Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Are there instances where TAVR should be considered for patients with moderate AS and HFrEF?
Perhaps this is better asked provocatively; did AS (with less than severely elevated gradients) result in a decline in LVEF, or did moderate AS cause HFrEF? In the absence of an alternate cause of LV dysfunction, AS may be the only causative elephant in the room. Other subtle markers of AS severity,...
Is dexrazoxane recommended for cardioprotection in AYA patients with Hodgkin lymphoma who are receiving anthracyclines as part of their upfront therapy?
This is a good question that reflects the growing body of evidence in favor of dexrazoxane cardioprotection being safe and beneficial (Chow et al., PMID 26014292; Getz et al., PMID 32343641). For AYAs with Hodgkin lymphoma, doxorubicin remains a key component of therapy even for lower stage disease ...
What is your approach when a patient has concomitant acute decompensated heart failure and rapid atrial fibrillation?
Is the patient stable? If not stable, then I would move towards immediate cardioversion. If stable (good BP) but poor oxygenation, then diuretic with consideration of metoprolol, digoxin, or amiodarone. If unable to tolerate BB due to lower BP, then would lean towards amiodarone or digoxin. Anticoa...
What is your approach to VTE prophylaxis in hospitalized patients who are already on DAPT?
DAPT by itself is not considered DVT prophylaxis in patients at high risk of DVT. However, LMWH at prophylactic doses can increase the need for transfusions in patients on DAPT, without decreasing VTE rates. In general, I consider patients individually: Do they still need DAPT? With discontinuity o...
What is your approach to statin and/or PCSK9i initiation and counseling in a patient who has an HDL above 100, LDL within normal range, but markedly elevated calcium score exceeding 1000?
First, I'd like to know how high is the HDL. They could have a SCARB1 mutation that confers increased atherogenic risk alongside very high HDL levels, likely because of decreased hepatic clearance. I would also like to know their Lipoprotein (a) level and their ApoB level. The LDL can be low while e...
What are your preferred methods for QTc calculation for normal, tachycardic and bradycardic heart rates?
This depends on the need for precision. If for clinical purposes, the Fredericia correction formula will suffice and is less sensitive to heart rate distortion than Bazett's. If the goal is to precisely define the QT interval in a clinical trial, such as a thorough QT study of a new chemical entity,...
How do you approach caring for patients admitted with decompensated CHF, but who also exhibit hypotension and do not have overt signs of hypervolemia on exam?
This is a case where you might be concerned about the patient sliding into cardiogenic shock. Remember that in the context of chronic heart failure, cardiogenic shock tends to present more insidiously because these patients are typically compensated at low or borderline low cardiac output (Abraham e...
How would you balance the risk of intracranial hemorrhage with thrombosis of mechanical valves in patients with infective endocarditis?
I'm not sure that there is a good answer to this question. If you look at it segmentally, clearly, patients with mechanical valves require anticoagulation, especially in the mitral position. In patients with endocarditis and native valves, whether or not to anticoagulate the patient after or before ...
How would you counsel patients with type 1 or type 2 diabetes mellitus and heart failure on the use of SGLT-2 inhibitors when they have a history of DKA?
Making a recommendation to prescribe this class will really require a case-by-case clinical assessment. It is clear that SGLT-2 inhibitors are very effective in preventing hospitalization for heart failure, and so we will want to suggest their use whenever possible. But it is also clear that DKA (mo...
Do you use DOAC in patients with mild or moderate rheumatic mitral stenosis?
Although using DOACs in this population may be safe, these patients were excluded from the large DOAC trials. In addition, MS progresses, so what may be moderate disease today will progress rapidly in some patients. Thus, if anticoagulation is necessary and a VKA is a major issue for the patient, a ...