Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
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).
What is your approach to using beta-blockers in patients with acute myocardial infarction with preserved LV ejection fraction who undergo early coronary angiography in light of the REDUCE-AMI trial findings?
I would not change practice based on the findings of this study alone. Treatment cross-over in both arms of the study may obscure the potential benefits of post-MI beta-blocker therapy in patients with preserved EF.
Should an ischemic evaluation be pursued in cases of unexplained complete heart block or high-degree AV block?
Not necessarily. There are many factors to consider including the site of block (AV nodal versus distal conduction system), the presence of previously diagnosed coronary artery disease, and symptoms at the time of the event.
What is your step-wise approach to differentiating SVT with aberrancy versus VT?
Good question, this is addressed with classic algorithms such as the Brugada criteria.They can be a little cumbersome so I use the best parts of that, which would be: The likelihood of VT is increased with: Age > 35 (positive predictive value of 85%) Structural heart disease Ischemic heart diseas...
How are you incorporating the newer RCT data suggesting no mortality benefit to indefinite beta-blocker therapy for patients who are several years out from an MI with preserved LVEF and no angina or arrhythmia?
I have been de-prescribing after counseling once the patient is a couple of years out. This reduces symptoms, pill burden, drug interactions, etc., so I see an active benefit even if the patient seems to be tolerating medication. Obviously, they would have no other indication for BB, mainly arrhythm...
Knowing that there is going to be significant PR prolongation with RA pacing, should a LBBA pacing lead be recommended in patients with a PPM indication and a significant first degree AV block (>250msecs) especially if the patient has a borderline LVEF (~45-55%) to prevent diastolic MR-pacemaker syndrome ?
Yes, this would certainly be reasonable, but less likely required. There are other considerations with LBAP, such as extended procedure time and lack of specific reimbursement for this extra time. If the patient is already tolerating this significant PR, it may not be worth the LBAP if it turns out ...
Do you recommend transitioning elderly patients from thiazide diuretics to alternative agents when managing hypertension given the increased concern for hyponatremia in this patient population?
In short, no.If hyponatremia from a thiazide occurs, which is rare (~2% among individuals in the intensive treatment arm of SPRINT), it is more likely to be in the first month after thiazide initiation. Hyponatremia occurring in an individual with chronic thiazide use very likely represents the pres...
When and should you consider Watchmans for patients with high bleed risk/recurrent GI bleeds and valvular atrial fibrillation with moderate-severe mitral stenosis?
I am not aware of any studies that include those patients.In terms of watchmen in general, the debate still rages on. The most recent trial (non-industry funded) is the CLOSURE-AF Trial, which found that standard medical therapy (anticoagulation) was superior to catheter-based left atrial appendage ...
Could you describe the variables that influence your decision against or advocating for performing atrial fibrillation/flutter ablations in morbidly obese patients, versus opting for medical therapy and if so, choice of antiarrhythmic agent?
The short answer is yes. We know extreme obesity will increase procedural complications, including but not limited to anesthesia issues, groin access issues, etc. We also know the chances of meaningful long-term success in very obese patients are lower than what would be in the trials. Different EPs...
Which anticoagulant (DOAC or Warfarin) would you recommend in the case of a 70-year-old male with persistent atrial fibrillation and history of rheumatic mitral stenosis now status post bioprosthetic MVR?
There won't be perfect data on this, per the 2023 guidelines:The distinction between “valvular” and “nonvalvular “AF remains a matter of debate. Their definitions may be confusing. Recent trials comparing vitamin K antagonists with non-vitamin K antagonist oral anticoagulants in AF were performed am...