Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Based on most current research regarding the more widespread use of class IC antiarrhythmic drugs, what are your prescribing practices in patients with coronary artery disease?
Fair question, as we know the definition of "structural heart disease" is unknown. In the trial, it was likely ischemia driving the poor outcomes, so I will get stress with imaging on everyone >50 years old (CAD risk). Given the common finding of "questionable" stent placement in the community, I wi...
In a patient with cardiac light chain amyloid who has significant heart failure symptoms, including inotrope dependence at presentation, how much clinical benefit does treatment provide?
In patients with cardiac light chain (AL) amyloidosis who present with significant heart failure symptoms and inotrope dependence, the clinical benefit of treatment is a complex and nuanced issue. This scenario often reflects an extreme end of the disease spectrum. Historically, patients with advanc...
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...
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...
Do you have a strict age cut-off for not referring patients for CABG evaluation?
Simple answer: No. The risks and benefits of any procedure should be assessed and balanced for all patients, regardless of age, and decision-making should be undertaken in the context of the patient's overall health status, comorbidity burden, geriatric syndromes (esp. frailty and cognitive impairme...
How long do you recommend waiting before competitive sports athletes resume sports activities following inpatient management for an NSTEMI?
Great question. Assuming complete revascularization, and they are low risk, no symptoms, normal LVEF, no residual CAD stenosis over 70% and then I usually exercise them after 3 months to confirm no ischemia. I do a full 3 months of rehab, get LDL to under 60 and manage other CAD risk factors.
What is the minimum duration of weeks on anticoagulation in which you would consider performing a DCCV without the need for TEE, provided the patient is an excellent historian and otherwise reliable?
If this were a board question, I agree with the guideline-listed answers here - it's 3 weeks. The most recent 2023 ACC AHA hours Atrial Fibrillation Guidelines by Joglar et al., PMID 38033089 are consistent: In patients with AF duration of ≥48 hours, a 3-week duration of uninterrupted therapeutic an...
How do you use NT-proBNP in patients with chronic kidney disease or end-stage kidney disease, given that these conditions can affect NT-proBNP levels?
NT-proBNP is most useful for (a) diagnostic uncertainty in patients who present with dyspnea, and (b) prognostication in heart failure. It is released as a result of ventricular wall stress. In CKD, the clearance of NT-proBNP is impaired, leading to elevated levels. In late-stage CKD and ESRD, volum...
Under what clinical circumstances, if any, would you prescribe fenofibrate along with statin therapy?
Yes, I do sometimes combine fibrates and statins. Usually, it’s in the setting of needing to treat severe hypertriglyceridemia with the fibrate in a patient who also has hypercholesterolemia and an indication for a statin. If a patient is on a statin and still has mild to moderate hypertriglyceridem...
What would be your approach for the management of asymptomatic, severe AS with a peak velocity of 5 m/s in an otherwise physically active patient in their mid-90s without significant co-morbidities?
The EARLY TAVR trial (Généreux et al,. PMID 39466903) showed that in patients with asymptomatic severe AS, early TAVR was associated with a 50% reduction in the primary composite endpoint of death, stroke, or unplanned hospitalization for cardiovascular causes compared to clinical surveillance over ...