Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How do you decide between administering or deferring upstream P2Y12 inhibitor treatment until patient is in the lab for NSTEMI or STEMI cases with unknown coronary anatomy?
Unless you are using clopidogrel there’s no need to consider upstream use in STEMI. In NSTEMI, you can use heparin/lovenox or a P2Y12 no need for both. If you don’t know the anatomy you’re gambling to give upstream P2Y12. In ACS administration of a P2Y12 inhibitor before assessment of coronary anato...
When would be your threshold to consider obtaining an exercise RHC for undifferentiated dyspnea to help diagnose HFpEF?
When to Consider Exercise Right Heart Catheterization (RHC) for Diagnosing HFpEF in Patients with Undifferentiated Dyspnea: Persistent, Unexplained Dyspnea: Clinical Context: Exercise RHC is indicated in patients with persistent dyspnea not explained by common conditions such as chronic obstructiv...
In light of the NOAH-AFNET6 and ARTESiA trials, how would you approach the decision regarding anticoagulation for patients with incidentally-detected AF <24 hrs on pacemakers/defibrillators?
Finding the right answer for subclinical atrial fibrillation is sometimes hard to tease out the subtleties. The 2023 ACC/AHA/HRS atrial fibrillation guidelines were published in Jan 2024 (Joglar et al., PMID 38033089) and a section (6.4.1) is dedicated to patients with CIED without prior atrial fibr...
Should all kidney transplant patients be started on statin therapy post operatively given their increased risk of CVD?
A kidney transplant is not an indication for statin therapy per se. The 2018 cholesterol guidelines list CKD (but not ESRD or Transplant) as a risk-enhancing factor. I would guide the decision to use statin therapy based on the patient's risk as assessed for non-transplant patients. Having said that...
How do you risk stratify patients with different WHO groups of pulmonary hypertension prior to non-cardiac surgeries?
First, I would direct the audience to recent AHA guidelines on the perioperative management of PH in non-cardiac surgery. Rajagopal et al., PMID 36924225In general, the severity of pulmonary hypertension and relevant comorbidities are likely more important than the WHO group. In patients with CTEPH,...
What is your approach to GDMT uptitration (particularly dosing for ARBs/ARNIs/MRA) if there is further evidence of renal dysfunction, especially in situations with worsening AKI on CKD?
Titration of RAAS inhibitors in the setting of AKI on CKD is challenging. First, look at the patient: if they have an increase in Cr after an increase in the RAAS inhibitor but no/stable HF symptoms and appear euvolemic on examination, then I will decrease diuretic therapy and see if the Cr improves...
What is the optimal approach to treat isolated diastolic hypertension?
Isolated diastolic hypertension occurs less commonly in the adult population, where the majority of the outcome trials in hypertension have been conducted. Much of the treatment of hypertension in younger patients is extrapolated from these trials. In my practice, I look more closely for secondary c...
Would you consider switching choice of P2Y12 inhibitor for patients with ISR (non-ACS presentation), with acceptable bleeding risk?
There is no need to change P2Y12 inhibitor in case of ISR without ACS. There are no studies that suggest such approach is indicated or can be helpful. Also, patients are taking their current P2Y12 inhibitor for a while and they are used to the medications. Changing the medication can raise cost with...
When would you consider obtaining a cardiac CT in lieu of standard TEE for the detection of a left atrial appendage thrombus in atrial fibrillation?
TEE is still the gold standard for the evaluation of left atrial appendage thrombus. That being said, there is certainly a role for cardiac CT as well, especially in patients with esophageal pathology or other conditions that increase the risk or contraindicate the use of TEE such as significant thr...
Would you recommend normal saline for pre- and post-LHC hydration in patients with CKD stage III to IV with reduced LV systolic function, and if so, what is a reasonable amount of volume?
The POSEIDON trial, or Prevention of Contrast Renal Injury with Different Hydration Strategies, was a randomized controlled trial that found a personalized hydration strategy can reduce the risk of contrast-induced acute kidney injury (CI-AKI) in patients undergoing cardiac catheterization. The tria...