Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Under what circumstances would you consider withdrawing aspirin and continuing with potent P2Y12 inhibitor monotherapy after successful PCI in patients with acute coronary syndromes, based on the findings of the NEO-MINDSET trial?
The NEO-MINDSET trial suggests that aspirin may not be essential after STEMI treated with PCI in selected patients. Its findings indicate that early aspirin withdrawal, continued with potent P2Y12 inhibitor monotherapy, can be safe, particularly when bleeding risk is elevated and ischemic risk is ty...
What is your approach during DCCV if you have an obese patient with atrial fibrillation refractory to up to 3, 360 J shocks?
To some degree it depends on what happened with the first three shocks, (I would have applied pressure to shorten the AP diameter for the second and/or third). If the patient converted but it didn't stick, I would consider AAD loading followed by a repeat procedure. If the patient did not appear to...
How would you treat an elderly patient with borderline cardiac dysfunction who has stage 3 HR+ HER2- breast cancer?
If she has an invasive lobular carcinoma and is a borderline candidate for chemotherapy, can possibly try using neoadjuvant letrazole for 3-6 months with close monitoring with breast MRI every 2 months to make sure there is no progression and assess response. If she is lucky and has CR/PR, then poss...
What is your systolic blood pressure target for patients over 80 with frailty and multiple comorbidities?
The target of 150/90 mmHg for adults over 80 primarily comes from the HYVET study, which demonstrated benefit in reducing stroke and mortality in this age group. However, as with all decisions in geriatric care, treatment should be individualized and guided by the patient’s functional status and goa...
What is your approach to anticoagulation in patients with hypertrophic cardiomyopathy and an apical aneurysm?
Patients with hypertrophic cardiomyopathy and an apical aneurysm are at higher risk for sudden cardiac death (hence the 2a guideline recommendation for primary prevention ICD) and thromboembolism. Rowin et al., PMID 29122139 previously noted that non-anticoagulated HCM patients with apical aneurysms...
What is your approach for patients who have marked inter-arm blood pressure differences on home and in office measurements?
I'd first confirm that there is a difference in BP between arms by having the patient alternate BP measurements at home while seated with the back supported in a chair. In the office, I may perform AOBP measurements in both arms, but definitely would compare radial pulses simultaneously. If there is...
What is your approach to initiating spironolactone in patients with end stage kidney disease and heart failure?
Not sure that we have a consensus answer for this question, but spironolactone in hemodialysis patients likely causes more harm than good.There are data suggesting that spironolactone increases the risk for arrhythmia (heart block or bradycardia; Mc Causland et al., PMID 36763641) and hyperkalemia (...
How do you decide between manual pressure versus opting for a specific vascular closure device at the conclusion of a femoral access case?
Manual vs closure devices depend on the following: cathlab turnover- if fast turnover needed, manual pressure with sheath pull in PACU speeds up stuff, as long as the “puller” is not the provider cath’ing evidence for closure device vs manual pressure is only good for hospital LOS and early deambul...
Do you recommend patients with hypertensive kidney disease transition from wrist to upper-arm home blood pressure monitoring prior to making dose adjustments to their antihypertensive regimen?
Possibly, if I think the measurements are not accurate. Home BP monitoring is an important part of hypertension management. In my practice, I've noticed that positioning while taking the BP is more important than the specific device type. I advise patients to check their BP at home in a hard-backed ...
Do you favor ticagrelor or prasugrel first-line for the treatment of ACS with planned PCI, provided no contraindications to either agent?
I prefer Prasugrel based on the latest data from ISAR-REACT 5 trial. I almost never use ticagrelor as it is expensive and there are significant side effects (Shortness of breath being the most common).