Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How would you approach the management of a patient who develops an accelerated junctional rhythm who exhibits no symptoms and has no prior history of cardiac issues, aside from consulting a cardiologist?
There would be many clinical factors to consider before making a decision to treat to suppress such an arrhythmia including the age of the patient, presence of associated structural heart disease, symptoms associated with the arrhythmia, its rate and putative mechanism, and its pattern and persisten...
What is your preferred duration for triple therapy post-PCI in patients on systemic anticoagulation?
Most practitioners extrapolate data from the AUGUSTUS and PIONEER-AF trials to answer this question.These trial used apixaban and rivaroxaban, respectively, along with use of DAPT with clopidogrel 75mg qd and ASA 81mg qd. From these 2 trial, Augustus demonstrated lower bleeding risk compared to trip...
For isolated and very high lipoprotein (a) levels (LDL of > 140, has an Lp(a) > 100) in a patient with no cardiac symptoms or risk factors, would you start lipid lowering treatment, such as with a PCSK9i if they develop statin intolerance?
There are a number of trials going on for reduction of Lp(a) with both IM and PO meds. We know that lifestyle modification does not help for reduction of this very atherogenic protein. If calc scores are high, I would look into entering one of the trials. If the score is low (unlikely), I would wait...
What are some immunosuppression regimens to consider in a patient with refractory cardiac sarcoidosis?
Unfortunately, there is no high quality data at this point to directly answer this question but here are some options. For patients who have only been treated with oral steroids, I would first consider the addition of weekly methotrexate at a dose of between 10 - 20 mg WEEKLY with supplemental folic...
When would you consider referring a patient with suspected cardiac sarcoidosis based on PET and MRI for endomyocardial biopsy given degree of patchy involvement, as opposed to initiating empiric immunosuppressive therapies?
I would avoid initiating empiric immunosuppressive therapies without a firm diagnosis of sarcoidosis. I will mention however that the latest Japanese Circulation Society criteria for the diagnosis of sarcoidosis do include criterion for the non-invasive diagnosis of likely cardiac sarcoidosis based ...
What are some TTE findings that suggest worsening function of a bioprosthetic AVR that would require further surveillance or diagnostic imaging?
Doppler findings of an increasing transaortic gradient; 2D findings of decreased valve excursion and increased cusp calcification.
What is your approach to a newly diagnosed LBBB in individuals >70 years old who are free of any signs or symptoms of heart disease and without other significant ASCVD risk factors besides age?
The presence of BBB; whether IVCD or RBBB or LBBB, signifies infranodal conduction delay from a myopathy. That myopathy may be hypertensive (LVH) or ischemic (LAD disease) or something less common (inflammatory etc). The ideal test would evaluate anterior septal LV thickness and vascular flow; it’s ...
What are the best techniques to reduce POCUS artifact and increase the diagnostic accuracy of lung ultrasound?
It is important to first clarify that essentially all of lung ultrasound is artifact, and this is a great illustration of how artifact can actually help us to make a diagnosis rather than obscuring it. When we see B-lines, for example, that is an artifact that does not represent a similarly appearin...
What are your top 5 reasons to choose between a TAVI valve Edwards SAPIEN 3 (Edwards Lifesciences) vs an Evolut FX (Medtronic) and what favors one over the other?
Considering the SMART trial, for patients with a small annulus I favor Medtronic. However, evaluating other studies comparing hemodynamics and EOA, I favor Medtronic for most patients (FAVORS MEDTRONIC). If patients have lower coronaries, especially with the history of coronary artery disease, prev...
What is your approach to determining the safety, appropriateness, and timing of SPECT or PET MPI in patients admitted with NSTEMI and who remain chest pain-free and hemodynamically stable?
Patients with NSTEMI who are stable should have a coronary angiogram as soon as possible. If an angiogram is not available or may be higher risk due to renal failure then a stress test is reasonable but it should be also be done as soon as possible. The goal is to revascularize a vulnerable plaque b...