Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Do you discontinue amlodipine or use an alternative approach to manage peripheral edema when it occurs as a side effect of the medication?
Peripheral edema is a common complaint and can be exacerbated by any vasodilator therapy, including hydralazine and minoxidil. My initial approach to swelling is to 1) make sure there is no proteinuria, which can be easily overlooked in a diabetic who infrequently sees doctors; 2) assess heart and l...
Is there a role for measuring plasma aldosterone to guide the treatment of heart failure in specific populations?
Typically, there is no role in measuring aldosterone to guide therapy. In patients with HFpEF, the use of Aldactone is to help with membrane stabilization and management of RAAS inhibition. There are some reports of prior research supporting LV remodeling and reduction in myocardial fibrosis.
When should you consider adding clonidine to an antihypertensive regimen for patients with advanced CKD?
Clonidine patch is useful in severely uncontrolled hypertension. In patients with CKD, not responding to conventional medications - like calcium blockers. Though the side effect profile is not great, it is less expensive and practical.
When would you consider endomyocardial biopsy for newly noted LVH with genetic testing significant for MYH7 mutation but also a TTR VUS also present?
This is an interesting question. However, it is important to know further information about the patient, such as age, sex, family, history, and the specific variant of unknown significance in the TTR gene (since some so called variants of unknown significance have descriptions in the literature that...
What is your approach to the management of incidentally elevated HDL levels in isolation and is there any utility for further ASCVD risk stratification and/or genetic testing for lipid disorders?
Although the U-shaped curve for HDLC and ASCVD was a surprise (probably missed until huge population cohorts were studied), the data have been reasonably confirmed in many studies now, with some heterogeneity regarding gender as well as CVD vs total mortality. If I see a patient now with an HDL over...
For elderly patients (i.e. older than 80) with only one documented episode of paroxysmal atrial fibrillation following a stress event (such as acute illness/steroid administration) and a CHADsVASc score greater than 1, how would you counsel them on the risks/benefits of anticoagulation and subsequent monitoring for afib recurrence?
If it were an isolated event, I would advocate continued monitoring for recurrence before starting an anticoagulant with the understanding that the risk of AF recurrence is relatively high.
How do you decide which patients with upper GI bleeds should be monitored on telemetry?
Telemetry use has some standard indications in GI bleeding, specifically for patients with hemodynamic instability and significant cardiac comorbidities. Such situations include unresolved hypotension, >4 units transfused, known arrhythmia, and severe HFrEF. In these cases, I’m worried about someone...
What is your approach to secondary stroke prevention in patients with atrial fibrillation and intracranial stenosis (>70%)?
The patient clearly needs to be on an anticoagulant for stroke prevention with atrial fibrillation and I would choose apixaban. If an antiplatelet is added to the apixaban, the risk of a major bleeding side effect is significantly increased. It is uncertain if apixaban is effective in reducing the r...
What patient factors do you consider when selecting between a small interfering RNA, like inclisiran, and PCSK9 inhibitors in patients with recent acute coronary syndrome?
Insurance coverage and out-of-pocket costs usually drive my choice. It is fairly easy to get approval for evolocumab for most of my patients. I have had a hard time getting approval for inclisiran with the exception of those with traditional Medicare + supplemental medication coverage. I usually sta...
How do you use IVC caliber and collapsibility to guide decisions about diuresis?
I use IVC caliber in conjunction with my lung exam to assist with the assessment of right and left atrial pressures respectively. The IVC assessment has many caveats in different patient populations, and evaluation with POCUS can be done in two planes to better understand IVC shape.Caveats - IVC siz...