Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Would you recommend cardiac radiotherapy for malignant pericardial effusion refractory to pericardial fenestration?
Yes. I have done this several times and have gotten some reasonable palliative responses. Typically one cannot determine the exact source for the malignant cells, and one presumes that there are tumor deposits throughout the pericardium, in which case the target is the whole heart. This then limits ...
Would you consider lifelong versus short-term (i.e. several months) course of anticoagulation for patients with elevated CHADSVASc score presenting with newly diagnosed paroxysmal atrial fibrillation triggered in the setting of acute illness (i.e. tachyarrhythmias with COVID-19 or bacterial pneumonia)?
AF during an acute illness could result from the stress of an infection, however, these patients do seem to be at higher risk of recurrence. It might also simply represent the first time that AF has been recognized in a patient who is at risk for atrial arrhythmias. Anticoagulation is indicated in t...
What EKG findings are most concerning when screening asymptomatic athletes in the outpatient setting?
The first answer is quite simple: anything that fulfills the International/Seattle Wash U/Stanford criteria for further evaluation of young athletes was first proposed in 2011 by Uberoi et al., PMID 21824936, and subsequently modified Drezner et al., PMID 28258178.From my personal experience, I "lig...
When would you consider offering PVC ablation for otherwise healthy patients with preserved LV systolic function?
I would generally not offer an ablation for PVC burden alone but may consider further workup/counseling or even ablation if other factors are present. I would obtain a more detailed history to determine if the patient has symptoms/limitations that they did not initially express, which would lead me ...
For patients who have previously undergone MAZE ligation presenting with paroxysmal atrial fibrillation, how would you counsel them on the risk of stroke long-term when deciding whether or not to start or continue anticoagulation?
The decision to start or continue anticoagulation in patients with atrial fibrillation can be challenging, even after LAA closure. Specifically related to surgical closure of the LAA (excluding percutaneous LAAO, such as Watchman or Amulet), anticoagulation is still recommended indefinitely if suppo...
If prompted as an outpatient, how do you counsel patients on the rare cardiac complications of vaccinations including myocarditis?
Not a common event so the incidence is low and depends on patient exposure as to why getting vaccinated in the first place and always a good idea to discuss the risks and benefits of vaccination.
When is the best time to consider left atrial appendage closure for secondary stroke prevention in patients with atrial fibrillation?
There is equipoise about the timing of left atrial appendage closure following ischemic stroke. Due to the need to temporarily treat a patient with either dual antiplatelet or anticoagulation therapy, it is reasonable to wait until after the acute stroke period has passed to allow for healing of inf...
What is your preferred rate control agent for atrial fibrillation with rapid ventricular rate, and why?
It really depends on the clinical scenario. My preferred first line agent is short acting metoprolol. Non-dihydropyridine calcium channel blockers such as diltiazem or verapamil are also effective but should generally be avoided in patients with reduced LVEF. In hospitalized patients with tenuous he...
What is your intraprocedural approach to reducing time to reperfusion in STEMI cases: opting for culprit lesion PCI first then complete angiography, or complete angiography followed by culprit lesion PCI?
Great inquiry. A lot of it depends on the clinical acuity of the presentation as well as systems-based processes as well. If the patient is more unstable with hypotension/bradycardia or other unstable vital parameters, and the EKG is clearly pointing to a certain territory, then in order to avoid de...
Would you recommend starting a moderate-intensity statin in a patient under the age of 40 years old with HIV and a 10-year ASCVD risk estimate below 5%?
I am impressed by the benefit of statins in HIV patients but wonder if the benefit is affected by viral load (which may cause generalized inflammation and/or immune activation). I have not yet reached the point where I am ready to put low-risk, non-hypercholesteremic HIV patients on statins, but am ...