I've worked with many great PCPs over my career and I can tell you would be fantastic to work with. . But I've also worked with many who are very much wedded to the old paradigm of CAD and who were very much complicit in the freight train to the cath lab mind set. At one health center I worked it was not uncommon for the PCPs to directly contact a cardiologist who only did caths/stents, i.e. he didn't do cardiology consults, didn't manage cardiology patients post stent or pre-stent, just did any cath that any doctor wanted done. Frequently, if the PCP wanted a cath done and the cardiologist felt it wasn't warranted , that cardiologist would not get any more referrals. On top of that, if any lesion was found it got a stent, somewhat irrespective of the severity and without any requirement of ischemic testing, FFR, etc.
Many PCPs view the stable CAD patient as a "hot potato" and only feel comfortable once the coronary anatomy is outlined by an invasive angiogram and a stent implanted.
What they don't realize is that the patient has been converted from stable CAD to an unstable situation with that stent.
You would be fantastic to work with, and be careful not to move to Philly area or you’ll be deluged with my referrals 😉
I hesitate to say this, but a lot of primary care docs, myself included at times, fear doing the passive thing, the lawsuits, and feel like we should err on the side of (over)caution? You’ve explained how this is counterproductive and potentially harmful sometimes - often less is more, thanks again!
Just circled back and read this at a leisurely pace. Fantastic stuff for a primary doc to read, too. Many thanks, bookmarking this to reread once a year 👌
I had svc repair with stent rush because I was having episodes of unconsciousness. Summer of 2016 was the original stent, within weeks (2) failed kink it located in common vena cava, required revision and reinforcing stent, clotted again within few days. It was a nightmare clotted and adding more now left and right innominate stents, again one kink more declotting , more stent to the right subclavian, clotted again revised more stents now continue to axillary, now 3 different anticoagulation meds. At the end of the this adventure is disadvantage for patients management and quality of life, it has take away other opportunities to improve my health.
I'm not a big advocate of the CAC scan in your age group unless we are looking to deprescribe.
Believe it or not 450 is the average score of an 82 year old white man so your risk is neither lower nor higher than most men your age.
As such, whether you should take anything for cholesterol is highly debatable and should be determined by you after a good discussion with your doctor on the risks and benefits.
No value in repeating the CAC as it will be >450 now.
Very well done exploration of therapeutic cardiovascular misguidance. These reviews are an invaluable roadmap to providers who know these assertions to be true but who need the evidence based corroboration. Great job!
Really eye opening Dr. John. You are such a service to the population. If only we could accelerate the points you make, based on the research, into practice faster.
I'm 82 yrs old. What are your thoughts on CAC sets? I had it done a couple of years or so and had a score of around 450 involving 2 arteries. I have been on and off statins don't like how I feel when taking them! Have been using beets, black garlic, Nattokinase ,niacinamide, fish oil etc. I'm asymptomatic with good blood pressure, CRP of 1.7 Lp(a) 13mg/dl, Ap(b) 106 mg/dl I'm thinking about having the test repeated but they say the results generally get worse so I'm having some doubts? Also my wife who is 79 yr old and also asymptomatic but taking a weak dose of blood pressure med., is being asked to have the test done by her internist. Seems like the CAC test is becoming more popular? Thank you so much for just reading my babble!! Cliff Kozian
Interesting article! My bypass was over 16 years ago and follow up care seems to be different these days. I haven't had any stress tests, EKGs or Echocardiograms since you left St. Luke's and I've been free of any cardiac symptoms!
Follow up care varies markedly from center to center.
I continue to see patients who were previously taken care of by more mercenary physicians who are still getting routine annual stress nuclear testing. In addition to generating false positives which lead to unnecessary catheterizations, the nuclear tests provide substantial radiation exposure which accumulates over time.
I've worked with many great PCPs over my career and I can tell you would be fantastic to work with. . But I've also worked with many who are very much wedded to the old paradigm of CAD and who were very much complicit in the freight train to the cath lab mind set. At one health center I worked it was not uncommon for the PCPs to directly contact a cardiologist who only did caths/stents, i.e. he didn't do cardiology consults, didn't manage cardiology patients post stent or pre-stent, just did any cath that any doctor wanted done. Frequently, if the PCP wanted a cath done and the cardiologist felt it wasn't warranted , that cardiologist would not get any more referrals. On top of that, if any lesion was found it got a stent, somewhat irrespective of the severity and without any requirement of ischemic testing, FFR, etc.
Many PCPs view the stable CAD patient as a "hot potato" and only feel comfortable once the coronary anatomy is outlined by an invasive angiogram and a stent implanted.
What they don't realize is that the patient has been converted from stable CAD to an unstable situation with that stent.
You would be fantastic to work with, and be careful not to move to Philly area or you’ll be deluged with my referrals 😉
I hesitate to say this, but a lot of primary care docs, myself included at times, fear doing the passive thing, the lawsuits, and feel like we should err on the side of (over)caution? You’ve explained how this is counterproductive and potentially harmful sometimes - often less is more, thanks again!
This is Philly:
https://opmed.doximity.com/articles/a-sick-culture-of-malpractice-and-personal-injury-billboards-along-the-highway
Great article on malpractice!
Thank you so much!
Just circled back and read this at a leisurely pace. Fantastic stuff for a primary doc to read, too. Many thanks, bookmarking this to reread once a year 👌
I had svc repair with stent rush because I was having episodes of unconsciousness. Summer of 2016 was the original stent, within weeks (2) failed kink it located in common vena cava, required revision and reinforcing stent, clotted again within few days. It was a nightmare clotted and adding more now left and right innominate stents, again one kink more declotting , more stent to the right subclavian, clotted again revised more stents now continue to axillary, now 3 different anticoagulation meds. At the end of the this adventure is disadvantage for patients management and quality of life, it has take away other opportunities to improve my health.
Clifton,
I'm not a big advocate of the CAC scan in your age group unless we are looking to deprescribe.
Believe it or not 450 is the average score of an 82 year old white man so your risk is neither lower nor higher than most men your age.
As such, whether you should take anything for cholesterol is highly debatable and should be determined by you after a good discussion with your doctor on the risks and benefits.
No value in repeating the CAC as it will be >450 now.
Dr. P
I am neither the Dr. John the NiteTripper nor the Dr. John Mandrola of Sensibile Medicine Substack but I am a huge fan of both.
Very well done exploration of therapeutic cardiovascular misguidance. These reviews are an invaluable roadmap to providers who know these assertions to be true but who need the evidence based corroboration. Great job!
Really eye opening Dr. John. You are such a service to the population. If only we could accelerate the points you make, based on the research, into practice faster.
I'm 82 yrs old. What are your thoughts on CAC sets? I had it done a couple of years or so and had a score of around 450 involving 2 arteries. I have been on and off statins don't like how I feel when taking them! Have been using beets, black garlic, Nattokinase ,niacinamide, fish oil etc. I'm asymptomatic with good blood pressure, CRP of 1.7 Lp(a) 13mg/dl, Ap(b) 106 mg/dl I'm thinking about having the test repeated but they say the results generally get worse so I'm having some doubts? Also my wife who is 79 yr old and also asymptomatic but taking a weak dose of blood pressure med., is being asked to have the test done by her internist. Seems like the CAC test is becoming more popular? Thank you so much for just reading my babble!! Cliff Kozian
Interesting article! My bypass was over 16 years ago and follow up care seems to be different these days. I haven't had any stress tests, EKGs or Echocardiograms since you left St. Luke's and I've been free of any cardiac symptoms!
Christie,
So glad you are continuing to do well!
Follow up care varies markedly from center to center.
I continue to see patients who were previously taken care of by more mercenary physicians who are still getting routine annual stress nuclear testing. In addition to generating false positives which lead to unnecessary catheterizations, the nuclear tests provide substantial radiation exposure which accumulates over time.
Dr. P