Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
When would you consider starting lipid-lowering therapy for young adults < 30 years of age who have markedly elevated LP(a) and family history of elevated LP(a) and ischemic heart disease?
Years ago, there was a cartoon where two men were sitting eating dinner, and one said to the other, “My physician told me that worrying about your cholesterol was the leading cause of hypertension.” Our discussion question is appropriate given the recently released new guidelines for treating choles...
How does VExUS evaluation differ in a patient with a transjugular intrahepatic portosystemic shunt (TIPS)?
This is a very interesting question, and I don't think I have ever tried to look at VExUS in a patient with a TIPS before! Although, based on what I understand about this study, I would be cautious about relying on the original VExUS algorithm that incorporates hepatic vein, portal vein, and intrare...
Do you plan to incorporate fish-oil supplementation into the care of hemodialysis patients to reduce cardiovascular events in light of the PISCES trial results?
I showed the paper to an Internal Medicine friend of mine who is more statistically savvy than me. He wrote this: "So I read the study, and I’m still at a loss to understand it. I’m pretty Bayesian, but this study breaks my priors. Prior studies were basically negative, not to mention that nothing e...
What degree of aortic valve insufficiency is reasonable to tolerate for Impella supported PCI provided that the Impella will be removed at conclusion of case?
Mild or moderate AI would be tolerated for a short period of time, so long as the patient tolerates it from a hemodynamic standpoint. I do not think severe AI would be tolerated, even for a short duration, such as the time it takes to do a PCI.
Are there still clinical situations in which you deliberately treat patients with a DOAC besides apixaban?
Thank you for your question. Apixaban has been my preferred agent for a long time for patients requiring therapeutic anticoagulation. Apixaban’s lower bleeding risk was shown prior to and now has additional evidence to support this with the COBRRA trial. The risk is also ameliorated by the safety in...
What would be your approach for the management of asymptomatic, severe AS with a peak velocity of 5 m/s in an otherwise physically active patient in their mid-90s without significant co-morbidities?
The EARLY TAVR trial (Généreux et al,. PMID 39466903) showed that in patients with asymptomatic severe AS, early TAVR was associated with a 50% reduction in the primary composite endpoint of death, stroke, or unplanned hospitalization for cardiovascular causes compared to clinical surveillance over ...
Do you recommend initiating treatment with an SGLT2 inhibitor or semaglutide first for a patient with obesity and heart failure with preserved ejection fraction?
Irrespective of body weight status, my first line of treatment for patients with HFpEF is with SGLT2 inhibitors if there are no contraindications (DELIVER trial and EMPEROR preserved trial). For patients with obesity (cardiometabolic) phenotype HFpEF, who qualify for GLP1 receptor agonists, I add on...
What objective tools do you use to help determine if a patient is too high risk for anticoagulation to prevent stroke or DVT?
There are a number of risk scores, like HAS-BLED, that can be used, but I continue to use clinical judgment and shared decision-making. The excellent risk profile of NOACs and the availability of LAAO mean that I can usually come up with a solution for almost every patient that will protect them fro...
What is your approach to treating patients with decompensated heart failure when their hypervolemia is refractory to oral furosemide?
Depending on the oral dose, it may just be a problem of underdosing or even perhaps non-adherence. We would typically transition to intermittent IV Lasix dosing with close monitoring, if minimal response, we can double the dose to try and get to the ceiling effect of Lasix, depending on the renal fu...
What is the frequency in which patients should be taking pill in the pocket medication for paroxysmal atrial fibrillation before you begin to consider maintenance dosing medications instead?
This is very patient-specific; they need to have a good understanding of the process and good access to an EKG (even if it is a consumer device like Kardia). I find many patients either do not understand fully or respect the potential dangers of these medications. For example, they will take multipl...