Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Do you prefer ivabradine over a beta-blocker as first-line heart rate control in a patient with hyperadrenergic postural orthostatic tachycardia syndrome?
To quote Voltaire, "If you are going to speak with me, you must first define your terms." Hyperadrenergic POTS, so-called, is an ill-defined entity for which there are no agreed-upon criteria. There are four generally accepted markers of excessive sympathetic tone, however: Standing norepinephrine ...
How do you manage patients with atrial fibrillation having a thromboembolic infarct despite being on adequate anticoagulation?
This scenario is always challenging. In terms of anticoagulation, the efficacy of DOACs in preventing embolic events in AF patients is around 70%, which is impressive compared to warfarin but not foolproof. In cases of a second embolic event while on anticoagulation, two reasonable approaches are of...
How soon after initiating oral anticoagulation therapy for atrial fibrillation can it be interrupted for surgery or procedures?
As with most things medical, multiple answers. If a patient walks into my office for preOp "clearance" and behold, they are in atrial fib, but asymptomatic, then it would depend on the urgency of their surgery. If elective, then you have time to work up his atrial fib and look for a reversal cause (...
Would you perform a diagnostic paracentesis for first-time ascites in a patient with established CHF or pulmonary hypertension, but without apparent liver or other intra-abdominal disease?
Great question. Yes, we should perform a diagnostic paracentesis for first-time ascites, even in patients with established CHF or pulmonary hypertension, unless there is an obvious alternative explanation and the procedure is unsafe or technically not feasible. After the etiology is established, rep...
Do you prescribe hydroxychloroquine to patients who are on other medications that can prolong the QT interval?
First, I'll remind everyone that before COVID-19, case reports of QT-prolongation-associated arrhythmias were rare. It wasn't until COVID that we all at once saw cases with the caveats that these were in patients treated with higher doses of HCQ, commonly loading doses of 800 mg daily, plus COVID-1...
What is your approach to using coronary calcium scoring to select older adults for statins in primary prevention without diabetes or known ASCVD?
A definition of older adults needs to be made. If greater than 75, it’s a class IIb indication and of limited value. Risk score, also in patients under 75, should be at least 5%, preferably closer to 7.5%. I tend to give the patients the data and let them make the decision; it’s definitely not a mus...
How do you decide between obtaining routine, outpatient ETT versus stress TTE when screening for CAD, especially given insurance company preference on ETTs?
Before getting into the opinion on the above question, it has to be said that the practice of utilizing any stress test to "screen" for coronary artery disease is currently frowned upon, and it is recommended that proceeding with a diagnostic workup should be based on the patient being both at risk ...
What is your approach to secondary stroke prevention in patients with atrial fibrillation and intracranial stenosis (>70%)?
The patient clearly needs to be on an anticoagulant for stroke prevention with atrial fibrillation and I would choose apixaban. If an antiplatelet is added to the apixaban, the risk of a major bleeding side effect is significantly increased. It is uncertain if apixaban is effective in reducing the r...
When would you consider referring a patient with suspected cardiac sarcoidosis based on PET and MRI for endomyocardial biopsy given degree of patchy involvement, as opposed to initiating empiric immunosuppressive therapies?
I would avoid initiating empiric immunosuppressive therapies without a firm diagnosis of sarcoidosis. I will mention however that the latest Japanese Circulation Society criteria for the diagnosis of sarcoidosis do include criterion for the non-invasive diagnosis of likely cardiac sarcoidosis based ...
When would you consider tapering glucocorticoids in a patient with ICI-associated myocarditis?
Patients with ICI myocarditis are treated with 1g solumedrol for 3-5 days and then transitioned to oral prednisone at 1mg/kg per day. In general, a slow prednisone taper is recommended (i.e. decrease by 10mg per day every 1-2 weeks). Prior to de-escalating steroid therapy at each stage, there should...