Interventional Cardiologist

[Bevo 13870]

@Fat Bastard or anyone else, who are the best interventional cardiologists in Texas. Non-relative has stenosis of the internal jugular and was told that nothing can be done. I was curious on who would be the best to address the issue. Unfortunately, this is the type of patient people don't like to see - self-diagnoses a multitude of things and pesters. But, I'm curious at the very least.

 

 

[Fat Bastard 669]

We more commonly see thrombosis (clots) in veins than stenosis (tightening). Usually when the internal jugular (IJ) goes down it’s from previous instrumentation from a cath or central venous line. It’s usually chronic and nothing needs to be done. If it’s known acute and, say, occurred during a recent hospitalization, we give Eliquis/Xarelto/or Coumadin based on what the patient can afford. 
 

I’d suggest making sure it’s the IJ that’s affected and not carotid artery (or subclavian artery) stenosis - which is treated much differently.   
 

And, if the patient is adamant about seeing a cardiologist, it would help to know what city they’re located in. I can give tons of recs in Houston, some in Dallas/Austin/El Paso. Don’t know many in San Antonio or other cities. 
 

Hope that helps. 

[Fat Bastard 669]

I should add that venous thrombectomy is a booming field and there tons of new devices on the market (Inari, Penumbra, AlphaVac, Jeti, etc). I’ve never used any of those for an IJ clot (only for DVT/PE) and know, without a shadow of a doubt, it has never been done for IJ thrombosis at my institution. 

[Bevo 13870]

23 minutes ago, Fat Bastard said:

I should add that venous thrombectomy is a booming field and there tons of new devices on the market (Inari, Penumbra, AlphaVac, Jeti, etc). I’ve never used any of those for an IJ clot (only for DVT/PE) and know, without a shadow of a doubt, it has never been done for IJ thrombosis at my institution. 

 

I'm in Austin but I would recommend that she go to Methodist or THI mainly because I knew a lot of the old-timers. I don't know Dallas/Southwestern very well. And don't recommend yourself - she's a PITA.

[Fat Bastard 669]

lol. I work out of THI. If you want to take this to PM’s I can give you some recs and you can give me her contact info to pass along. 

[Vegas64 713]

@Fat Bastard I'm getting up there in age, what do you think about The Cooper Institute and their full workup they do on the heart?

https://www.cooperinstitute.org/

[Fat Bastard 669]

On 12/17/2024 at 3:58 PM, Vegas64 said:

@Fat Bastard I'm getting up there in age, what do you think about The Cooper Institute and their full workup they do on the heart?

https://www.cooperinstitute.org/

Never heard of them. But through skimming their webpage seems like they preach healthy living and preventive medicine, which is what any good cardiologist would. Unfortunately, the bulk of my patients come to me after a lifetime of poor dietary indiscretion with diabetes, hypertension and hyperlipidemia +/- tobacco history on board, and we are left with slowing progression (and, if necessary, invasive treatment) of their atherosclerosis 

[Vegas64 713]

16 hours ago, Fat Bastard said:

Never heard of them. But through skimming their webpage seems like they preach healthy living and preventive medicine, which is what any good cardiologist would. Unfortunately, the bulk of my patients come to me after a lifetime of poor dietary indiscretion with diabetes, hypertension and hyperlipidemia +/- tobacco history on board, and we are left with slowing progression (and, if necessary, invasive treatment) of their atherosclerosis 

They do like a full, preventative, (out of pocket) cardio workup and read-out, is the pitch. Curious if you had heard of this. It's like a cash only, wealthier people type thing from what I understand, and I'm just an old poor guy but my heart is getting up there in age!

[Fat Bastard 669]

Honest opinion? It’s a cash grab

[blacklab 12062]

I did something similar at the heart hospital of Austin. Was given a 100% clean report from them.

I had a heart attack less than a year later.

[DalTxHornFan 3130]

The less that you cross paths with doctors, the better, IMHO.  I don't know anyone that has been in that Heart Hospital of Austin that didn't end up with some sort of surgical procedure.

When your only tool is a hammer - errything starts looking like a nail.  YMMV.

[Fat Bastard 669]

Any of you old enough to be seeing a cardiologist regularly and they order yearly nuclear stress tests, echos, and other dopplers (carotid/lower extremity, etc) are seeing criminals who just generate revenue and milk the system. None of that is based off sound medicine or guideline directed. 
 

there are exceptions (if you’ve had previous valve surgery, a yearly echo is fine for surveillance, or if you’ve had abdominal aneurysm repair, AAA ultrasounds or CTA’s to evaluate for endoleaks/AAA growth, is acceptable)

Edited yesterday at 12:32 AM by Fat Bastard

[RDCanecutter 26868]

4 hours ago, blacklab said:

I did something similar at the heart hospital of Austin. Was given a 100% clean report from them.

I had a heart attack less than a year later.

It's not their fault you launched into a spree of hookers, pet monkeys, and blow.

 

[serious]Glad you're OK.[/serious]

[Bevo 13870]

3 hours ago, Fat Bastard said:

Any of you old enough to be seeing a cardiologist regularly and they order yearly nuclear stress tests, echos, and other dopplers (carotid/lower extremity, etc) are seeing criminals who just generate revenue and milk the system. None of that is based off sound medicine or guideline directed. 
 

there are exceptions (if you’ve had previous valve surgery, a yearly echo is fine for surveillance, or if you’ve had abdominal aneurysm repair, AAA ultrasounds or CTA’s to evaluate for endoleaks/AAA growth, is acceptable)

 

I forgot what you told me (a long time ago), but for someone in good health with good habits and good BMI but with a family history of MI, what tests would you recommend as they enter their 50s, 60s, etc?

[Tonesky 1056]

23 hours ago, Fat Bastard said:

Never heard of them. 

Dr. Kenneth Cooper pretty much invented the field of aerobics. 

[Fat Bastard 669]

2 hours ago, Tonesky said:

Dr. Kenneth Cooper pretty much invented the field of aerobics. 

Really? Figured it was Richard Simmons

2 hours ago, Bevo said:

 

I forgot what you told me (a long time ago), but for someone in good health with good habits and good BMI but with a family history of MI, what tests would you recommend as they enter their 50s, 60s, etc?

Lipid Panel and a coronary artery calcium score. 

[Bevo 13870]

7 hours ago, Fat Bastard said:

 

Lipid Panel and a coronary artery calcium score. 

So no angiogram? I thought calcium scores weren’t diagnostic.

[Fat Bastard 669]

Angiograms should only be for those with classic symptoms of angina (nit controlled with anti-anginals), positive stress tests (in the setting of angina), pre-op for valve surgery to make sure you don’t need concomitant bypass surgery and myocardial infarctions.
 

I put stents in for a living and there’s nothing more I like doing than opening up a blocked coronary artery. But, when I bring a patient to the Cath lab for an angiogram, my hit rate is >75%. When I’m doing a Cath for one of my partners and they don’t have the appropriate indications, it falls to <30% and pisses me off. 
 

Heart caths are invasive procedures and carry risk to the patient (including emergency bypass surgery and death). We need to have a good indication to justify the benefits being > risks. That doesn’t always happen “in the community” unfortunately 

 

if you’re asymptomatic, you don’t need an angiogram (or a nuclear stress test). There are obviously extenuating circumstances, eg, if you’re going for an intermediate/high risk surgery and have multiple risk factors, a nuclear is not unreasonable for pre-op risk stratification 

[Fat Bastard 669]

3 hours ago, Bevo said:

So no angiogram? I thought calcium scores weren’t diagnostic.

Calcium scores are not diagnostic. You just said you’re in good health, with no major risk factors. A coronary artery calcium score will risk stratify you and let us know if we need to be aggressive with risk factor modification like aspirin and statins. 

[tx 3 putt 78664]

great stuff @Fat Bastard thanks for sharing. i have a dr appointment jan 13, im taking notes. im thankful for years of decent / good blood work but need to keep working  harder on dropping lbs 

 

all men should keep up with their regular dr appointments. find a dr you jive with 

Edited 8 hours ago by tx 3 putt

[Bevo 13870]

10 minutes ago, Fat Bastard said:

Heart caths are invasive procedures and carry risk to the patient (including emergency bypass surgery and death). We need to have a good indication to justify the benefits being > risks.

 

Yeah, my grandfather on my mom's side died getting an angiogram when they use to go in through the neck 50 years ago so it isn't like I'm asking for it. But, I'm also a bit of a hypochondriac about heart issues because my dad has had lots of issues and was in good health until he wasn't.  I wish there was something diagnostic but less invasive.

10 minutes ago, tx 3 putt said:

great stuff @Fat Bastard thanks for sharing. i have a dr appointment jan 13, im taking notes. im thankful for years of decent / good blood work but need to keep working  harder on dropping lbs 

 

all men should keep up with their regular dr appointments. find a dr you jive with 

Or just ask surly

[Fat Bastard 669]

22 minutes ago, Bevo said:

 

Yeah, my grandfather on my mom's side died getting an angiogram when they use to go in through the neck 50 years ago so it isn't like I'm asking for it. But, I'm also a bit of a hypochondriac about heart issues because my dad has had lots of issues and was in good health until he wasn't.  I wish there was something diagnostic but less invasive.

Or just ask surly

I have tons of patients that have come to me from other cardiologists who milk the system getting yearly nuclear tests, asking for a nuclear for themselves. All of them asymptomatic. 
 

there’s a misconception that stents prevent heart attacks. Completely untrue. There are only two good indications for coronary stents:

 

1) during an acute heart attack - to save the patient’s life and prevent further myocardial necrosis

 

2) to limit symptoms of angina when medications haven’t helped

 

when we Cath patients, we frequently encounter blockages that are 20-60% that we do absolutely nothing about besides aspirin, statin and BP meds. We are only supposed to stent blockages that are >70% stenosed because it’s at that point that there’s flow limitation downstream. 
 

getting a nuclear on an asymptomatic pt is bad medicine, and if positive, puts us in a bad predicament because at that point we’re left having to perform an unnecessary angiogram on a pt and possibly stenting them, commuting them to 2 blood thinners, and the risk of the invasive procedure which becomes even riskier when you’re “fixing” the artery, all for an asymptomatic pt. You did all that shit for a patient who never had any symptoms to begin with (all while not decreasing their MI risk)

[Bevo 13870]

3 minutes ago, Fat Bastard said:

when we Cath patients, we frequently encounter blockages that are 20-60% that we do absolutely nothing about besides aspirin, statin and BP meds. We are only supposed to stent blockages that are >70% stenosed because it’s at that point that there’s flow limitation downstream. 

 

Is there anything out there that is proven to reverse blockages (foods, medicines, treatments) or is the course of action mainly to keep blockages from worsening and limiting bloodflow?

[Bevo 13870]

10 minutes ago, Fat Bastard said:

there’s a misconception that stents prevent heart attacks. There are only two good indications for coronary stents:

1) during an acute heart attack - to save the patient’s life and prevent further myocardial necrosis

2) to limit symptoms of angina when medications haven’t helped

 

Edited 7 hours ago by Bevo

[Fat Bastard 669]

20 minutes ago, Bevo said:

 

Is there anything out there that is proven to reverse blockages (foods, medicines, treatments) or is the course of action mainly to keep blockages from worsening and limiting bloodflow?

Nothing yet. All about halting progression. 
 

In some animal models, PCSK9–Inhibitors like Repatha and Praluent have shown evidence of plaque regression

[Bevo 13870]

5 minutes ago, Fat Bastard said:

Nothing yet. All about halting progression. 
 

In some animal models, PCSK9–Inhibitors like Repatha and Praluent have shown evidence of plaque regression

 

and those are both mAbs - so not without their own risks and I am sure they are quite pricey.