Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
In a patient identified as having APLS because of recurrent pregnancy loss without history of thrombosis, but now has a new DVT/PE during pregnancy despite use of enoxaparin—for how long would you recommend anticoagulation?
First, as far as I know, enoxaparin has not been proven to prevent pregnancy loss in obstetric APS. Second, we know that enoxaparin has not been shown to be as effective as heparin in preventing thrombotic events in APS. Third, the patient is pregnant, a thrombophilic state, separate from APS. All t...
At what age do you recommend annual skin exams in a patient without a personal or family history of skin cancer?
I don't have a specific age but rather it depends on the risk factors: Male, fair skin, and older age are risk factors, certain occupations Evidence of actinic damage Immunosuppression, especially organ transplants Multiple nevi > 50 History of dysplastic nevi Childhood radiation exposure Chronic l...
When do you consider referral to hand surgery for management of joint deformity in RA?
This is individualized to the patient's needs. If a patient is uncomfortable due to pain, quality of life or lack of function due to the deformity, I would arrange a consultation with a hand surgeon. Some patients do get distressed by the cosmetic appearance of the deformities and this is an indicat...
How do you monitor a patient with scleroderma during pregnancy?
One of the most important aspects of monitoring scleroderma patients in pregnancy is the preconception visit to review the stage of the disease including getting cardiopulmonary studies before pregnancy and reviewing medications and adjusting any immunosuppressive medications. Although prospective s...
How do you counsel high-risk women with congenital heart disease who are looking to conceive?
Most women with CHD do well during pregnancy; however, some are very high risk and should not get pregnant. These include women with mWHO classification IV for example pulmonary arterial hypertension, severe systemic ventricular dysfunction, or severe mitral stenosis (see ECS 2018 guidelines for com...
When should we integrate CT calcium scoring into routine outpatient practice to arbitrate severity of aortic stenosis?
CT Aortic valve calcium scoring can be especially useful in cases of low flow/low gradient aortic stenosis or in cases where the severity of AS on echocardiography is equivocal. I don’t think there is a need for routine use in cases of unequivocal severe AS except perhaps in asymptomatic patients to...
When should cardiac MRI be obtained alongside standard echocardiography for outpatient monitoring of the progression of chronic aortic regurgitation?
Aortic regurgitation impacts left ventricle with pressure and volume overload. In a patient with chronic, particularly moderate to severe or severe aortic regurgitation, the drop in left ventricular ejection fraction, increasing left ventricular dilation, and patient developing symptoms dictate the ...
When would you consider discharging post-TAVR patients on outpatient mobile cardiac telemetry with baseline right bundle branch block without further signs of conduction abnormalities 24-48 hours after the procedure, given risk of developing later-onset conduction abnormalities?
I agree with Dr. @Dr. First Last's comments. Preexisting RBBB is one of the most potent predictors for need development of significant AVB warranting a pacemaker post-TAVR and this represents roughly 10% of patients undergoing the procedure. Though there have been expert panel recommendations (Rodés...
Should we refer patients with nonischemic cardiomyopathy without a reversible cause for genetic screening, in the absence of any family history of heart failure or sudden cardiac death?
Genetic testing continues to become more available and useful for family screening. There is no clinical benefit to routine genetic testing in DCM. The Dilated Cardiomyopathy Precision Medicine Study continues to identify subgroups of patients genetic testing may be useful for in the future.Huggins ...
How are PA diastolic goals established and individualized to reduce HF readmission risk post-CardioMEMs, recognizing the overall unclear clinical value of outpatient PA sensor monitoring?
The PA diastolic goal is generally set to <20 mm Hg to aim for euvolemia. Consideration should also be given to mPAP (<25 mm Hg). However, the goals need to be individualized, taking into consideration underlying pathology of HF (HFpEF vs HFrEF with steeper PV curves in patients with HFpEF), pulmona...