decompensated heart failure and shock is exhibiting insufficient perfusion in spite of a given level of support, whether pharmacologic or mechanical, it is appropriate to pause and ask why. Options at this point could include an escalation of inotropic therapy (dose escal...
What is your clinical approach to deprescribing vs continuing low-dose aspirin used for primary prevention in older adults who are already taking this medication?
I generally continue a low-dose aspirin in patients at higher risk (e.g., diabetes, CKD, strong family history) who would be at risk for a significant reduction in quality of life were s/he to have a cardiac/vascular/cerebrovascular event, provided there is no history of significant anemia (transfus...