Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How do you prioritize semaglutide versus intensive lifestyle therapy when addressing residual cardiovascular risk in a patient with established ASCVD, obesity, and no diabetes?
In a patient with established ASCVD and a BMI of 27 or great I discuss semaglutide therapy in addition to lifestyle therapy as an important and evidence-based therapy to reduce their risk for recurrent ASCVD events. This would be a shared decision with the patient based on their preferences, coverag...
How are you using fish oil to reduce the risk of stroke and heart attack in CKD patients?
I am not, as of yet. I would like more data before doing that.
Is there a role for routine stress testing in intermediate-high risk CAD patients with a significantly elevated coronary calcium score who are otherwise asymptomatic?
Current data does not support stress testing in asymptomatic intermediate risk individuals in general and those with incidental CAC also do not have an indication for the test. ASCVD risk factor modification suffices.
In ischemic stroke patients with low LDL levels (<30-50 mg/dl), would you consider lowering LDL levels to lower values without concern for any side effects?
If LDL levels are already below 70, I don’t target a lower goal. The SPARCL trial showed that reducing LDL to this range has an NNT of about 45 to prevent one stroke, which I find to be modest at best. From my perspective, lowering LDL further (<30-50 range) shifts the focus to treating a number rat...
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 would you approach the timing of hemodialysis for an ESKD patient with no urgent indications who has NSTEMI with a troponin level of 10 ng/dl, has not had dialysis in 2 days, and is planned for left heart catheterization the next day?
Proceed with coronary angiogram and dialysis after the procedure.
Do you require an ECG to assess the QTc interval before administering ondansetron to a hospitalized patient without a known cardiac history or QT-prolonging medications?
There is a nice "Things We Do For No Reason" article in Journal of Hospital Medicine on this: "Hospitalists need not order an initial and subsequent ECGs when administering standard doses of intravenous ondansetron for patients without significant risk factors for QTc prolongation. To assess risk fa...
How do you counsel patients with metabolic syndrome who decline statin therapy and have low coronary calcium scores regarding their long-term CVD risk?
This is a great question with many ramifications, and I can only give an incomplete answer that includes personal opinion. First, what is the risk? The MESA Risk Score Calculator (check it out) gives a CAC percentile score as well as a 10-year risk. The 10-year risk may be low, but a high percentile...
What is a reasonable imaging modality for older patients with pAfib already on systemic anticoagulation outpatient but presenting with suspected cardioembolic stroke and TTE without evidence of LV thrombus?
Gold standard is TEE.
For patients who have undergone ablation for atrial fibrillation with elevated bleeding risk, what is your risk/benefit approach when deciding to continue oral anticoagulation long-term?
I would generally determine the continuation of anticoagulation based on the patient's ChADSVASC score rather than the perceived success of ablation as many will have a burden of subclinical PAF despite ablation. So, if they are at high risk for stroke/systemic embolism, based on ChADSVASC, I would ...