Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Would testing for ATTR cardiac amyloidosis be considered in an older patient with bilateral carpal tunnel surgeries and multiple spinal stenosis surgeries, but no obvious cardiac symptoms?
I would not look for ATTR-CM in the absence of cardiac findings such as abnormal echo (increased LV thickness) or conduction abnormalities that are suggestive. Only 10% of patients with bilateral CTS have ATTR-CM. I would do an echo if not done and review ECG. As much as we are concerned about under...
With the FDA recently approving acoramidis for ATTR cardiac amyloidosis, how should we decide on optimal drug therapy and options for our patients?
Both tafamidis and acoramidis are stabilizers of transthyretin (TTR) and both have been shown in clinical trials to lessen hospital admissions for CHF and to reduce death in TTR cardiomyopathy compared to placebo. Although acoramidis is said to produce "near complete stabilization" of TTR, and is re...
What are high-risk clinical and echocardiographic features in pregnant patients with congenital heart disease?
The most commonly used risk stratification tool available has been the mWHO maternal cardiovascular risk classification which places women into different categories (I-IV) based on diagnosis/ residual lesions. Class IV patients are considered very high risk for cardiovascular events (bleeding, throm...
What are your first-line vasopressors of choice for the management of acute severe aortic regurgitation and persistent hypotension/shock?
Clinically, it's a surgical emergency, but I would reach for norepinephrine in the acute setting for hypotension, keeping a lower MAP target to manage after load as best as possible.
How do you decide between ordering coronary calcium scoring versus coronary CTA in asymptomatic patients with low to moderate risk for CAD?
Arteries try to “heal” atherosclerotic plaques by calcifying them. Consequently, the presence of coronary artery calcium (CAC) indicates that there is at least some coronary atherosclerotic plaque. The amount of coronary calcium is quantified using the “Agatston” CAC score. The higher the score, the...
What is your outpatient approach to patients with new-onset paroxysmal atrial fibrillation in the setting of acute illness but who are otherwise asymptomatic with normal sinus rhythm post-hospital discharge?
I tend to individualize my approach. In general, I consider any significant episode of atrial fibrillation with a chadsvasc 2 score =/>2 to warrant long-term anticoagulation provided no bleeding contraindications. An acute illness involving infection, trauma or surgery would not likely steer me awa...
When would you consider PPM implantation for intermittent episodes of high-degree AVB that persist following a successful PCI in a patient presenting with an inferior STEMI?
AV block that occurs with an inferior STEMI is not usually caused by interruption of the distal conduction system and is often reversible. The key term in the question is "persistent." How long after the MI has AV block been observed, what is the heart rate, and is the escape rhythm wide or narrow? ...
What is your approach to persistently low INR despite escalating doses of warfarin in a patient with bioprosthetic mitral valve replacement who is unable to be on DOACs?
The assumption here is that the mitral valve is mechanical, or there are presumably other reasons that a DOAC cannot be used. If this is, in fact, a mechanical mitral valve, it would make sense to start with low molecular weight heparin injections as soon as feasible while awaiting a therapeutic INR...
In patients with post-MI LV thrombus which resolves after 3-6 months of anticoagulation, would you consider surveillance imaging for thrombus recurrence if there is persistent apical akinesis?
I think the key word here is akinesis (or dyskinesis); effectively, an immobile segment of myocardium gravitationally farthest south of the ‘northward’ flow of blood across the aortic valve. This effectively allows for stasis in an injured and immobile region... two of the three components of Vircho...
What factors influence your choice between low-dose DOAC therapy and dual antiplatelet therapy for the first 3 months after percutaneous left atrial appendage occlusion?
Using the ADALA study and previous observational studies, the use of apixaban 2.5 mg BID appears to be at least as safe if not safer than the use of DAPT. As a result, in patients who are unable to tolerate full-dose anticoagulation, low-dose DOAC is my first line. However, if patients have cerebra...