Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What are reasonable next steps in the work-up of suspected ATTR amyloidosis if the PYP scan is equivocal, in light of the potential risks of endomyocardial biopsy?
Before addressing the next move after an equivocal PYP scan, some comments on PYP scan reporting are in order. Unfortunately, despite the relative simplicity of obtaining a high quality PYP scam, around 10 -20% of the ones that we see done at outside institutions (including teaching institutions) ar...
Under what circumstances would you consider withdrawing aspirin and continuing with potent P2Y12 inhibitor monotherapy after successful PCI in patients with acute coronary syndromes, based on the findings of the NEO-MINDSET trial?
The NEO-MINDSET trial suggests that aspirin may not be essential after STEMI treated with PCI in selected patients. Its findings indicate that early aspirin withdrawal, continued with potent P2Y12 inhibitor monotherapy, can be safe, particularly when bleeding risk is elevated and ischemic risk is ty...
Do you pursue stress testing before discharge for a patient admitted with chest pain who has negative serial high-sensitivity troponins and a low HEART score?
I usually do not since the HEART score (0-3) has such a low incidence of cardiac events in 6 weeks, and in the study, those patients were discharged. That being said, I would ensure the patient has a follow-up within a week to set up any testing that you feel is necessary to work up the chest pain.
For stroke patients with ablated paroxysmal atrial fibrillation without known recurrence and ICAD, would you recommend dual antiplatelet therapy or anticoagulation with or without an antiplatelet agent?
Ablation treats cardiopulmonary symptoms, but it has not been adequately tested against anticoagulation for AFib-related stroke. Anecdotally, at least once a month, I will see a patient with an acute embolic-appearing stroke after their cardiologist has stopped their anticoagulation because they wer...
How do you use NT-proBNP in patients with chronic kidney disease or end-stage kidney disease, given that these conditions can affect NT-proBNP levels?
NT-proBNP is most useful for (a) diagnostic uncertainty in patients who present with dyspnea, and (b) prognostication in heart failure. It is released as a result of ventricular wall stress. In CKD, the clearance of NT-proBNP is impaired, leading to elevated levels. In late-stage CKD and ESRD, volum...
Would you consider amiodarone for the treatment of atrial fibrillation with RVR in patients who cannot tolerate beta blockers but have a high CHA2DS2-VASc score and are not on anticoagulation?
We typically do not due to risk of chemical cardioversion and precipitating an embolism.
How do you decide between stereotactic arrhythmia radiation (STAR) and repeat catheter ablation in patients with refractory ventricular tachycardia who have already failed one prior ablation?
This is a great question and something that the ongoing RADIATE-VT trial is working to answer (NCT05765175). In this phase III RCT trial, recurrent VT patients who have had at least one prior catheter ablation, are considered to be candidates for a repeat catheter ablation by their electrophysiologi...
How soon after an acute upper GI bleed do you restart therapeutic anticoagulation in a patient with atrial fibrillation and a high thromboembolic risk (CHA₂DS₂-VASc ≥4)?
In real-world inpatient practice: ~72 hours after endoscopic control for high-stroke-risk AF with stable hemoglobin and no rebleeding. Extending hold to 5–7 days if the lesion is high risk or the bleed was severe.
What techniques do you use in the lab to reduce the amount of contrast that needs to be used in patients with CKD?
Avoid LV angiogram. Use ECHO instead to assess LV function.
How frequently do you obtain lipoprotein (a) levels on asymptomatic patients without a prior history of CAD?
Recent recommendations are considering that the entire population ought to be tested at least once in their lifetime given the estimated prevalence in the general population of some degree of elevation in as many as 20% of the population. That said I certainly check in most people with a family hist...