Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Among asymptomatic patients with chronic, severe primary MR, can serial global longitudinal strain measurements assist with determining timing for repeat surveillance TEEs and/or facilitate timing for MVR?
The first issue when discussing asymptomatic, severe valve disease is clarifying symptom status. Hemodynamic stress echocardiography or catheterization may unmask symptoms or elevated pulmonary artery pressures at an age-appropriate workload; abnormalities of functional capacity or pulmonary pressur...
What is a reasonable surveillance strategy and length of time to maintain patients with thrombosed bioprosthetic valves on systemic anticoagulation?
When a patient is clinically stable, CT scans and echocardiography can help in differentiating thrombus from pannus formation in bioprosthetic valves (though not perfectly). In the setting of significant symptoms or hemodynamic compromise, surgical valve replacement should be considered (transcathet...
When should we consider using acarbose for postprandial hypotension?
Primarily in neurogenic Orthostatic Hypotension patients, and less frequently in POTS patients, they give a history of dizziness and hypotension with meals. First, we like to confirm the cause and recommend the following, checking before and after BPs at baseline and then with the following: Try sm...
Should a toe-brachial index be obtained in lieu of resting ABI as an initial screen for PAD in high-risk patients such as those with longstanding diabetes or advanced age with stiffened vessels?
Yes, a TBI should be used instead of an ABI in patients with diabetes and chronic kidney disease as the ABI is likely to be inaccurate due to non-compressible vessels. An arterial duplex and TBI should be the test of choice in this patient population.
Would you consider coronary artery calcium scoring or coronary CTA for asymptomatic elite competitive sports athletes undergoing routine screening visits, without a family history significant for coronary artery disease?
I think that would be a "bridge too far" given no family history of premature CAD if we are speaking about a young athlete. If we are speaking about an obese 65-year-old who recently retired and has decided to train for a marathon which has been his/her goal for many years, then yes, coronary calciu...
For young adults (20-39 years of age) with moderate hypercholesterolemia, should we aim to reduce LDL-C levels by > or equal to 50% and maintain them on long-term statin therapy?
Cumulative lifetime exposure to elevated LDL levels is associated with cardiovascular events. That is, even modest elevations of LDL, if present for a long time, can contribute just as much if not more to risk than late-life, elevated LDL. In observational studies, the cumulative lifetime exposure t...
Can DOACs be a reasonable alternative (instead of VKA) for management of LV thrombus post-MI and what is a reasonable follow-up time for surveillance outpatient imaging and subsequent duration of therapy outpatient?
DOAC use is reasonable and would reecho at 6 months. Further therapy is dependent on echo results.
Should statin initiation be considered in young adult patients with autoimmune disease or chronic inflammatory conditions without an elevated ASCVD risk score given risk of underestimation of underlying CVD?
I would if the cholesterol/LDL is elevated or if there is a family history of premature CAD. Otherwise, additional risk stratification with a CT coronary calcium score would be appropriate.
What is your approach to a young adult patient with significant nail psoriasis and not much cutaneous disease?
This is a great question and honestly it depends on how aggressive the patient wants to be. An algorithm could look like this but ultimately you’d discuss it with the patient and see where they stand: Tazarotene +/- Calcipotriene during the week and clobetasol on weekends vs. taclonex or wynzora ev...
How do you manage anti-seizure medications at follow-up in patients who had acute symptomatic seizures due to PRES?
Repeat MRI in 6 months to see if there is a resolution of PRES changes. If resolved and no clinical history concerning for sz then repeat EEG. If EEG and MRI are negative, with no clinical symptoms then slowly taper of AED. Also educate the patient while tapering of meds there is risk of sz, (thi...