Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
Do you start a statin for cardioprotection in a patient with no lipid indication who is beginning anthracycline chemotherapy?
My answer is that this is a nuanced and shared decision making discussion.First, patient starting new chemo needs pre cancer cardiotoxicity risk assessment using the HFA-ICOS risk calculator https://www.cancercalc.com/hfa-icos_cardio_oncology_risk_assessment.php.Next the patient needs optimization o...
What factors would guide your decision to safely resume anticoagulation for atrial fibrillation following a recent intracranial hemorrhage?
Whether a patient with atrial fibrillation and an intracerebral hemorrhage should resume anticoagulation depends on whether the bleed was attributed to cerebral amyloid angiopathy (CAA). Most patients with CAA should not be on long-term (lifelong) anticoagulation. If a bleed was attributed to hypert...
When do you opt for the use of intracoronary nitroprusside over nitroglycerin and how do you determine the appropriate dose to administer in no-reflow situations?
I generally start with intracoronary nitroglycerin because it is familiar, readily available, and effective when epicardial vasospasm is contributing to slow flow. I consider nitroprusside when there is persistent slow flow or no-reflow despite adequate epicardial patency and nitroglycerin, particul...
How do you decide whether to prescribe electrolyte supplementation at discharge for patients with persistent mild derangements?
I would only prescribe electrolyte supplementation at discharge for mild derangements if there is a clear medical/medication-related reason (such as a new diuretic) and would ensure the patient has close outpatient follow-up.
How do you prioritize and sequence GDMT classes when polypharmacy or frailty limits up-titration in an older patient with symptomatic HFrEF?
I am also concerned about pushing too much and too high levels of GDMT in elderly patients with a chance for hypotension, falls, and fractures. I usually try to get my elderly CHF patients on carvedilol at a modest dose and an ACEI/ARB at a moderate dose. I have the patients keep a first AM BP log t...
Based on most current research regarding the more widespread use of class IC antiarrhythmic drugs, what are your prescribing practices in patients with coronary artery disease?
Fair question, as we know the definition of "structural heart disease" is unknown. In the trial, it was likely ischemia driving the poor outcomes, so I will get stress with imaging on everyone >50 years old (CAD risk). Given the common finding of "questionable" stent placement in the community, I wi...
How do you decide on the speed and target of blood pressure reduction for spontaneous intracranial hemorrhage?
I think the target and speed of blood pressure reduction in ICH depend on several variables, including initial SBP, clinical stability, hematoma size, and renal function. For patients presenting with SBP >220, I typically aim to lower the pressure to around SBP 160 over the first 12 hours, then grad...
Does the presence of diastolic dysfunction guide subsequent pharmacological, pacing and ablative therapies for atrial fibrillation?
For the majority of patients with atrial fibrillation, symptoms are generated by the elevated heart rates rather than the irregularity or the loss of the atrial contribution to ventricular filling. The exception to this is patients with heart failure with preserved ejection fraction (diastolic dysfu...
Does anyone utilize P2Y12 assays to determine if clopidogrel may be ineffective when used for DAPT?
Yes, I use P2Y12 assays in two distinct settings. Medical management: If a patient on clopidogrel mono/dual therapy has disease progression with ICAD or experiences a recurrent ischemic event, I obtain a P2Y12 assay to assess responsiveness. This helps guide the decision to switch to ticagrelor and ...
How long do you recommend waiting after variceal bleeding and banding before a transesophageal echocardiogram can be performed safely?
In the exact wording of this question, the scenario that is being presented is that the patient has had a variceal hemorrhage (VH) recently and urgent banding has already been performed to stop the VH (so that the concern would be of the TEE probe knocking off a band that is actively treating an eso...