Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Do you recommend the use of bempedoic acid (Nexletol) for treatment of hyperlipidemia in patients with elevated baseline uric acid levels?
I would still use bempedoic acid in patients with asymptomatic hyperuricemia if they have no previous history of gout, and will clearly benefit from lipid lowering (high risk ASCVD and statin intolerance). Would monitor uric acid levels in such individuals. However if they have had recurrent gout, I...
When do you consider revascularizing chronic total occlusions after failing medical management?
CTO revascularization is recommended for refractory symptoms despite optimal medical management with anti-anginals and after treating non-CTO lesions (grade 2b recommendation- 2021 AHA/ACC/SCAI revascularization guidelines).
For how long would you hold anticoagulation before percutaneous left atrial appendage closure with Watchman or Amulet devices?
Elective left atrial appendage occlusion with both Watchman and Amulet systems most often utilizes continuous uninterrupted oral anticoagulant administration (including the day of procedure) along with intra-procedural heparin to ACT 250-400 during implant. Procedural heparin is reversed immediately...
Given findings from the LIFE trial, are there any benefits in using Entresto over valsartan alone in HFrEF patients?
Thank you for your question. The LIFE trial studied more advanced heart failure patients. In this patient population, there was no apparent difference in overall outcomes between the two groups in the primary and secondary endpoints but a rise in non-life threatening potassium levels in the Entresto...
What patient characteristics prompt you to prescribe vericiguat for patients with heart failure with reduced ejection fraction who are already on standard therapy?
When considering the addition of vericiguat for patients with HFrEF who are already on standard therapy, several patient characteristics guide my decision-making process: Recent Decompensation: I particularly consider vericiguat for patients who have experienced a recent episode of heart failure de...
How would you lead a goals of care discussion in terms of prognosis/survival likelihood for patients with inotropic dependent HFrEF with CRT-D on maximally tolerated GDMT?
I usually start by reviewing the prognosis with inotrope-dependent HF, quote data from DT VAD trials (REMATCH). I assess the eligibility for DT VAD and transplantation and review the shared decision-making pathways (IDECIDE LVAD) if the patient is eligible for DT VAD. If the patient is not a candida...
How soon following pacemaker implantation can patients safely undergo elective cardioversion?
That is a good question. From a technical standpoint, a cardioversion can be done at any time after a pacemaker implantation. In the past, we often did defibrillation threshold testing on patients on the EP lab table after implanting an ICD and sometimes they would require a shock externally. This w...
For asymptomatic, incidentally found Lambl's excrescence, should long-term surveillance imaging be considered and if so, how often should repeat imaging be ordered?
For small Lambl's excrescence (often characterized as less than 10mm) and found incidentally in asymptomatic individuals, there is no data to support repeat imaging or surveillance. For large/giant growths, or those in the setting of cryptogenic or embolic stroke, further imaging with TEE may be nee...
What would be your approach to a patient with new diagnosis of seropositive rheumatoid arthritis manifesting as a constrictive pericarditis with no joint pain complaints?
This is an interesting clinical scenario. It highlights some of the current issues we face as rheumatologists, namely an atypical presentation of one of our more common diseases. This patient is labeled as having seropositive rheumatoid arthritis yet lacks arthritis features. I suspect the diagnosis...
What is your preferred diagnostic approach to suspected immune checkpoint inhibitor cardiotoxicity in patients who are otherwise not clinically stable enough for cMRI?
The initial diagnostic imaging for a patient with suspected ICI myocarditis/myositis that is not clinically stable enough for a cardiac MRI should be transthoracic echocardiography. However, if the patient is clinically unstable to the degree that they are unable to have a cardiac MRI performed, the...