What is the preferred treatment regimen for cardiovascular syphilis, specifically syphilitic ostial coronary artery disease?

The standard treatment with benzathine pen G 2.4 MU IM, 1-3 doses at weekly intervals, depending on likely duration of syphilis, should be sufficient. Most likely there is no need for especially high dose penicillin therapy. I can understand a theoretical rationale for it, for urgent or potentially life threatening consequences, which might include coronary artery involvement. However, the rationale for high dose treatment for neuro, ocular or otic syphilis is pharmacokinetic and not because of clinical severity -- i.e. because BPG doesn't provide therapeutic levels in CSF.

My bottom line is that I would not criticize a decision for high dose IV penicillin, but I do not think it is necessary.