Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
In patients presenting with ACS and multivessel disease, when do you favor immediate versus delayed complete revascularization?
My approach is to defer the PCI to a few weeks (as outpatient) as long as the patient is asymptomatic and does not have a critical lesion (i.e. greater than 90% stenosis in the proximal LAD, LCX or RCA). I have been very consistent with this approach and I recall one patient who came back with unst...
What are your preferred lipid-lowering agents and target LDL reduction goal following initiation of therapy for patients with familial hyperlipidemia without underlying CAD?
It is not easy to address this question without specifics of the 'familial hyperlipidemia," but I will give examples: Monogenic familial hypercholesterolemia - since the LDL is very high from early childhood, we tend to treat adolescents with statins with a goal of a 50% reduction (20 or 40 rosuvas...
Have you changed your approach to delaying hip surgery in the context of decompensated CHF given the findings of the HIP-ATTACK study?
That is an interesting question. Patients with a hip fracture have a high mortality, and delaying surgery could contribute to this mortality. On the other side of the pendulum is acute heart failure. Patients with acute heart failure have increased mortality in the perioperative period. Some of this...
What is a reasonable hemoglobin goal for patients with chronic anemia presenting with acute MI?
The diversity of acute myocardial infarction (AMI) does not allow a monolithic answer to this question. The recent MINT study—an important contribution presented at AHA 2023 and published in NEJM—highlights this complexity. Although MINT, which randomized anemic patients with AMI to liberal versus r...
Would you favor additional work-up for abnormally elevated ABIs that suggest noncompressible vessels to confirm the presence of PAD?
Any ABI greater than 1.4 is due to calcification of the blood vessels. This is abnormal, and the risk of MI, Stroke, and CV death is increased in these individuals. Therefore, I would treat them as if they had peripheral artery disease and would go for an LDL below 55. I would not necessarily do fur...
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 ...
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...