Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Do you routinely hold SGLT2 inhibitors prescribed for CHF or CKD in acutely ill patients upon admission to the hospital?
Thanks for this great question. The use of SGLT2 inhibitors in the hospital has been increasing dramatically, given their great effects on CKD and CHF for both diabetic and non-diabetic patients. There are simple direct contraindications for using SGLT2s, which would include patients with ketosis in...
What has been your stepwise approach to oxygenation, including when to consider the use of inhaled nitric oxide or epoprostenol, in refractory hypoxemia due to cardiogenic pulmonary edema in patients who are otherwise not ECMO candidates?
Stepwise Approach to Oxygenation in Refractory Hypoxemia Due to Cardiogenic Pulmonary Edema: Initial Stabilization and Oxygen Therapy: Start with supplemental oxygen to maintain SpOâ‚‚ > 90%. Use noninvasive ventilation (NIV), such as CPAP or BiPAP, to provide positive end-expiratory pressure (PEE...
Can a dihydropyridine calcium channel blocker (CCB) like amlodipine be prescribed in addition to a non-dihydropyridine CCB such as diltiazem or verapamil for treating hypertension?
Yes, with extreme caution. Diltiazem and Verapamil are CYP450 inhibitors, which can interfere with the metabolism of many medications (commonly statins and calcineurin inhibitors), but also can increase levels of nifedipine and presumably other dihydropyridine CCBs, like amlodipine. Diltiazem or ver...
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 often do you recommend performing an advanced lipid panel for monitoring of lipid lowering therapy?
I am late to the responses, but I do not ever order an advanced lipid panel. Our institution does not have it on the lab menu either (one has to go to an outside lab to get it done). Anything needed for CV risk assessment can be gleaned from the history, including family history and a standard lipid...
Would you routinely initiate a high-intensity statin before discharge in an elderly patient presenting with a STEMI s/p revascularization who has an LDL below 70 mg/dL on no prior lipid-lowering therapy?
Yes. High dose stain therapy’s pleiotropic effects after a ‘plaque rupture’ event cannot be overlooked. Also, LDL-C in plaque rupture events (ACS, STEMI, NSTEMI) can be transiently lower due to the acute-phase response/inflammation. Starting high-intensity therapy ensures the ≥50% drop and addresses...
Are you more likely to initiate a calcium channel blocker rather than a beta-blocker as first-line therapy in patients with symptomatic nonobstructive hypertrophic cardiomyopathy, in light of emerging randomized data suggesting potential physiologic advantages with verapamil?
Verapamil, in my experience, has a far greater incidence of side effects, especially at moderate to high doses.
How do you approach prescribing statins in patients with an ASCVD <7.5% but have a strong family history and/or elevated LDL (but <190)?
When considering statin therapy for patients with an ASCVD risk of less than 7.5%, but with a strong family history of cardiovascular disease or elevated LDL cholesterol levels, the decision is nuanced. Here’s how I approach this situation: Shared Decision-Making: Involve patients in the discussion...
Would you recommend delaying left heart catheterization until development of ESKD in a patient with CKD Stage 5 and stable coronary artery disease given concern for contrast-induced nephropathy?
This is a complicated scenario and one in which there are more factors than just medical ones. I am far less concerned about contrast nephropathy (even arterial as in this case), compared to a decade ago. The more important question is whether a patient with stable CAD requires a cardiac cath. If th...
Has the CLOSURE-AF trial changed your threshold for referring a patient with atrial fibrillation for left atrial appendage closure?
The totality of data from recent clinical trials affirms that LAAO implantation should be viewed as a useful alternative strategy for patients at high risk of stroke and systemic embolism. Although closure can be used as a first-line treatment in select patients, I continue to recommend a trial of a...