Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
During a coronary intervention, if the activated clotting time (ACT) is not within the therapeutic range despite administering weight-based unfractionated heparin, what alternative options do you consider?
I would consider additional boluses of 2000–5000 units of heparin and recheck ACT. If the ACT continues to be below the therapeutic range, consider alternate anticoagulation such as bivalrudin, 2b3a inhibition, and low molecular weight heparin. I also assume we have checked the ACT device. In additi...
How do you advise patients on cardiotoxicity when they are expected to receive a low mean heart dose and low cardiac substructure doses with their radiation plan?
I would say something along the lines of: "Radiation therapy is an effective tool for treating your cancer. However, whenever we give radiation therapy, there is always some incidental dose delivered to the adjacent normal tissues. We cannot make the dose zero to all of the normal tissues. Thus, we ...
What is your preferred method for subclinical CAD screening prior to initiation of class IC antiarrhythmic drugs for atrial fibrillation?
Flecainide and propafenone are the IC agents in use for atrial fibrillation. Encainide and moricizine were predominantly used for ventricular arrhythmias and encainide was pulled a long time ago due to proarrhythmia concerns and I believe Ethmozine stopped being marked many years ago.The CAST trial ...
Is there a particular PVC/NSVT burden on inpatient telemetry in which you would consider discharging a patient with a LifeVest post-STEMI with newly reduced LVEF <35% while optimizing GDMT?
The PVC/NSVT burden is not part of the equation for post-STEMI LifeVest. The guidelines clearly state that if you have an EF of <35% and are within 40 days of an MI, or any revascularization within the past 90 days, the wearable defibrillator is a class IIb indication while optimizing GDMT. If the p...
How should we approach the recommendation of intermittent fasting for weight loss in patients with pre-existing cardiovascular conditions, given the observed association of increased CV mortality with eating durations of less than 8 hrs?
I will admit my prejudice on this topic. I don’t understand the biologic plausibility of shortening the time during which meals are consumed to 8 consecutive hours a day with no snacking for 16 hours a day (but without calorie restriction) in order to lose weight. This would be like saying “have bru...
What is your preferred intervention for diffuse severe ISR involving two layers of stent?
Drug coated balloons
Do you counsel patients to take antihypertensives at specific times of day to maximize efficacy or minimize side effects?
I counsel my patients to take antihypertensives in the morning. The only exception is the alpha-1 antihypertensives. I use them only as an add-on, to be taken at bedtime for two reasons: one is to avoid the blood pressure surge in the early morning hours, and two is to minimize orthostatic blood pre...
How do you approach the use of benzodiazepines in patients with chronic medical illnesses that may be susceptible to respiratory compromise (e.g., CHF, COPD, ILD)?
It’s a very good question and answers may vary among different specialty providers. Yes, a slow or gradual weaning of the benzodiazepines would be advisable. When they reach lower doses the taper should be even slower over weeks or longer. There is a risk for not weaning them off benzodiazepines inc...
When do you usually introduce conversations regarding tracheostomy placement in patients with refractory status epilepticus, or other conditions where one may anticipate delayed awakening?
It depends on the underlying pathology and how long the patient is expected to have impaired airway reflexes requiring prolonged mechanical ventilation. In the Setpoint 2 trial, among patients with severe stroke receiving mechanical ventilation, a strategy of early tracheostomy (</= 5 days), compare...
Does anyone utilize P2Y12 assays to determine if clopidogrel may be ineffective when used for DAPT?
Yes, I use P2Y12 assays in two distinct settings. Medical management: If a patient on clopidogrel mono/dual therapy has disease progression with ICAD or experiences a recurrent ischemic event, I obtain a P2Y12 assay to assess responsiveness. This helps guide the decision to switch to ticagrelor and ...