Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
In a patient with cardiac light chain amyloid who has significant heart failure symptoms, including inotrope dependence at presentation, how much clinical benefit does treatment provide?
In patients with cardiac light chain (AL) amyloidosis who present with significant heart failure symptoms and inotrope dependence, the clinical benefit of treatment is a complex and nuanced issue. This scenario often reflects an extreme end of the disease spectrum. Historically, patients with advanc...
Do you discontinue amlodipine or use an alternative approach to manage peripheral edema when it occurs as a side effect of the medication?
Peripheral edema is a common complaint and can be exacerbated by any vasodilator therapy, including hydralazine and minoxidil. My initial approach to swelling is to 1) make sure there is no proteinuria, which can be easily overlooked in a diabetic who infrequently sees doctors; 2) assess heart and l...
What are some tips for visual estimation of ejection fraction when trying to difference between low-normal (50-55%) and mildly reduced (45-50%)?
Differentiating between a low-normal (50–55%) and a mildly reduced (45–50%) ejection fraction (EF) is inherently difficult with visual estimation alone because the difference is subtle. When evaluating point-of-care ultrasound, it is important to consider the limitations of the device you are using....
Should there be a role for sacubitril-valsartan in the management of patients with heart failure with preserved ejection fraction?
When it comes to HFpEF, we don't have a lot of effective therapies in our armamentarium. SGLT2 inhibitors have known cardiovascular benefits and were shown primarily to reduce hospitalization in EMPEROR-Preserved and DELIVER. Arguably, spironolactone can be included here despite a trial (TOPCAT) tha...
How do you approach cardiac surveillance in an asymptomatic adult who received anthracycline-based chemotherapy for a childhood cancer and presents to you without an active survivorship program?
At our children's hospital, we are not allowed to follow patients >23 years old if they were not diagnosed and treated at our institution. However, we do offer a 1 time courtesy consultation in the survivor clinic. We request roadmaps and create a treatment summary for the patient, perform a history...
How often do you have worsening hypoxia with patients started on sotatercept?
I have not observed hypoxia with sotatercept. I have seen in a proportion of patients on IV Remodulin as they are titrated in the ICU, usually those with borderline wedge pressures and diastolic dysfunction.
What clinical parameters or CV imaging considerations would prompt you to consider AV nodal ablation for patients with cardiac amyloidosis and symptomatic atrial fibrillation?
We do this quite often. Atrial fibrillation in amyloidosis often causes considerable clinical deterioration and the first approach should be to attempt to restore sinus rhythm. This can safely be done with electrical cardioversion after adequate anticoagulation. No pre Cardioversion transesophageal ...
Are there any radiation dosimetric considerations for patients with lung cancer that have had a TAVR?
No, the new valve solves a mechanical problem. It will have some metal in it, so it would be visible whether it is a mechanical or biosynthetic type. I'd suggest not having a direct beam hit it, as that is the area of the coronary arteries' origins, and avoid dose spillage to reduce late toxicity. T...
What is your approach to the management of incidentally elevated HDL levels in isolation and is there any utility for further ASCVD risk stratification and/or genetic testing for lipid disorders?
Although the U-shaped curve for HDLC and ASCVD was a surprise (probably missed until huge population cohorts were studied), the data have been reasonably confirmed in many studies now, with some heterogeneity regarding gender as well as CVD vs total mortality. If I see a patient now with an HDL over...
Are there other scenarios besides prior history of TIA or stroke or LV dysfunction in which systemic anticoagulation for LV non-compaction would be considered?
There is limited data in this area, but LV non-compaction by itself is not always an indication for anticoagulation. In addition to prior history of TIA, stroke or LV dysfunction, other conditions that anticoagulation should be considered include a history of atrial fibrillation or LV thrombus. The ...