Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How do you counsel patients with metabolic syndrome who decline statin therapy and have low coronary calcium scores regarding their long-term CVD risk?
This is a great question with many ramifications, and I can only give an incomplete answer that includes personal opinion. First, what is the risk? The MESA Risk Score Calculator (check it out) gives a CAC percentile score as well as a 10-year risk. The 10-year risk may be low, but a high percentile...
What is your approach to performing outpatient hemodialysis in patients with LVADs, particularly regarding blood pressure assessment and ultrafiltration management when Doppler measurements are required due to low pulsatility?
Doppler-based MAP monitoring via Doppler ultrasound with a sphygmomanometer is the primary method for blood pressure monitoring during hemodialysis in these patients with LVAD. Crit-Line monitoring during hemodialysis may potentially be useful in guiding the rate of ultrafiltration in these patients...
Are there robust clinical data on the safety of IV amiodarone for atrial fibrillation of unclear duration and very difficult to control HR in the current era of widespread DOAC use, as opposed to older data with warfarin?
In the current DOAC era, there are no prospective or randomized data specifically evaluating IV amiodarone administered for rate control in atrial fibrillation of uncertain duration. The principal safety concern is not the agent itself but the possibility of unintended pharmacologic cardioversion, w...
What has been your approach to percutaneous intervention for calcified nodules and threshold for intervention?
Very high threshold for intervention in these cases. Generally, there is severe calcification all around and sometimes multiple calcified nodules. There has to be a strong indication for me to consider such cases. I generally start with rotational atherectomy (multiple runs) followed by angioplasty ...
What advice would you give to patients who are concerned about statin use and its controversies around brain health and dementia risk, based on previous studies?
I cannot think of any class of medications in cardiology that has undergone such scrutiny and investigation to try to find a reason not to take such an effective medication. From the earliest days of its use, one concern after another has arisen; from muscle deterioration, to increasing the risk of ...
What is a reasonable management strategy for severely symptomatic atrial fibrillation with persistent LAA thrombus in spite of compliance with several different anticoagulation agents?
Typically, with an appropriate anticoagulation regimen, it is not common to see a thrombus develop. However, there are sometimes cases, such as the scenario posed that LAA thrombus is noted despite compliance with anticoagulation. In my practice, if a thrombus develops despite compliance with a part...
Are there specific types/brands of drug-eluting stent you prefer that perform well in terms of lower ISR rates or ones that are better for patients with high bleeding risk?
That is a great question. All of the currently available drug-eluting stents are very safe, and you can now get away with just one month of dual antiplatelet therapy (DAPT) in a patient with high bleeding risk. There is more and more evidence of using clopidogrel only monotherapy instead of using DA...
Does theophylline have a role in bradyarrhythmias, and if so, in what patient population(s) can this be considered?
The only time I have ever used theophylline is in the post-transplant setting and really only as a bridge until a permanent pacemaker could be installed. I have rarely seen a case where theophylline works reliably long term to consider a permanent solution. The procedural risk of inserting a pacemak...
When should you suspect TR related to pacemaker lead placement as a cause of RV dysfunction rather than pulmonary HTN or other etiologies for RV failure associated with tricuspid regurgitation?
It would be patient-specific but would need to include RHC to rule out pHTN (of any group). That should point you in the right direction. I suspect this would be pretty rare and would have to have very severe TR. We know there is a magic amount of slack to put in the RV lead to minimize TR, but this...
How do you determine which patient may be a good candidate for the Aurora EV-ICD and its smart sense algorithm?
The Aurora Extra-Vascular ICD (EV-ICD) was approved by the FDA in October 2023. The system consists of a lead that is tunneled beneath the sternum, with the lead tip positioned around the level of the carina, and a generator that is placed in the axillary area. The lead is anchored through a small i...