Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How do you discuss the benefits and potential risks of anticoagulation for a strong indication (e.g., atrial fibrillation with high CHA2DS2-Vasc score) with older adult patients with frequent falls?
Current guidelines from AHA/ACC emphasize that oral anticoagulants should not be withheld simply because a patient is at risk of falling.Instead, I try to manage involving shared decision-making with the patient or DPOA that weighs stroke risk against modifiable bleeding and fall risk factors( with ...
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...
What neurologic and hemodynamic parameters do you use to determine candidacy for emergent cath lab activation following out of hospital cardiac arrest from VT/VF in patients with NSTEMI after ROSC has been achieved?
Neurologic Futility: Immediate coronary angiography is not recommended if the patient is comatose with clinical signs of severe, irreversible brain damage or brain death. Viability Assessment: If the patient presents with refractory cardiogenic shock or ongoing ischemia, emergency catheterization is...
For older adults undergoing intermediate-risk non-cardiac surgery, do you routinely check pre-operative pro-BNP levels for risk stratification based on emerging data and updated Canadian guidelines?
Pre-operative NT-proBNP and BNP levels have been featured, not just in the cited Canadian guidelines but also in the 2024 update of the AHA/ACC preoperative evaluation guidelines. (Thompson et al., PMID 39316661). Those guidelines recommend evaluating a pre-op NT-proBNP level if the results will cha...
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...
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...
How do you decide between atorvastatin versus rosuvastatin and their high-intensity doses for statin-naive patients following a STEMI and PCI?
20 mg of Crestor is highly effective and tolerable.
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...