Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Among asymptomatic patients with structurally normal TTE undergoing treatment with anthracyclines or alkylating agents that develop mildly elevated BNP and/or troponin levels, would you consider referring them for cardiac MRI to evaluate for subclinical cardiotoxicity?
If TTE images are adequate and the echo is entirely normal, but BNP and/or troponin levels are mildly elevated after anthracyclines or alkylating agents, differential diagnosis includes HFPEF, ischemia, or subclinical cardiotoxicity. If Echo shows unexplained significant LVH, CMR is reasonable to ru...
Would you empirically elective to anticoagulate patients with a remote (i.e. >10 year) history of paroxysmal atrial fibrillation presenting with newly diagnosed CVA, presumed cardioembolic in etiology, without any documented recurrence of AF?
Yes, I would, especially if the etiology is suspicious for being cardio-embolic. As per the ACC/AHA/HRS 2019 Updated Guidelines for AF management, patients with non-sex-related CHA2DS2-VASc score of >/=1 should be offered oral anticoagulation. For this particular patient, that score would be 2.
Would you start an amiodarone load for new onset atrial fibrillation with RVR intermittently in normal sinus rhythm to further suppress AF recurrence in the acute setting?
The answer to this question really depends on the clinical scenario. Does the patient have a structurally normal heart? Is this a post-op setting where the AF is expected to settle down with time? Age of patient? Co-morbidities? Candidacy for less toxic drugs or ablation? If this were a post-op pati...
When would you consider discharging post-TAVR patients on outpatient mobile cardiac telemetry with baseline right bundle branch block without further signs of conduction abnormalities 24-48 hours after the procedure, given risk of developing later-onset conduction abnormalities?
I agree with Dr. @Dr. First Last's comments. Preexisting RBBB is one of the most potent predictors for need development of significant AVB warranting a pacemaker post-TAVR and this represents roughly 10% of patients undergoing the procedure. Though there have been expert panel recommendations (Rodés...
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...