Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What is your approach to initiating spironolactone in patients with end stage kidney disease and heart failure?
Not sure that we have a consensus answer for this question, but spironolactone in hemodialysis patients likely causes more harm than good.There are data suggesting that spironolactone increases the risk for arrhythmia (heart block or bradycardia; Mc Causland et al., PMID 36763641) and hyperkalemia (...
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...
Are there instances when you recommend 48-hour ambulatory blood pressure monitoring over typical 24-hour studies for evaluation of patients with hypertensive kidney disease?
48-hour ambulatory BP monitoring can be helpful in gathering BP data for patients on hemodialysis with 3-day per week dialysis treatments. However, it is rarely done outside of research.
When do you perform routine defibrillation testing at the time of subcutaneous ICD implantation?
Perhaps the best way of answering this question may be broadly approaching why do we perform defibrillation threshold (DFT) testing and what factors affect an implanter's success (for both subcutaneous and transvenous ICD). To answer the first question, we hope that DFT will simulate real-life funct...
If a pregnant patient with a mechanical heart valve takes warfarin throughout her pregnancy, what are the chances that the fetus will be harmed?
Warfarin is effective for thromboembolic prevention in pregnant patients with mechanical valves. There is however an overwhelming evidence that warfarin taken during pregnancy is deleterious to the fetus. Its use during the first 6–12 weeks of gestation can be associated with important fetal complic...
Are there still clinical situations in which you deliberately treat patients with a DOAC besides apixaban?
Thank you for your question. Apixaban has been my preferred agent for a long time for patients requiring therapeutic anticoagulation. Apixaban’s lower bleeding risk was shown prior to and now has additional evidence to support this with the COBRRA trial. The risk is also ameliorated by the safety in...
How soon after an acute upper GI bleed do you restart therapeutic anticoagulation in a patient with atrial fibrillation and a high thromboembolic risk (CHA₂DS₂-VASc ≥4)?
In real-world inpatient practice: ~72 hours after endoscopic control for high-stroke-risk AF with stable hemoglobin and no rebleeding. Extending hold to 5–7 days if the lesion is high risk or the bleed was severe.
What is your stepwise approach to supporting the RV in the setting of RV failure from unrevascularized RCA disease in an unstable patient in the absence of RP impella availability?
Physiology RV infarct → preload dependent, afterload sensitive, rhythm/AV-synchrony dependent. Aim to optimize preload (not too little/not too much), reduce RV afterload, maintain perfusion pressure, preserve sinus/AV synchrony, and relieve ischemia where possible. 1) Immediate stabilization (fir...
What is your approach to checking preoperative cardiac biomarkers such as troponin and BNP?
While now recommended as a means of risk stratification for those over 65 years with cardiac risk factors across all three guidelines (AHA/ACC, CCS, ESC), we mostly reserve the use of biomarkers preoperatively for patients in whom we are on the fence for obtaining additional cardiac workup. We view ...
Do you accept a decline in eGFR during aggressive diuresis for heart failure if the patient is successfully decongesting, given data suggesting modest eGFR decline with improved congestion may still be associated with lower mortality?
Yes, I accept a modest decline in eGFR during diuresis in patients with heart failure. Previous studies of patients hospitalized with acute decompensated heart failure have shown that mortality and readmission rates are reduced by effective decongestion even if the creatinine rises. The study by Oka...