Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
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...
What is a reasonable hemoglobin goal for patients with chronic anemia presenting with acute MI?
The diversity of acute myocardial infarction (AMI) does not allow a monolithic answer to this question. The recent MINT study—an important contribution presented at AHA 2023 and published in NEJM—highlights this complexity. Although MINT, which randomized anemic patients with AMI to liberal versus r...
Is there any role for adjusting how long to hold anticoagulation perioperatively based on DOAC dose?
The PAUSE trial evaluated perioperative management of DOACs. However, only 20% and 16% of patients were on prophylactic doses of apixaban and rivaroxaban, respectively. It was suggested to hold the drugs for two days, and one day before high-risk and low-risk procedures. A useful review of this appr...
What would be the minimum duration of IL-1 therapy you would recommend for chronic pericarditis?
There is no great data. In my experience, it depends on the reason for IL-1 initiation, the severity of cMRI findings, and how chronic the pericarditis was prior to initiation.. If this is used as a steroid-sparing strategy or steroid weaning, probably 1-2 years minimum. In Rhapsody, the majority fl...
What would be a reasonable next-step approach to the evaluation of mild LV systolic dysfunction with regional wall motion abnormalities on TTE in a patient receiving carboplatin/paclitaxel for ovarian cancer without any cardiac symptoms?
Given the regional abnormalities observed, I would obtain stress testing to determine if an ischemic component may be contributing. If stress testing is negative, I would start low-dose GDMT for presumed non-ischemic cardiomyopathy.
What is a reasonable stepwise approach to diagnostic imaging when there is ongoing concern for cardiac amyloidosis?
Abnormalities on CMR are not diagnostic of cardiac Amyloidosis. Although LGE, abnormal ECV, and abnormal T1 are findings commonly seen in Cardiac amyloidosis, the absence of one or more does not rule out amyloid. In the setting of increased LV thickness and clinical suspicion of amyloid, I would hav...
How long do you recommend waiting after variceal bleeding and banding before a transesophageal echocardiogram can be performed safely?
In the exact wording of this question, the scenario that is being presented is that the patient has had a variceal hemorrhage (VH) recently and urgent banding has already been performed to stop the VH (so that the concern would be of the TEE probe knocking off a band that is actively treating an eso...
Is there any evidence to support further uptitration of dobutamine beyond 5mcg/kg/min for patients with advanced HF and/or cardiogenic shock, or should further investigation into potential MCS be considered at that point?
When a patient with acutely decompensated heart failure and shock is exhibiting insufficient perfusion in spite of a given level of support, whether pharmacologic or mechanical, it is appropriate to pause and ask why. Options at this point could include an escalation of inotropic therapy (dose escal...
Based on most current research regarding the more widespread use of class IC antiarrhythmic drugs, what are your prescribing practices in patients with coronary artery disease?
Fair question, as we know the definition of "structural heart disease" is unknown. In the trial, it was likely ischemia driving the poor outcomes, so I will get stress with imaging on everyone >50 years old (CAD risk). Given the common finding of "questionable" stent placement in the community, I wi...
What is the minimum duration of weeks on anticoagulation in which you would consider performing a DCCV without the need for TEE, provided the patient is an excellent historian and otherwise reliable?
If this were a board question, I agree with the guideline-listed answers here - it's 3 weeks. The most recent 2023 ACC AHA hours Atrial Fibrillation Guidelines by Joglar et al., PMID 38033089 are consistent: In patients with AF duration of ≥48 hours, a 3-week duration of uninterrupted therapeutic an...