Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Is there any contraindication to the use of ezetimibe in patients with a history of statin-induced necrotizing myopathy?
These types of questions are always great to discuss. The reality is there is a risk-benefit ratio to be considered. On one hand, there is a concern for the need for lipid-lowering to prevent cardiovascular disease, and some situations are more pressing than others. A diabetic with a known cardiovas...
What is your approach to evaluating a patient with a suspected myocardial contusion?
Echocardiogram and troponin levels...
Should systemic anticoagulation be considered for patients with a less than 1% atrial fibrillation burden on outpatient monitoring with an elevated CHADSVASc score and acceptable bleeding risk?
This is a recurrent question. My policy is to anticoagulate such patients. The cutoff for anticoagulation is still controversial though. I believe that any episodes lasting longer than 5 min deserve anticoagulation. Not so sure what to do with shorter episodes but my philosophy is that prevention of...
What is your outpatient approach to monitoring paroxysmal atrial fibrillation (i.e. mobile cardiac telemetry, decision to anticoagulate if high likelihood of recurrence) in young adults with CHADsVASC score of 0, in light of potential remodeling and increased Afib burden as they age?
This is an important question, especially in light of the most recent data suggesting that early maintenance of sinus rhythm is beneficial in patients. If the patient truly has a CHADsVASC score of zero, they have lone atrial fibrillation, low stroke risk, and our major concern is prevention of remo...
How do you determine the feasibility of doing a valve-in-valve for patients requiring AVR with index surgical aortic valve replacement?
The feasibility of doing a valve-in-valve TAVR for patients with preexisting SAVR all rests on a high-quality CT pre-planning analysis. a good high-quality study will reveal important information regarding the primary access approach for the TAVR, coronary heights, sinus widths, valve-to-coronary di...
For patients over 90 years old, is there any foreseeable benefit to undergoing left atrial appendage occlusion over permanent cessation of anticoagulation, particularly for those at high risk for major bleeding?
I would have no qualms about referring a 90+ year-old patient with a-fib and high bleeding risk for an LAA occlusion device. However, this requires a shared decision-making process whereby the risks and benefits of the various treatment options are discussed with the patient and, when appropriate, t...
When would you consider initiating patients with CAD and aortic stenosis on PCSK9 inhibitors (as an adjunct to statin therapy), given favorable findings in the FOURIER trial?
There are limited data to support PCSK9 inhibitors in the treatment of aortic stenosis, and in fact, most is theoretical. Elevation of lipoprotein (a) levels independently increases the risk of in early-onset CAD and calcific aortic stenosis. Lp(a) levels are lowered by PCSK9 inhibitors by ~20-30%, ...
Are there scenarios in which pericardiocentesis should be considered for large pericardial effusions without tamponade physiology?
Yes
Is there evidence to support empiric atrial flutter ablation for patients undergoing PVI for atrial fibrillation in the absence of clinical evidence of atrial flutter?
Presumably, triggers for typical atrial flutter, emerge from the left atrium. No randomized trial has shown the combined ablation is more sensible than performing one sided atrial ablation without evidence of typical right atrial flutter.
Do you routinely perform echocardiography in patients with Staphylococcus aureus bacteremia deemed low risk for metastatic infection, or do you selectively omit it based on specific clinical criteria?
A limitation of the applicability of this study is that no isolates of MRSA were detected. Thus, there would be no strains, such as USA300-like strains, with both virulence and resistance mechanisms. In this situation, the goal is to avoid morbidity and mortality from a uniformly deadly disease: S. ...