Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How do you view the balance between opting for percutaneous coronary intervention and prioritizing optimal medical therapy as the initial treatment choice for patients with stable angina?
This is the holy grail of Cardiovascular practice on how to marry the prevalent scientific data to clinical practice. In my opinion, an astute history and in-depth analysis of patient symptoms (angina and ischemia with their varied clinical presentations) hold the key to individualized patient care....
How soon after initiating oral anticoagulation therapy for atrial fibrillation can it be interrupted for surgery or procedures?
As with most things medical, multiple answers. If a patient walks into my office for preOp "clearance" and behold, they are in atrial fib, but asymptomatic, then it would depend on the urgency of their surgery. If elective, then you have time to work up his atrial fib and look for a reversal cause (...
What is your preferred choice of anticoagulant (VKA vs. DOAC) in patients with an LV thrombus and apical infarct?
Traditionally, warfarin is recommended. However, there has been recent evidence to suggest that DOACS are effective as well. In my practice, I have migrated to DOACS for ease of use. Many elderly patients are overwhelmed when they are discharged with 6 or 7 medications and add to that the complexity...
What is the optimal BP target for patients with diabetes and hypertension to reduce their risk of MI/stroke?
From the 2025 ADA Standards of Care, section 10 discusses Cardiovascular Disease and Risk Management. With proper blood pressure technique, the recommended blood pressure treatment goal is less than 130/80 mmHg if this can be achieved safely. Several randomized controlled trials are referenced with ...
For patients presenting with ACS and severe aortic stenosis with critical left main disease, would you consider BAV prior to PCI to the left main?
This sounds like a CABG AVR case on the surface; if inoperable or at prohibitive surgical risk, CHIP of the LNA lesion, followed by same setting or elective setting TAVR remains an option. CFA access with a large bore sheath (for CHIP/IABP or IMPELLA) will allow for an easy transition exchange for t...
What has been your approach to using contrast enhancement agent in the echo lab in pregnant patients if there is concern for LV thrombus or poor imaging windows for LVEF/valvular disease assessment?
This is a quote from a recent ACC article: "The use of agitated saline for evaluation of intracardiac shunting is not recommended in the setting of pregnancy. There are no empirical safety data on the use of ultrasound-enhancing agents (perflutren, sulfur hexafluoride) in pregnancy, although data fr...
Is there evidence to support the use of automated blood pressure checks during exercise stress testing, or does manual BP remain superior in terms of accuracy and consistency?
While there are certainly some advantages with automated blood pressure monitors, there are some limitations that require a manual backup or check. Exercise peak BPs should be verified with manual cuffs as well as measurements during arrhythmias, which can affect the accuracy of automated devices. A...
Are there other scenarios besides prior history of TIA or stroke or LV dysfunction in which systemic anticoagulation for LV non-compaction would be considered?
There is limited data in this area, but LV non-compaction by itself is not always an indication for anticoagulation. In addition to prior history of TIA, stroke or LV dysfunction, other conditions that anticoagulation should be considered include a history of atrial fibrillation or LV thrombus. The ...
How do you counsel patients who develop DVT or atrial fibrillation requiring anticoagulation when being treated with lecanemab or donanemab?
I do not think that anticoagulation is contraindicated in patients with these Alzheimer's disease antibodies, but I would want to check APOE status. I would not initiate the AD treatment if the patient is E4E4, and even one E4 would make me hesitant to have a patient on anticoagulation and an Alzhei...
In ischemic stroke patients with low LDL levels (<30-50 mg/dl), would you consider lowering LDL levels to lower values without concern for any side effects?
If LDL levels are already below 70, I don’t target a lower goal. The SPARCL trial showed that reducing LDL to this range has an NNT of about 45 to prevent one stroke, which I find to be modest at best. From my perspective, lowering LDL further (<30-50 range) shifts the focus to treating a number rat...