Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What is your approach for patients who have marked inter-arm blood pressure differences on home and in office measurements?
I'd first confirm that there is a difference in BP between arms by having the patient alternate BP measurements at home while seated with the back supported in a chair. In the office, I may perform AOBP measurements in both arms, but definitely would compare radial pulses simultaneously. If there is...
How do you decide between manual pressure versus opting for a specific vascular closure device at the conclusion of a femoral access case?
Manual vs closure devices depend on the following: cathlab turnover- if fast turnover needed, manual pressure with sheath pull in PACU speeds up stuff, as long as the “puller” is not the provider cath’ing evidence for closure device vs manual pressure is only good for hospital LOS and early deambul...
Do you recommend patients with hypertensive kidney disease transition from wrist to upper-arm home blood pressure monitoring prior to making dose adjustments to their antihypertensive regimen?
Possibly, if I think the measurements are not accurate. Home BP monitoring is an important part of hypertension management. In my practice, I've noticed that positioning while taking the BP is more important than the specific device type. I advise patients to check their BP at home in a hard-backed ...
Do you favor ticagrelor or prasugrel first-line for the treatment of ACS with planned PCI, provided no contraindications to either agent?
I prefer Prasugrel based on the latest data from ISAR-REACT 5 trial. I almost never use ticagrelor as it is expensive and there are significant side effects (Shortness of breath being the most common).
Are there standardized, discrete cut-off values in T1/T2 mapping and extracellular volume fraction to aid in the diagnosis of various cardiomyopathies, or are these values largely scanner/institution specific?
T1/T2 mapping and extracellular volume fraction (ECV) are advanced parametric mapping MRI techniques increasingly used in the diagnosis and tissue characterization of different cardiac pathologies. However, the standardization of cut-off values for these parameters remains a challenge. These values ...
How have the findings from DanGer Shock RCT changed your perspective on which patients presenting with acute MI complicated by cardiogenic shock would benefit from Impella for additional hemodynamic support?
First and foremost, it is notable that DanGer Shock (Møller et al., PMID 38587239) was the first randomized trial to show a mortality benefit with the use of a microaxial flow pump in acute MI-associated cardiogenic shock - a practice that proliferated based upon promising outcomes in non-randomized...
With the rise in home monitoring devices, how should we approach asymptomatic NSVT detected in healthy individuals with no prior cardiac history and with low risk cardiac profile?
With home monitoring devices, we are finding a lot of arrhythmias that would have previously remained unidentified. If episodes of NSVT are being found on home monitoring devices, the patient should receive a formal monitor to confirm NSVT. The formal monitor should be a Holter monitor that is able ...
How do you consider and approach transition to hospice in a patient with HFrEF who does not appear to tolerate GDMT?
I approach this situation similarly to any illness that has reached end-stage or is approaching end-stage. First, I determine the patient's goals of care. By this, I mean, what does the patient value? If time is getting short, how do they want to spend their time? Where and with whom? How do they de...
In patients presenting with ACS and multivessel disease, when do you favor immediate versus delayed complete revascularization?
My approach is to defer the PCI to a few weeks (as outpatient) as long as the patient is asymptomatic and does not have a critical lesion (i.e. greater than 90% stenosis in the proximal LAD, LCX or RCA). I have been very consistent with this approach and I recall one patient who came back with unst...
What are your preferred lipid-lowering agents and target LDL reduction goal following initiation of therapy for patients with familial hyperlipidemia without underlying CAD?
It is not easy to address this question without specifics of the 'familial hyperlipidemia," but I will give examples: Monogenic familial hypercholesterolemia - since the LDL is very high from early childhood, we tend to treat adolescents with statins with a goal of a 50% reduction (20 or 40 rosuvas...