Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
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...
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...