Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Should an ischemic evaluation be considered in the diagnostic work-up for new-onset diastolic heart failure/HFpEF in patients without clear anginal symptoms?
The ischemic phenotype is a well-recognized class among HFpEF patients. For men, this usually manifests as macrovascular disease with epicardial CAD, and for females, the more common manifestation is microvascular disease with CMD. Therefore, ischemic evaluation should be considered as part of the w...
Would you recommend a GLP-1 agonist as an option to reduce the risk of dementia in patients with a strong family history?
I'm recommending GLP-1 for many things right now, but I haven't yet independently recommended it just to reduce the risk of dementia. However, if microvascular disease can contribute to vascular dementia, then there may be a benefit to better controlling diabetes with this drug.
Would you recommend a GLP-1 agonist as an option to reduce the risk of dementia in patients with a strong family history?
I'm recommending GLP-1 for many things right now, but I haven't yet independently recommended it just to reduce the risk of dementia. However, if microvascular disease can contribute to vascular dementia, then there may be a benefit to better controlling diabetes with this drug.
What therapeutic approaches have you found effective for athletes with anorexia nervosa whose eating disorder symptoms are intertwined with sport-driven weight pressures?
The gold standard for treatment of anorexia nervosa and all eating disorders is a team-based approach, including the individual, psychiatrist, counselor, primary care or sports medicine physician, dietician, appropriate family members, and, in the case of elite athletes, sometimes their coaches. Rap...
For elderly patients (i.e. older than 80) with only one documented episode of paroxysmal atrial fibrillation following a stress event (such as acute illness/steroid administration) and a CHADsVASc score greater than 1, how would you counsel them on the risks/benefits of anticoagulation and subsequent monitoring for afib recurrence?
If it were an isolated event, I would advocate continued monitoring for recurrence before starting an anticoagulant with the understanding that the risk of AF recurrence is relatively high.
How do you approach the management of post-concussion syndrome with symptoms including vertigo, headaches, persistent fatigue, and/or mood symptoms?
Each persistent post-concussion symptom that you listed has interventions that can be helpful. For vertigo, I recommend referral to vestibular therapy. I also use our behavioral health providers very regularly in the PPCS population. Because a concussion is a neuro-psychiatric condition, therapy is ...
How do you integrate HIV (+) serostatus into a patient's ASCVD if they would not otherwise qualify for a statin either for primary or secondary prophylaxis?
HIV (+) serostatus is a significant risk-enhancer for the development of cardiovascular disease and should be taken into account when making treatment decisions regarding statin initiation, even if the patient's viral load is low or not detectable. In a patient >40 years old and with a risk >5%, wou...
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.
How do you approach a patient with high titer ANA and a new diagnosis of ITP, but no other signs or symptoms suggestive of active rheumatologic disease?
I would certainly treat the ITP with hematology involvement if necessary but would continue to monitor for lupus or similar CTDs. I have seen patients present with an ITP-like picture for years before lupus declared itself eventually. It may take years. I would also check a UA for proteinuria. This ...
Considering only cerebrovascular indications, are there circumstances in which you would use aspirin along with a DOAC in patients with atrial fibrillation and stroke?
I will use aspirin 81 mg and a DOAC together in patients who "fail" (I hate that term) the DOAC. The combination was used in patients in the original DOAC trials, so it is not unreasonable. Not my first choice, but can be done. It is worth noting that the evidence does not support doing this upfront...