Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What is your preferred pharmacologic agent for recurrent VT suppression in arrhythmogenic right ventricular cardiomyopathy?
In general, I like VT/PVC-focused beta-blockers which tend to be nadolol and propranolol (for example in CPVT, nadolol bested other BBs - Heart Rhythm 2016 Leren et al and propranolol over metoprolol in VT storm - JACC 2018 Chatzidou et al). According to the 2019 HRS expert consensus statement on ar...
What is your stepwise approach to initiating GDMT in the inpatient setting for newly diagnosed HFrEF?
The decision to preferentially initiate one of the 4 first line GDMT agents (BB, RAASi, SGLT2i, MRA) other the other, is to a large extend determined by patient characteristics, such as BP (can start all medications at low doses if BP permits), HR (prefer BB if tachycardic), presence of AKI (delay i...
Should we routinely incorporate iron studies into admissions for acute decompensated heart failure?
Low serum Iron level in ADHF patients is an independent predictor of poor prognosis. Iron is an essential element in oxygen transportation, delivery, and utilization. I would check the Iron panel in patients with ADHF. However, the frequency of follow-up has not been well defined. Iron deficiency is...
When is an appropriate time to consider endomyocardial biopsy for non-ischemic cardiomyopathy?
Endomyocardial biopsy is mostly indicated when there is a suspicion for acute myocarditis specially if related with arrhythmias at presentation to r/o giant cell myocarditis, chemotherapy agents related cardiomyopathy specially a tracy clones and immune checkpoint inhibitors, restrictive disease of ...
Should we refer patients with nonischemic cardiomyopathy without a reversible cause for genetic screening, in the absence of any family history of heart failure or sudden cardiac death?
Genetic testing continues to become more available and useful for family screening. There is no clinical benefit to routine genetic testing in DCM. The Dilated Cardiomyopathy Precision Medicine Study continues to identify subgroups of patients genetic testing may be useful for in the future.Huggins ...
How are PA diastolic goals established and individualized to reduce HF readmission risk post-CardioMEMs, recognizing the overall unclear clinical value of outpatient PA sensor monitoring?
The PA diastolic goal is generally set to <20 mm Hg to aim for euvolemia. Consideration should also be given to mPAP (<25 mm Hg). However, the goals need to be individualized, taking into consideration underlying pathology of HF (HFpEF vs HFrEF with steeper PV curves in patients with HFpEF), pulmona...
Which clinical and echocardiographic parameters (i.e. LVEF, AVA) do you use when determining patient candidacy for LV device-assisted percutaneous balloon aortic valvuloplasty in patients with cardiogenic shock and severe AS?
This is a tough one and there is no one best answer. The entire clinical picture must be taken into account. Typically, use of an RHC can help guide a patient in cardiogenic shock the best. Historically, patients with mean gradients over 40 mmHg with AVA < 1.0 cm sq by echo or by invasive testing wi...
Is there a preferred heart rate range for patients with moderate to severe paravalvular leak post-TAVR?
There is no optimal heart rate in managing moderate to severe paravalvular regurgitation after TAVR. I generally begin at 70 BPM. Depending on associated conditions such as CAD or mitral stenosis the rate can be increased with echo guidance for optimal rate
What would be a reasonable means of mechanical circulatory support as a bridge to AVR for patients with severe aortic regurgitation complicated by cardiogenic shock?
Options are limited when dealing with severe aortic regurgitation. LAVA-ECMO should be considered to provide needed support. This can reduce the increased left-sided filling pressures and urgent surgery is warranted. Tandem heart can also be considered to help provide needed support without increase...
Among asymptomatic patients with chronic, severe primary MR, can serial global longitudinal strain measurements assist with determining timing for repeat surveillance TEEs and/or facilitate timing for MVR?
The first issue when discussing asymptomatic, severe valve disease is clarifying symptom status. Hemodynamic stress echocardiography or catheterization may unmask symptoms or elevated pulmonary artery pressures at an age-appropriate workload; abnormalities of functional capacity or pulmonary pressur...