Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How do you decide the duration of DAPT following TAVR, especially for patients already on a DOAC?
ASA mono Rx usually suffices after TAVR. If PCI + TAVR is performed, then triple Rx for 2-4 weeks, followed by Clopidogrel + DOAC therefore.
At what cumulative anthracycline dose is it recommended to use dexrazoxane for cardioprotection?
Typically considered in patients with anticipated >300 mg/m2 doxorubicin, as has been mentioned, which is most commonly seen in patients with sarcoma or recurrent lymphomas. Great discussion re: evidence and considerations in this piece in JACC Cardio-Oncology Upshaw et al., PMID 38773999.In practic...
Do you prefer TTE, CMR, or cardiac CT for the evaluation of PFOs?
In my experience, CMR does not have the spatial resolutions required to assess for a PFO, and cardiac CT (CCTA), while it has the spatial resolution, cannot reliably be performed with provocative maneuvers to increase RA pressure and induce right-to-left shunting as needed to visualize most PFOs. So...
Do you always give 325 mg aspirin if not already loaded with antiplatelets prior to the start of every LHC, even just for diagnostics in the absence of ACS?
Yes. I favor loading almost all patients prior to a LHC even if only diagnostic. That includes those on a DOAC as well. The reason I favor this is in case there was a complication and need for PCI that the patient at least has one anti-platelet in their system.
Would you continue SAPT beyond 12 months after left main stenting in an elderly patient on DOAC for paroxysmal atrial fibrillation?
Many clinical decisions like this one require tailoring the pharmacologic regimen to the individual patient. Obviously, elderly patients on a DOAC are inherently at risk for bleeding, but the risk of a left main stent thrombosis must also be considered. Clinical trials and retrospective data help us...
Do you prescribe hydroxychloroquine to patients who are on other medications that can prolong the QT interval?
First, I'll remind everyone that before COVID-19, case reports of QT-prolongation-associated arrhythmias were rare. It wasn't until COVID that we all at once saw cases with the caveats that these were in patients treated with higher doses of HCQ, commonly loading doses of 800 mg daily, plus COVID-1...
For SVG graft stenting, do you consider routinely embolic protection devices (EPD), and do you factor lesion location (prox vs distal) for decision making?
I would prefer to use an embolic protection device, provided it can be easily deployed and the lesion is suitable for it. Avoid, if the lesion is a very distal graft or attachment site. In most cases, I prefer to do direct stenting of the SVG graft to avoid any embolization even with a protection de...
Do you routinely check digoxin levels, and if so, when would you consider using Digibind in chronic digoxin use patients?
The subanalysis of the DIG trial gave some insight into the value of keeping digoxin levels below 1.0. If HF patients, I tend to look at the levels for that reason. I rarely use digoxin for AF as there is little evidence of benefit with some evidence of harm. Re: use of digibind, I limit this if t...
Should low-intensity statins be favored to minimize the risk of diabetes onset while still offering cardiovascular benefit for patients with prediabetes where a statin is indicated?
While higher-intensity statins are associated with a slightly higher incidence of diabetes, it would not be recommended to start with low-intensity statins as there are no data to support this. Essentially, all of the CV outcomes trials with statins have been with moderate and high-intensity statins...
How do you determine which atrial fibrillation patients with a high thromboembolic risk and a contraindication for oral anticoagulation should undergo left atrial appendage occlusion?
If the contraindication is absolute, all high risk patients need to be informed about the availability of LAAO devices. If the patient cannot take an anticoagulant or antiplatelet for a short period after implant, an epicardial approach could be considered.