Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How does evidence of cerebral amyloid angiopathy/microbleeds affect choices for secondary stroke prevention in patients with a history of ischemic stroke and atrial fibrillation?
This is a discussion I have with the patient, mentioning that the positive predictive value of cortically based cerebral microhemorrhages is not absolute, especially when there is a small number of them and there are no other signs of small vessel disease (such as FLAIR changes or enlarged peri-vasc...
What is your approach to CLL in patients with atrial fibrillation and/or on anticoagulation?
Before the availability of venetoclax, the only approved targeted oral therapy for patients with CLL was ibrutinib. Given the lack of alternative options, patients with atrial fibrillation and/or patients on anticoagulation were treated with ibrutinib. Use of anticoagulation with ibrutinib can incre...
How do you counsel patients regarding the cardiovascular risk of febuxostat?
We understand that gout is a very inflammatory state and in general that inflammatory states can be a risk factor for cardiovascular disease. Although studies such as this have shown an increased all cause and cardiovascular mortality in febuxostat group compared to allopurinol group, it is importan...
Given the "LDL Paradox", in which RA patients with the highest levels of inflammation can have ultra-low levels of LDL (<70), how do you approach initiation of statin therapy in these patients?
Evaluate lipids at the time of remission/low disease activity and if elevated and the patient is a good candidate for statin therapy, initiate a statin using criteria for the general population.
Do you consider 10MV beams safe in a patient with an implantable cardiac device?
I follow the AAPM TG-203 which considers beams up to 10 MV photons to be non-neutron producing. For example, in a lung, abdominal, or pelvis tumor, I find the reduction in total body dose worthwhile to use 10 MV.
What are your considerations for peri-operative anticoagulation in patients with a mechanical heart valve undergoing a major noncardiac surgery?
For a patient with a modern (e.g St Jude bi-leaflet) mechanical valve (with or without AF) and who does NOT have a h/o of stroke or TIA, the available evidence suggests that "bridging" may have more risk than benefit: See Kovacs et al., PMID 34108229 and Siegal et al., PMID 22912386. Based on this e...
Would you consider using DOACs in a young patient with SLE and Libman-Sacks endocarditis, who is negative for APS?
In this scenario, our patient with lupus is young and does not have features of APS. Nevertheless, any patient with Libman Sacks endocarditis carries a heightened risk for embolization. Regarding anticoagulation, the literature on this subject is anecdotal and conflicting with some authors recommend...
What are the alternatives to anticoagulation in an individual with an atrial thrombus and absolute contraindications to anticoagulation?
This is not an easily answered question in this sort of a forum. This clinical situation requires multidisciplinary input and individualized approach. Factors to consider include but not limited to, 1) estimated risk of systemic arterial embolism (note, current tools/calculators provide the annual r...
At what heart dose would you prospectively refer a patient to cardiology due to anticipated long term risks?
If a patient had prior BCT and now inflammatory, I would refer given the most likely plan for additional chemotherapy and RT. In general, I refer for cardiac oncology based on a combination of cardiac risk factors (HTN, DM, HLP), family cardiac history, anthracycline receipt, and cardiac dose (ex. I...
Are there situations where you would start treatment for cardiac amyloid in a patient with amyloid seen on biopsy, but still pending mass spectrometry results?
I do not think of treating cardiac amyloid without the results of mass spec. You really need to know what type of amyloid you are dealing with.