Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Would you pursue imaging to clear the left atrial appendage or have a risk/benefit discussion with a patient prior to semi-urgent cardioversion if there was concern for delayed administration or a single missed dose of anticoagulation?
This would probably depend on the CHA2DS2VASc score. If CHA2DS2VASc <=2 for men or <=3 for women, I would have a risk/benefit discussion with the patient and consider proceeding without preprocedural imaging after shared decision-making. If CHA2DS2VASc risk is higher, I would favor pre-procedural im...
Would you consider overdrive pacing for recurrent torsades des pointes in a patient without an obvious drug causing QTc prolongation or significant electrolyte abnormality?
Overdrive pacing is a guideline-recommended treatment for recurrent torsade de pointes in the setting of prolonged QT interval, particularly for patients with bradycardia exacerbating the QT prolongation. Isoproterenol infusion is another option to treat these patients. In these patients, the overdr...
How soon would you repeat PET/CT in a patient with cardiac sarcoid after starting treatment with infliximab?
Very good question. There is no consensus on this answer, and it is also important to consider the medical burden on a patient to repeat such involved testing. Our approach is to follow the resolution/improvement of patient-reported cardiac-related symptoms and follow less invasive testing such as E...
What type of DES should you opt for if a patient has or is concerned about possible nickel allergy?
For a coronary stent, I would lean toward a Medtronic DES. There are published recommendations for nitinol with a durable polymer. That said, I cannot remember more than one case in 25 years where I thought that a metal allergy may have played a role in a patient receiving a stent and that was prior...
How would you approach warfarin management in patients with mechanical aortic valve and atrial fibrillation, if they develop chemotherapy-related severe thrombocytopenia?
In general, anticoagulants are held once the platelet count drops to < 50K due to excessive bleeding risk. In patients at very high thrombotic risk (i.e, mechanical mitral valve, tilting disk valve), unfractionated heparin can be considered with close PTT monitoring, though most case reports still h...
Do you prefer telmisartan over other ARBs given its longer half life elimination?
When considering a specific medication within a class, I try to take into account: cost, side effects, efficacy, pharmacodynamics, and long-term compliance. In regard to pharmacodynamics, I am trying to maximize the duration of action. This often, but not always, correlates with drug half-life. For ...
What is a reasonable approach to coronary calcification that is incidentally found on CT in a patient who does not have symptoms suggestive of angina?
This patient needs aggressive medical therapy and risk factor modifications. Statins will be the primary lipid-lowering agent but other agents as needed to get an LDL under 70. Hypertension needs to be identified and controlled. Aspirin is also a consideration depending on the extent of coronary cal...
How do you monitor for cardiac toxicity in patients taking osimertinib?
There are multiple studies that have explored the issue of cardiotoxicity from osimertinib. A large single-center retrospective observational cohort series from Taiwan, (n=401) compared a matched cohort of patients treated with osimertinib (n=253) to those treated with other EGFR TKIs (n=195) and fo...
What are your thoughts on the results from the AQUATIC trial which showed that the addition of aspirin daily + oral anticoagulation in patients > 6 months from PCI and with high atherothrombotic risk was associated with a higher risk of death, MI, stroke, coronary revascularization and acute limb ischemia, compared to oral anticoagulation alone?
I think AQUATIC is a well-designed definitive trial. It shows that in patients with chronic CAD (at least 6 mo. out from stent) who are also receiving anticoagulation (typically for AFib), the use of anticoag monotherapy is safer (statistically lower risk in terms of a composite endpoint as well as ...
Should we be more cautious with the use of GLP 1 R agonist therapy in patients with Type 1 diabetes mellitus and obesity given the increased risk of cardiovascular disease with high body weight variability?
There doesn't seem to be any evidence that GLP-1 RA would increase the risk of CV disease. Biologically, the benefits that have been shown in patients without Diabetes (the SELECT trial) should still be applicable for patients with Diabetes Type 1.The trials that didn't show much efficacy in glucose...