Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What is the optimal anti-platelet/anticoagulant strategy and duration following a left atrial appendage occlusion with a watchmen device and is a CTA good enough to assess if the device is well seated and without any peri device leaks?
There is no guideline based answer. Based on observation: High bleeding risk patients: half dose apixaban for 45 days, then confirmation of LAA successful closure with TEE/CTA (depending on centers preference), followed by antiplatelet monotherapy (usually ASA or clopidogrel).
What would be your threshold to recommend TEE guided DCCV in a patient who has remained in atrial fibrillation in the post-operative period following CABG, who has achieved adequate amiodarone loading dose?
If not anticoagulated for a sufficient period of time, TEE would be mandatory prior to electrical cardioversion.
Do you recommend avoiding ESAs in ESKD patients with heart failure who require a left ventricular assist device?
I have not had such a patient as of yet but my sense would be to give them ESAs. We want to keep the Hgb above a certain level and avoid blood transfusions. The most logical way to accomplish that would be an ESA.
What is your approach to maintenance of sotalol in terms of drug monitoring and duration of therapy for outpatients who remain in normal sinus rhythm?
I have a healthy respect for the proarrhythmic potential of sotalol. I routinely load and increase the dose in the hospital setting. Not too dissimilar to dofetilide. I avoid as much as possible other drugs that prolong the QT interval and I use caution with other drugs that slow the HR. I monitor E...
Do you pursue a cardiac evaluation in all patients with an excised cutaneous myxoma?
I'm a dermatopathologist, not a clinician, but would note the following data points: Many things are called myxomas. Those associated with Carney complex, in which atrial myxomas also occur, are a specific variant, superficial angiomyxomas. They usually have inactivation of protein kinase regulator...
Is ABI (Ankle Brachial index) lower limb arterial doppler not recommended if patient already has arterial stents in the legs, and if so, what other imaging modality would you consider as first-line?
ABI is still helpful in follow-up of patients with arterial stents but only gives a sense of global perfusion to the distal limb and may not be helpful in patients with calcified non-compressible vessels, (e.g. CKD, diabetics), so a better assessment is arterial duplex that can visualize the entire ...
Given that high coronary calcium scores portend significantly increased cardiac mortality rates over 5-6 years, is there any data to support performing coronary angiography when the score is very high, e.g. over 1000, even in asymptomatic patients with no objective evidence of ischemia?
The question is; is coronary angiography necessary in asymptomatic folks with extensive CAD on EBCT? Will it tell us more than what we already know; that the patient has extensive CAD? Will it make an asymptomatic patient feel better? Will the information obtained from coronary angiography allow for...
What steroid sparing agent do you use for treatment of cardiac sarcoidosis?
Recognizing that corticosteroids will be needed to acutely stabilize cardiac sarcoidosis, a steroid sparing agent is usually a reasonable choice early. My choice of secondary agents depends on the other manifestations of sarcoidosis present at the time of diagnosis. I have rarely seen cardiac sarcoi...
Would you change an elderly, frail patient with atrial fibrillation who is already on a NOAC to VKA treatment?
I wouldn't on the basis of this study. Aside from the other limitations of the FRAIL-AF trial, this study only addressed the utility of switching a stable patient from VKA to NOAC and not vice versa. A patient who is doing well on an appropriately dosed NOAC may experience difficulty achieving adequ...
How do you choose between spironolactone and finerenone for patients with proteinuric diabetic kidney disease and heart failure?
Although finerenone may be easier to use due to its lower incidence of sexual side effects and hyperkalemia, it is more expensive than spironolactone and may be more difficult to prescribe. Many prescription drug plans require prior authorization for finerenone and documentation that the patient has...