Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
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...
Would it be reasonable to refer an otherwise healthy patient in their 40s for LHC after CCTA findings note significant proximal RCA stenosis, which was obtained following a transient episode of resting substernal chest pain but without subsequent reproducible symptoms with exercise?
I would favor a nuclear stress test to see if the lesion was associated with myocardial ischemia during exercise. If there was substantial evidence of ischemia, then I would proceed to LHC. If minimal or no myocardial ischemia, I would proceed with aggressive medical and lifestyle therapy.
Can mavacamten be considered for patients with HCM and ongoing dyspnea in setting of an elevated LVEDP but without significant LV outflow obstruction on imaging?
Yes, mavacamten may be a viable option for patients with HCM who have persistent dyspnea and elevated LVEDP, even without significant LVOT obstruction. While most of the evidence for mavacamten focuses on obstructive HCM, emerging data suggest it may have a role in non-obstructive HCM as well.The MA...
For a patient with known CAD and low baseline HDL, would a PCSK9 inhibitor be a better option than a statin, given concerns for paradoxical lowering of HDL levels with statin therapy that we can encounter in the outpatient clinical setting?
Statin therapy would still be your first choice as we know that they reduce CVD related outcomes regardless of the HDL. In fact, studies show that patients with low HDL benefit even more from statin therapy.
What would be your next diagnostic test of choice for a patient with findings concerning for silent ischemia on noninvasive functional testing in the absence of chest pain?
There are a lot of unanswered questions just from the information given. Why was the test done in the first place if truly asymptomatic? If not having chest discomfort, were they having an anginal equivalent - such as a new complaint of shortness of breath with exertion not previously present? What ...
What is your risk/benefit analysis when deciding on the appropriateness and timing for discontinuation of systemic anticoagulation in patients who underwent ablation for paroxysmal atrial fibrillation with CHADS2VASc score >2?
I typically do not discontinue oral anticoagulation in post-ablation patients with paroxysmal atrial fibrillation and a CHA₂DS₂-VASc score of >2. Catheter ablation is not considered a "cure" for atrial fibrillation; therefore, there is always a risk of recurrent arrhythmia. The patient may be asympt...
Do you recommend initiating treatment with an SGLT2 inhibitor or semaglutide first for a patient with obesity and heart failure with preserved ejection fraction?
Irrespective of body weight status, my first line of treatment for patients with HFpEF is with SGLT2 inhibitors if there are no contraindications (DELIVER trial and EMPEROR preserved trial). For patients with obesity (cardiometabolic) phenotype HFpEF, who qualify for GLP1 receptor agonists, I add on...
Is there any indication/benefit for heparin in a patient with suspected type 2 myocardial infarction?
There is no guideline rule for treating a type 2 MI like a type 1 MI. However, approximately 50% of type 2 MI patients have significant CAD (data from the University of Edinburgh published a year ago or so, in I think Circulation. My recommendation for type 2 MI is to treat the underlying condition ...
How do you approach a patient at intermediate ASCVD risk who has been referred to you because of an abnormal coronary CTA (obstructive lesion ~90%) but an excellent exercise capacity on treadmill without angina and a negative MPI?
Unless the reported lesion involves proximal LAD or LM (MPI can look normal if balanced ischemia), I would then treat medically (ISCHEMIA trial, ACC/AHA stable CAD guidelines).
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...