Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
In a patient with severe TR, when is the best time to start thinking about T-TEER?
When tricuspid regurgitation is symptomatic and is refractory to optimal medical therapy. Prior to irreversible RV dysfunction and hepatic dysfunction. In patients deemed too high-risk for surgical intervention.
What has been your stepwise approach to oxygenation, including when to consider the use of inhaled nitric oxide or epoprostenol, in refractory hypoxemia due to cardiogenic pulmonary edema in patients who are otherwise not ECMO candidates?
Stepwise Approach to Oxygenation in Refractory Hypoxemia Due to Cardiogenic Pulmonary Edema: Initial Stabilization and Oxygen Therapy: Start with supplemental oxygen to maintain SpOâ‚‚ > 90%. Use noninvasive ventilation (NIV), such as CPAP or BiPAP, to provide positive end-expiratory pressure (PEE...
Would you consider PPM implantation for patients during their hospital stay following TAVR if they were to develop lengthening PR intervals and widening LBBB QRS duration exceeding 150ms afterwards?
Would do an EP study to guide me further.
Would you consider adding niacin to the lipid lowering regimen in statin-intolerant patients who cannot afford PCSK9i or bempedoic acid?
Yes, in a patient who absolutely cannot take a statin or other common alternatives such as ezetimibe, PCSK9 inhibitors, or Bempedoic acid, Niacin for ASCVD risk reduction is still a reasonable choice. While the combination of statin and niacin has been shown to be unhelpful (and possibly of greater ...
Among patients with recovered LVEF on GDMT with a reversible cause for heart failure (i.e., tachycardia-mediated or alcohol-mediated cardiomyopathy), would you consider de-escalation of GDMT?
There are several cardiomyopathies wherein complete recovery in LV function is observed, especially those associated with tachycardia or thyroid disease, with alcohol cardiomyopathy ranking second. However, discerning whether the improvement in function stems from the biology of the disease or the u...
How do you identify the subset of heart failure patients who are likely to benefit from cardiac resynchronization therapy in the setting of an RBBB pattern?
There are no good criteria to delineate which patients with RBBB will benefit from traditional CRT. The best contemporary strategy is to consider CRT if a patient has an RBBB > 150 ms, an atypical morphology (suggesting an underlying delay in the LBBB or an IVCD), and Class III-IV HF symptoms. One m...
Would you consider a short duration of dual antiplatelet therapy following plain old balloon angioplasty (POBA) to a femoropopliteal bypass graft
Aspirin alone is sufficient after plain old balloon angioplasty, particularly in a high bleeding risk patient.
Do you prefer the routine use of bivalirudin over UFH during PCI cases in patients presenting with ACS?
The antiplatelet strategy is the key, in terms of pre-treatment, or post-treatment, maintenance therapy, or loading therapy, and choice of DAPT therapy. This antiplatelet regimen, in terms of timing of load and choice of non-ASA antiplatelet therapy, is a major factor in maximizing PCI outcomes. Int...
Following completion of antiplatelet monotherapy (i.e., Plavix) plus oral anticoagulation in patients with AFib post-PCI, would you favor continuing antiplatelet therapy + OAC, switching from Plavix to aspirin and continuing OAC, or stopping antiplatelet therapy and continuing OAC?
My practice has always been to continue ASA in addition to anticoagulation but I'm starting to change this practice and remove antiplatelet therapy and continue OAC alone, especially in higher bleeding risk patients. There have been a couple of studies (AFIRE and OAC-ALONE) that would seem to suppor...
What would be your index of suspicion for AL amyloidosis with cardiac involvement in a patient with MGUS to prompt further imaging (and which modality would be preferred)?
In short, we will usually be concerned for potential underlying AL cardiomyopathy (AL-CM) in a patient with MGUS if they have symptoms/signs of heart failure. NT Pro BNP is very sensitive for detecting cardiac involvement of amyloid (Zhang et al., PMID 33283202) and troponin can also help. While the...