Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Would you consider adding metoprolol succinate to a medication regimen for a patient with paroxysmal Afib on sotalol, known CAD, HF with mildly reduced LVEF, assuming hemodynamics could tolerate it?
Yes, the mechanism of action does not overlap entirely and metoprolol succinate would be indicated for HFmrEF.
Should an ischemic evaluation be considered in the diagnostic work-up for new-onset diastolic heart failure/HFpEF in patients without clear anginal symptoms?
The ischemic phenotype is a well-recognized class among HFpEF patients. For men, this usually manifests as macrovascular disease with epicardial CAD, and for females, the more common manifestation is microvascular disease with CMD. Therefore, ischemic evaluation should be considered as part of the w...
Is there a role for routine stress testing in intermediate-high risk CAD patients with a significantly elevated coronary calcium score who are otherwise asymptomatic?
Current data does not support stress testing in asymptomatic intermediate risk individuals in general and those with incidental CAC also do not have an indication for the test. ASCVD risk factor modification suffices.
When would you consider performing direct implantation versus prior dilatation with balloon aortic valvuloplasty during TAVR?
Severe calcification of the aortic valve and Valve area less than 0.5 cm² or very high gradients, which could cause difficulty of the TAVR valve to cross the native aortic valve. Bicuspid aortic valve with severe calcification. If the coronary heights are borderline low, concerning for post-TAVR co...
Would you ever consider switching a patient with an LVAD from warfarin to Eliquis, such as in the setting of recurrent GI bleeds?
In general, warfarin remains the agent of choice in VAD patients. However, in patients with INR non-adherence or recurrent GI bleeds, it is an option. In this situation, ensure that GI bleeding is stopped and start 2-3 days after warfarin is stopped. Monitoring with anti-factor Xa monitoring can be ...
Do you favor aspirin or P2Y12 inhibitor monotherapy following completion of 12 months of DAPT post-PCI in patients with elevated bleeding risk?
You could tailor based on bleeding risk. If prior upper GI bleed or symptoms - p2y12. If lower GI bleeds - aspirin. The field is moving towards p2y12 monotherapy. Also as mentioned should do genetic testing if thinking long-term clopidogrel monotherapy.
Should CT coronary calcium score be avoided in dialysis patients in light of presumed high prevalence of CAC in this population?
The incidence of coronary calcifications in patients on dialysis exceeds 80% and is between 50-80% in patients with CKD. In addition, dialysis and ESRD cause two types of vascular calcification - in the medial and intimal layers, the latter being the one that correlates best with atherosclerotic pla...
Are there data to support full-dose anticoagulation added to an antiplatelet in recurrent peripheral arterial thrombosis requiring revascularization and stenting?
This question comes up frequently at our institution. I previously consulted with our vascular surgery team who referred me to this trial of Edoxaban with SAPT, trying to avert what may be limb loss if the bypass graft/stent fails. We've often promoted rivaroxaban 2.5 mg po BID per VOYAGER PAD if we...
Are there any heightened risks for cardioversion following a recent PCI from a stent patency standpoint or hemodynamic concerns?
Most of our concerns about procedures soon after PCI revolve around the issue of anticoagulation. In this case, as long as the patient could receive an anticoagulant while on antiplatelet therapy (at a somewhat increased risk of bleeding), a cardioversion is possible. Though there is a hypothetical ...
How do you manage asymptomatic non-sustained atrial arrhythmia in patients with single ventricle and Fontan physiology?
This is an excellent, challenging question and I think experts will disagree and debate the issue depending if they are risk-minimizers or cost-minimizers and if patients are worriers (woulda, coulda, shoulda) or data-driven/evidence-based (need to see large studies with proof before action).I like ...