Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Which regimen would you recommend for a young patient with node-positive, triple-negative breast cancer with significant anthracycline-induced cardiomyopathy?
I would consider the NeoPact regimen, consisting of 6 cycles of docetaxel, carboplatin, and pembrolizumab, which is currently being directly compared to the Keynote-522 regimen in the SCARLET trial. Given some immune-related cardiac risks of pembrolizumab, I would strongly recommend that the patient...
What is your typical approach to the use of beta blockers in the setting of recent cocaine use amongst patients presenting with cocaine-related MI, arrhythmias, or new-onset heart failure?
I favor using or continuing non-selective beta-blockers in patients presenting with acute cardiac manifestations of recent cocaine use. My preferred agent in this setting is carvedilol.
What are standard selection criteria for patients who are eligible for heart transplantation?
Some of the selection criteria for isolated heart transplant are age </= 70 years, controlled DM (Hba1c </=7.5, BMI </=35 kg/m2 (may vary according to institution), absence of irreversible fixed pulmonary hypertension (PASP> 50 mm Hg and either TPG > 15 mm Hg or PVR > 3 WU), no illicit drug use in t...
What is your preferred mechanism for venting the left ventricle in patients on VA-ECMO?
Based on recent studies and evidence in the literature, my preferred approach for venting the left ventricle in patients on VA-ECMO would be guided by the individual patient's clinical scenario, with a cautious inclination towards using the intra-aortic balloon pump (IABP) over Impella. This prefere...
Would you recommend giving N-acetylcysteine in addition to holding diuretics in a patient with chronic kidney disease and mild hypervolemia who is planned to have a contrast study?
There are several meta-analyses showing conflicting evidence on the use of N-acetylcysteine to prevent contrast-associated AKI. However, the largest randomized trial (PRESERVE) did not show any benefit from using oral N-acetylcysteine in 4993 high-risk patients undergoing scheduled angiography (Weis...
In patients with Tetralogy of Fallot and an indication for primary prevention ICD (NSVT, induced VT during EPS, or Low LVEF), should pulmonary valve interventions be offered PRIOR to ICD to assess if improvement in VT burden/EF?
There is a lot to consider for this question.First, appropriate indications for primary prevention ICD in tetralogy of Fallot are not at all clear. While arrhythmias and left ventricular dysfunction are clearly risk factors for malignant arrhythmias, that is very different from saying that individua...
What other considerations for hyperlipidemia management would you have for a patient with multiple prior PCIs whose LDL remains above goal on high intensity statin, ezetimibe, and evolocumab, assuming the patient is compliant with medications?
There are a few options, most of which depend on insurance coverage and patient preferences. But first, would do a chart biopsy to assess the efficacy of each of the therapies to better understand the reason for persistent LDL elevation. Perhaps they have a dysfunctional LDL receptor, so upregulatio...
How should clinicians balance the use of finerenone with other heart failure treatments like SGLT2 inhibitors, considering their glycemic benefits?
Finerenone has a different mechanism of action from SGLT2 inhibitors and may have a synergistic effect when used in combination with other GDMT medications as a replacement for eplenerone or spironolactone, with a lower risk of progressive kidney disease. Similar to other MRAs, patients should be mo...
What are your typical recommendations for when a patient can return to work following a cardiac arrest, considering the variation in neurological recovery and the potential ramifications based on the type of job?
Impossible to answer categorically. As the question implies, there are so many variables, including the nature of the job, physical demands, patient age, co-morbidities, and extent of neurological and psychological recovery. The latter may be the most important since return to work may be helpful or...
What ECG features for ST depression would prompt you to report these ST changes if a patient exercised well and did not have any questions during their stress test?
During an exercise treadmill test many components are used to help decide the prognosis and risk of the patient. First is the amount of time the patient exercises on the treadmill. Traditionally doing greater than 10 METS has been shown to have a good prognosis. I say that in patients who are your a...