Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
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...
How long do you recommend waiting after variceal bleeding and banding before a transesophageal echocardiogram can be performed safely?
In the exact wording of this question, the scenario that is being presented is that the patient has had a variceal hemorrhage (VH) recently and urgent banding has already been performed to stop the VH (so that the concern would be of the TEE probe knocking off a band that is actively treating an eso...
Do you consider bleeding risk in elderly, frail patients with atrial fibrillation to be similar for all NOACs?
I believe that apixaban carries a lower risk of bleeding, with particular reference to GI bleed, when compared to rivaroxaban and dabigatran. This is true in the population of AF patients at large and most probably in frail patients as well.
Is there any evidence to support further uptitration of dobutamine beyond 5mcg/kg/min for patients with advanced HF and/or cardiogenic shock, or should further investigation into potential MCS be considered at that point?
When a patient with acutely decompensated heart failure and shock is exhibiting insufficient perfusion in spite of a given level of support, whether pharmacologic or mechanical, it is appropriate to pause and ask why. Options at this point could include an escalation of inotropic therapy (dose escal...
What is your clinical approach to deprescribing vs continuing low-dose aspirin used for primary prevention in older adults who are already taking this medication?
I generally continue a low-dose aspirin in patients at higher risk (e.g., diabetes, CKD, strong family history) who would be at risk for a significant reduction in quality of life were s/he to have a cardiac/vascular/cerebrovascular event, provided there is no history of significant anemia (transfus...
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 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.