Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Would it be reasonable to begin considering GLP1 RAs or finerenone for patients with heart failure with recovered LVEF in light of recent trials such as SELECT and FINEARTS-HF showing some success in HFpEF and HFmrEF populations?
I reject the premise of the question. Patients with HFrEF who improve on medical therapy do not become HFpEF. The pathophysiology of these diseases are entirely distinct and it speaks to the limitation of EF as a categorical variable. HFrEF patients have cardiomyopathy that manifests over time as di...
What is your stepwise approach to managing no re-flow during PCI?
It’s not so much the vasodilator cocktail, as much as it is, getting the vasodilator cocktail into the capillary bed. This is best achieved by very distal injection via any thrombectomy catheter (which can also be used for thrombectomy if needed). Adenosine at 24 mcg/cc + nicardipine (or verapamil) ...
How frequently do you opt to use IVUS as opposed to OCT or invasive hemodynamic assessment when evaluating coronary lesions?
For questions of lesion significance, I rely on FFR. But I use IVUS on nearly all PCI's for vessel sizing, plaque characteristics, and then stent results. Tend to favor IVUS over OCT because will often do 2-3 IVUS runs (or more) for stent optimization and want to avoid multiple contrast boluses. Are...
What is the clinical significance of a paradoxical decrease in HDL cholesterol after starting statin therapy?
Whether HDL goes up, goes down or stay stable on statin therapy is honestly not of much concern to me. I do not think it is of any clinical significance since we know that statin therapy improves outcomes. In fact, studies show that the clinical benefit of statins is even stronger in individuals wit...
How do you manage patients with central sleep apnea due to heart failure with reduced ejection fraction?
I assume you are referring to CSA with Cheyne-Stokes respiration. Several possibilities, but first ask yourself what your treatment goal is. If the patient does NOT have symptoms (frequent awakenings, daytime sleepiness, etc.) I contend that you don't need to treat at all. We already know that there...
Do you avoid high-potency P2Y12 inhibitors in favor of clopidogrel in patients with atrial fibrillation on a DOAC who undergo PCI?
Not in all cases, favor high potency P2Y12 in high-risk coronary/complex anatomy, clopidogrel in high-risk bleeding patients.
What are some practical ways to incorporate cardiac POCUS in the primary care setting?
In the primary care setting, I find cardiac POCUS most helpful for triage of undifferentiated patients and for monitoring of changes such as volume status, keeping in mind: Cardiac POCUS has a wide spectrum of accessibility for novice users, from systolic function and chamber sizes (attainable) thro...
Do you recommend routine use of protamine for hemostasis at the end of a transfemoral TAVI?
Always, in order to guarantee hemostasis of the femoral site and minimize femoral access complications. Dose is weight based, anegdotically lots of institutions give half the recommended dose as they still see some of the positive effects. Warning: ask about history of allergy/anaphylaxis. Protramin...
Do shorter door-to-balloon (D2B) times impact outcomes in STEMI, if it's already less than 90 minutes, and to what degree (i.e., 30 vs 60 minutes would have a more significant impact)?
No. Shorter door-to-balloon times have not been shown to improve survival or outcomes in STEMI. The reason is that the other variable is the time from the onset of chest pain to presentation to a medical facility. This time is beyond the control of the medical system. For example, a patient waits 4 ...
What is your approach to diagnosis and evaluation of nonbacterial thrombotic endocarditis (Libman-Sacks)?
Nonbacterial thrombotic endocarditis (NBTE), also known as Libman-Sacks endocarditis, is a form of endocarditis characterized by the presence of sterile vegetations on cardiac valves. It is most commonly associated with systemic autoimmune conditions, notably systemic lupus erythematosus (SLE) and a...