Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
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...
Does the presence of diastolic dysfunction guide subsequent pharmacological, pacing and ablative therapies for atrial fibrillation?
For the majority of patients with atrial fibrillation, symptoms are generated by the elevated heart rates rather than the irregularity or the loss of the atrial contribution to ventricular filling. The exception to this is patients with heart failure with preserved ejection fraction (diastolic dysfu...
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 ...
Besides treadmill, what other exercises may be considered for post-exercise ABIs, and are their diagnostic parameters identical to standard post-exercise ABIs?
2 minutes of Toe-raises has been demonstrated to be an acceptable alternative to exercise ABI's.
Would you favor culprit-only PCI, complete revascularization via percutaneous approach, or urgent CABG evaluation for a young diabetic patient with newly reduced LVEF < 35% presenting with an anterior STEMI and multivessel disease?
This is an uncommon scenario. Everything depends on the severity of the disease and the complexities of the lesions. I will favor multi-vessel PCI (after STEMI has been taken care of with primary PCI) if anatomy is suitable. I would favor CABG if there are long lesions, involvement of LM (particular...
How would you manage cardiac sarcoid with intolerance/contraindications to methotrexate, azathioprine, and mycophenolate/mycophenolic acid and that has proven refractory to adalimumab and infliximab as determined by PET?
I think it would be important to know the doses of the medications 'failed'. Similarly to allopurinol dosing and gout prophylaxis 'failures', I find most patients I see for consultation with this story are not on high enough doses, need combo therapy, or are not on the medication long enough. Meth...
When would you consider long-term cardiac monitoring to look for atrial fibrillation in patients with mitral stenosis given their baseline elevated risk for atrial fibrillation and thrombosis?
This is a thought-provoking question. Not only is Afib a risk factor for strokes but these strokes can be particularly devastating. While screening for subclinical Afib in large populations is described, there is little data to show that this leads to clinical benefits (1, 2). The benefit of detecti...
For patients presenting with suspected type 1 NSTEMI and atrial fibrillation on anticoagulation, do you favor triple therapy or SAPT with systemic anticoagulation instead while awaiting LHC?
Standard therapy for acute coronary syndrome is suggested including statin therapy, beta blocker therapy, ACE inhibitors with DOAC use while awaiting LHC/PCI. UFH with the addition of P2Y12 inhibition during hospitalization is suggested even with DOAC use. A radial approach should be taken to decrea...
Would you initiate anti-arrhythmic drug therapy in patients who are asymptomatic and have normal LV function but with a PVC burden > 20 percent?
I overall agree with Dr. @Dr. First Last's approach. There are important considerations with high-burden PVCs beyond LVEF. The morphology can be helpful with regard is this consistent or atypical appearance of idiopathic PVCs. I will typically do an assessment for underlying structural heart disease...
Do you prefer using unfractionated heparin or low molecular weight heparin in stable patients presenting with NSTE ACS awaiting primary PCI (assuming normal renal function)?
Unfractionated heparin, with its much shorter T 1/2, is preferred to enoxaparin (T 1/2 12 odd hours), even in the era of transradial procedures (as opposed to transfemoral cases with higher bleed risk).