Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Do you consider the use of bevacizumab in patients with HHT who have high output cardiac failure related to liver AVMs who also have cerebral AVMs?
Liver and cerebral AVMs are common manifestations in patients with HHT. Treatment of these manifestations should be considered and managed independently. Guideline recommendations to effectively eliminate the future risk of cerebral hemorrhage in patients with cerebral AVMs is consultation with HHT ...
Do you change management in patients that are taking bisphosphonates and develop atrial fibrillation?
I allow bisphosphonates in patients with afib. In both the alendronate and zolendronic acid trials subanalysis revealed a minimal increase of afib but FDA review suggested both conditions occur often in the elderly and there was no causality. Our group has given several thousand infusions with no af...
What is your approach to volume resuscitation in patients with obvious septic shock but also with a component of suspected cardiogenic shock?
I think it comes down to clinical decision-making at bedside with the help of a combination of modalities. POCUS to evaluate the IVC size and collapsibility is one option we commonly use and is quick and easy to obtain. Additionally, in situations of unclear shock state, our practice is to float a P...
How do you counsel high-risk women with congenital heart disease who are looking to conceive?
Most women with CHD do well during pregnancy; however, some are very high risk and should not get pregnant. These include women with mWHO classification IV for example pulmonary arterial hypertension, severe systemic ventricular dysfunction, or severe mitral stenosis (see ECS 2018 guidelines for com...
When should we integrate CT calcium scoring into routine outpatient practice to arbitrate severity of aortic stenosis?
CT Aortic valve calcium scoring can be especially useful in cases of low flow/low gradient aortic stenosis or in cases where the severity of AS on echocardiography is equivocal. I don’t think there is a need for routine use in cases of unequivocal severe AS except perhaps in asymptomatic patients to...
When should we consider screening patients with systemic sarcoidosis for cardiac involvement using cardiac MRI or PET given their high risk for sudden cardiac death and discrepancies between reported cardiac symptoms (2-5%) and evidence of cardiac inflammation on advanced imaging and autopsy findings (>25% of cases)?
The current guideline recommendations are only to pursue advanced imaging in patients who have symptoms, EKG abnormalities or abnormal echocardiogram. In our experience, we have been able to capture patients with strict assessment of these criteria. However, it certainly can be challenging in patien...
When should cardiac MRI be obtained alongside standard echocardiography for outpatient monitoring of the progression of chronic aortic regurgitation?
Aortic regurgitation impacts left ventricle with pressure and volume overload. In a patient with chronic, particularly moderate to severe or severe aortic regurgitation, the drop in left ventricular ejection fraction, increasing left ventricular dilation, and patient developing symptoms dictate the ...
Which molecular biomarkers do you favor to risk stratify patients (without CV risk factors) before and after undergoing treatment with cardiotoxic cancer treatments?
In general, troponin, NTproBNP or BNP, and lipid panel are the main biomarkers I use for CV risk stratification prior to cancer therapy. Baseline troponin and NTproBNP are primarily useful for cancer therapies that may cause cardiomyopathy or myocarditis (i.e. anthracyclines, anti-HER2 therapies, VE...
Is there a validated risk prediction model you favor to risk stratify patients for cardiotoxicity prior to initiation of chemotherapy?
I would recommend the HFA-ICOS risk calculator as recommended by the 2022 ESC/ICOS Cardio-Oncology guidelines. There is a great discussion here:Strategies for risk stratification and cardiovascular toxicity prevention in patients with cancerAnd there is an easy-to-use version online and on the ESC P...
Would you consider starting an ACE inhibitor on a patient without CVD or heart failure prior to initiation of anthracyclines to reduce the overall risk of myocardial toxicity?
Even though the patient does not have CVD or heart failure history, there are still factors to consider if they are at higher risk for anthracycline cardiac toxicity: Lower EF at baseline, significant valvular heart disease, prehypertension/hypertension, diabetes, obesity, advanced age, any subclini...