Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Do you recommend avoiding radial artery access for cardiac catheterization to preserve potential future dialysis access sites in patients with advanced CKD?
With Radial arterial catheterization ( RA-CA), structural damage to the artery manifests as intimal tears and medial dissection along the length of the vessel. Further, even though 2-30% of the arteries will thrombose, about 50% of these will recanalize at 1 month. In spite of this, endothelial func...
How do you approach the management of extremely low LDL levels in older adult patients receiving statin therapy for primary prevention of cardiovascular disease?
In the absence of side effects, I am not concerned about very low LDL levels (e.g., less than 20 mg/dL), as there is a fairly linear association between LDL and CV risk, and there is no convincing evidence that even extremely low LDL levels are associated with cognitive impairment, intracranial hemo...
What is a reasonable length of time to pass before considering TEE guided DCCV for atrial fibrillation in a patient with a suspected acute cardioembolic stroke and concerns for tachycardia-mediated cardiomyopathy?
There are many issues to consider before proceeding with DCCV. We need to make sure the patient is neurologically stable following the stroke and can be anticoagulated. We seek the opinion of a knowledgeable stroke neurologist in that regard. As soon as anticoagulation can be initiated with a DOAC t...
Would you recommend holding anticoagulation in a patient with persistent atrial fibrillation presenting with a mechanical fall and found to have a scalp hematoma in the absence of intracranial bleeding?
I would not hold anticoagulation in this situation, particularly if the patient has high vascular risk. However, there are a few caveats. First, I would seek an expert opinion about the strength of evidence that an intracranial bleed had not occurred and that it was unlikely to occur later. I would ...
Where does dronedarone fall in your list of antiarrhythmics drugs to use in terms of efficacy and patient selection in contemporary management of atrial fibrillation?
Dronedarone tends to be my last choice for treatment of AF to maintain sinus rhythm of all currently available oral antiarrhythmic meds available in the US - least effective and very expensive drug. I may use it in patients that I believe would be better served with catheter ablation- treatment with...
What should the LDL target be in patients with prediabetes and high lipoprotein (a) with family history of coronary artery disease?
I don’t think that using Lp(a) to guide treatment is quite ready for prime time yet. It’s an independent predictor of risk compared to the rest of the lipid panel, but as far as I am aware, we do not yet have data that treating people based on it makes a difference. What I may do in this scenario is...
In a patient with IABP set on 1:1, do you always maintain them on systemic heparin, and if so, is there a goal ACT range?
No, never been a problem.
How do you manage anticoagulation/antiplatelet therapies with strong indications for uninterrupted therapy in setting of urgent procedures?
If anticoagulation is absolutely contraindicated because of the bleeding risk of the procedure, then "bridging" will usually make the most sense, most of the time, with low molecular weight heparin such as enoxaparin. If dual antiplatelet agents are contraindicated, particularly in the first month a...
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...
What is/are your preferred technique(s) for obtaining LV-Ao pressure gradients in the cath lab?
Two other ways to do this I learned while the Langston Cather was on back order to use a 6F 75 or 85 cm R2P sheath parked in the ascending aorta and a 4F pigtail in the LV. With two transducers (on off the side of R2P and one on pigtail) and a 2F difference in size of catheters, you get nice fidelit...