Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How do you decide when to refer patients with obstructive hypertrophic cardiomyopathy for alcohol septal ablation versus septal myectomy?
If a patient with obstructive HCM remains severely symptomatic despite being on maximal standard-of-care medical therapy, (beta blockers, non-dihydropyridine calcium channel blockers, addition of disopyramide for combination therapy, or a cardiac myosin inhibitor if appropriate), septal reduction th...
What are your outpatient surveillance strategies (biomarkers, imaging, symptoms) to monitor response to treatment for ATTR amyloidosis with cardiac involvement?
I continue it indefinitely. Limited survival data shows a beneficial effect for at least 5 years with survival on the drug of 55% compared to 37% on placebo.Elliot et al., PMID 34923848However, if patients deteriorate dramatically on therapy and are class IV NYHA, I discuss with patients and family ...
How do you re-stratify patients with a primary prevention ICD in need of a generator change if their LVEF has improved to >40% and they have not previously required any device therapies?
This is an important question on which there remains a lack of consensus. We had tried to address this through an observational study which was published a few years back:(Appropriateness of primary prevention implantable cardioverter-defibrillators at the time of generator replacement: are indicati...
For patients on immune checkpoint inhibitors presenting with chest pain, dyspnea, fatigue, and troponin elevation, would you recommend early initiation of high dose steroids for empiric treatment of ICI myocarditis while pursuing workup with coronary angiogram, echocardiogram, and/or cardiac MRI, or wait until alternative etiologies have been ruled out?
This question raises an important point that the clinical presentation of ICI-associated myocarditis often overlaps with other cardiovascular disorders, including acute coronary syndrome, chronic CAD, congestive heart failure, and other nonischemic cardiomyopathies. Therefore, prompt initiation of w...
How do you manage patients blood pressures while on anti-angiogenic TKIs?
Advise patients to take BP daily, and inform us if the BP is high.
Should all patients with a remote history of immunotherapy, chemotherapy and/or radiation therapy have a baseline TTE regardless of ASCVD risk?
The current ASCVD risk assessment calculators we have available do not contain cancer-specific parameters and thus are inadequate for accurate assessment of a cancer survivor's risk of developing CHF and ischemic heart disease. If patients have received mediastinal radiation therapy or high-dose ant...
What is your approach to considering geriatric patients for complex PCI given their overall frailty and increased risk of complications such as bleeding and stroke?
I would do everything I could with respect to medical and lifestyle therapy for such a patient. They are at very high risk for a bad outcome in the cath lab.
When would you consider initiating GDMT for new onset HF in the geriatric population?
I would always treat with GDMT but would start low and slowly advance watching for AE's.
What is a reasonable blood pressure goal for refractory HTN in the geriatric population?
Resistant hypertension is defined as a blood pressure that remains above goal despite concurrent use of three antihypertensive agents of different classes taken at maximally tolerated doses, one of which should be a diuretic. Refractory hypertension is defined as uncontrolled blood pressure despite ...
How do you decide on an outpatient maintenance diuretic regimen for patients approaching discharge for ADHF?
Good question. More from my personal observational experience. I reduce the dose to minimal once the patient is well compensated clinically and other pillars are tolerated well. If the SGLT2i, ARNI, and beta blockers are already on board and the patient coming off the IV lasix, I will add low-dose M...