Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What is your approach to patient selection for cardioneuroablation for vasovagal syncope?
Cardioneuroablation (CNA) for vasovagal syncope is a potential treatment that I have enthusiasm for but my use is tempered by limitations in the currently available evidence base. My opinion is that the majority of patients with vasovagal syncope(VVS) should not undergo this procedure, especially in...
What are the current clinical practices for TEE to guide cardioversion and anticoagulation duration post-cardioversion for Afib/flutter in patients following left atrial appendage closure?
Right now, there is not a great deal of data to guide us to answer this question. In general, the safest thing from a stroke prevention standpoint would be to adhere to the same guidelines that we would for patients without left atrial appendage occlusion devices. However, of course, most of these p...
How do you manage calcium and vitamin D supplementation in patients with sarcoidosis on chronic steroids?
This is a great question with very limited data to help answer it well. The first-line therapy for sarcoidosis is corticosteroids, and chronic use can lead to decreased bone mass. Of course, Vitamin D supplementation is a very important factor in rebuilding bone mass. In sarcoid patients, this issue...
In what clinical context would you consider offering first time catheter ablation for symptomatic atrial fibrillation in patients with advanced heart failure, as opposed to a trial of antiarrhythmics and/or cardioversion?
I would favor first-time catheter ablation in patients with advanced heart failure as a way to improve LVEF%, symptoms, reduce risk for recurrent hospitalizations, and decrease mortality. Many patients with advanced heart failure have an enlarged LAVI, so DCCV will only be a temporary solution and a...
What radiation dose is a risk for damaging function or active leads from a pacemaker?
This is a complex issue sometimes asked on our weekly OLA/ABR website. According to the updated 2019 AAPM TG-203 report published in Medical Physics by Miften et al., PMID 31571229, and the JACC review by Fradley et al., PMID 34604807, care for patients with CIEDs requires careful attention to indiv...
When would you consider using acetazolamide to augment diuresis in patients with ADHF?
The ADVOR trial suggested that the addition of acetazolamide to a loop diuretic "upfront" in congested patients with heart failure achieves greater decongestion at 72 hours and discharge. While most would not use such a combination in "all" patients, this strategy is optimal in those demonstrating s...
In male patients in their 60s who had a single episode of PAF (24 hours, terminated spontaneously or with beta-blockers) without recurrence on 30-day monitoring, and without reversible triggers (such as OSA), should lifelong anticoagulation be started when they turn 65, thereby, increasing the CHA2DS2 VASc score to 1?
NO-score of 1 based on age alone coupled with a very low burden of AF=risks of anticoagulation likely greater than no anticoagulation. A reasonable option is PRN anticoagulation for an episode lasting longer than 6 hours-12 hours-certainly 24 hours-keeps options are open for doing cardioversion IF t...
Is moderate-intensity statin plus ezetimibe just as effective as high-intensity statin monotherapy in preventing major cardiovascular events?
The secondary stroke prevention trial showed that high/moderate-intensity statin therapy combined with ezetimibe and titrated to achieve LDLc <70 were equally effective (compared to goal LDLc <100). Overall, the most important determinant of risk reduction is the achieved LDLc, and so moderate inten...
Should bare metal stents be favored over drug eluting stents for pregnant patients presenting with acute coronary syndrome?
This is a great question. There is limited data that supports the safe use of DES in pregnant patients requiring revascularization (Regitz-Zagrosek et al., PMID 30165544). New-generation DES has a lower risk of stent thrombosis with shorter or even very short duration (28 days) of dual antiplatelet ...
Can sotalol initiation for atrial fibrillation be performed safely outpatient, and if so, what would be a reasonable protocol for implementing this?
In my opinion, sotalol (and Tikosyn) should never be initiated as an outpatient. We have all seen cases of torsades at some point in our careers related to sotalol initiation and QT prolongation, even when resuming a dose that was previously tolerated. There is a nice review article published in JAC...