Structural Heart Disease in Primary Care: When to Suspect Valve Disease & When to Refer

Cardiology

Jul 30

Valvular heart disease often presents gradually— often slowly becoming more fatigued, less active, or more short of breath over time— making it easy for symptoms to be attributed to aging or deconditioning. In this episode, I sit down with structural heart nurse practitioner Christy Cantey, FNP, to discuss how primary care clinicians can recognize subtle symptoms of valve disease, know when an echocardiogram is appropriate, and understand what happens after a patient is referred to a structural heart program.

We also discussed modern transcatheter valve procedures—including TAVR and TEER—and how these minimally invasive treatments have changed outcomes for patients with aortic stenosis and other valvular diseases.

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In This Episode, You'll learn:

Common symptoms of valvular heart disease that are often mistaken for "normal aging"
Better history questions to uncover subtle functional decline
Which symptoms should prompt an echocardiogram
When to refer patients to cardiology or a structural heart program
Common structural heart procedures (TAVR, TEER, TMVR) explained
What primary care should know about recovery after transcatheter valve procedures
Long-term follow-up, endocarditis prophylaxis, and annual echocardiograms
Counseling patients who are hesitant about referral or intervention

Key Takeaways

Ask patients how they spend their day and what they were able to do six months ago that they can't do today. Functional decline often reveals symptoms patients don't recognize themselves.
Fatigue, dyspnea, edema, chest pain, syncope, and presyncope may all represent symptomatic valvular heart disease and warrant further evaluation.
A normal physical exam does not rule out significant valve disease. Murmurs can be difficult to detect—even for experienced cardiologists.
When clinical suspicion is high, a transthoracic echocardiogram is an appropriate next step, followed by early cardiology referral if valve disease is identified.
Many patients are candidates for minimally invasive transcatheter procedures rather than open-heart surgery, with many returning home the next day.
Patients with prosthetic or repaired valves require lifelong infective endocarditis prophylaxis before dental procedures and ongoing cardiology follow-up.

Episode Chapters

00:00 Introduction
01:20 What is structural heart disease?
02:40 Common valvular conditions seen in practice
03:30 Understanding TAVR, TEER, and TMVR
06:30 Recognizing symptoms in primary care
10:40 When to order an echocardiogram
12:00 When to refer to cardiology
18:15 What patients can expect from structural heart procedures
21:15 Long-term follow-up after valve intervention
25:20 Counseling hesitant patients about referral and treatment
32:30 Resources and clinical pearls

About the Guest

Christy Cantey is a nurse practitioner specializing in structural heart disease and valvular heart interventions. She serves on the editorial board of The Nurse Practitioner journal and is actively involved with the American College of Cardiology, including leadership roles focused on cardiovascular team communication and health equity.

Resources mentioned in this episode:

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FAQs

Common symptoms include shortness of breath, fatigue, leg swelling, chest pain, dizziness, and reduced exercise tolerance. Because these symptoms often develop gradually, many patients attribute them to aging instead of heart valve disease.
Consider an echocardiogram when a patient has a new murmur, symptoms suggestive of valve disease, or clinical concern despite an unclear physical exam. An echocardiogram is the first-line test for evaluating suspected valvular heart disease.
TAVR (Transcatheter Aortic Valve Replacement) is a minimally invasive procedure used to replace a severely narrowed aortic valve without open-heart surgery. Many patients recover more quickly than they would after traditional valve replacement.
Yes. Patients who have undergone valve replacement or certain valve repair procedures generally require lifelong antibiotic prophylaxis before dental procedures to reduce the risk of infective endocarditis.

Continue Your Learning

The Hypertension Management in Primary Care Course is part of the Real World NP Chronic Care Series, a comprehensive continuing education program designed specifically for nurse practitioners. Through case-based learning and practical clinical frameworks, you'll learn how to confidently diagnose, evaluate, and manage hypertension using current evidence and guideline-based recommendations.

The course has been peer-reviewed by hypertension specialists to help ensure the content reflects current best practices while remaining practical for everyday primary care.

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Liz Rohr (they/she) (00:01.455)
Awesome, thank you so much for being here. I'm so excited for this conversation. Can you introduce yourself for the people?

Christy Cantey (00:08.043)
Yes, thank you for having me, Liz. I'm excited to talk about cardiology today. My name is Kristi and I'm a nurse practitioner in the structural heart program at a large community hospital. prior to that, I've been a nurse practitioner for, I guess about 12 years. And before I got into cardiology the last five years, I actually was in primary care office and doing family practice and really enjoyed that. But

I've always had some cardiology background as a nurse. And so when this kind of came open, I kind of jumped back into it. But I've been a nurse for over 25 years, which sounds really a long time. I started when I was 12. Right? But having said that, it's been really fun to kind of watch how things have evolved over time. I also am on the editorial board for the Nurse Practitioner Journal, which is really fun. I get to help.

Liz Rohr (they/she) (00:46.481)
you

Christy Cantey (01:03.202)
kind of guide that journal and do peer review and I'm right for publication. That's been something I've enjoyed and then I also am active in the American College of Cardiology group, which is the national cardiology group as a CV team communication chair and also on the health equity committee. So that's kind of what I do lots of fun things. So, yep.

Liz Rohr (they/she) (01:22.134)
I love that.

Liz Rohr (they/she) (01:26.267)
That's awesome. That's so cool. So you feel like it was like your general draw to cardiology that brought you away from primary care or like any, there any other pieces for you that like kind of had you wanting to specialize?

Christy Cantey (01:39.302)
I think I enjoy doing primary care, but I think it's really hard because you're having to, you're doing so many things and kind of being that gatekeeper. And it's been nice for me to kind of specialize again and just really focus on kind of one body system, essentially. But having that background has really been, I think, essential for certain things as I've gone along.

Liz Rohr (they/she) (02:02.137)
Absolutely, absolutely. So I want to clarify for people what exactly is structural cardiology versus just general cardiology.

Christy Cantey (02:11.114)
Yeah, that's a great question. So structural cardiology just means any part of the heart that's not the coronary artery. So we're talking about the valve structures, the valve apparatus, and the chambers of the heart. So that kind of encompasses structural heart. And so a lot of it is really focused, especially for older population on treating valvular heart disease. And that's my primary focus as well for adults.

Liz Rohr (they/she) (02:35.565)
Awesome. Yeah, so what are the types of patients that you see? What are the diagnoses that you're seeing in your clinic?

Christy Cantey (02:41.996)
Yeah, so mainly I'm seeing patients that have chronic mitral regurgitation or they might have severe aortic stenosis, so nearing of the aortic valve. They may have aortic regurgitation. And then also we've just kind of started seeing a lot more patients for tricuspid regurgitation. And it's really valvular heart disease treatment has evolved so much.

very quickly and so it's been really exciting and lots of things that we can do for these patients now that otherwise they didn't have any options. But those are kind of the primary diagnoses that we see in structural cardiology.

Liz Rohr (they/she) (03:18.714)
Yeah.

Liz Rohr (they/she) (03:22.713)
Yeah, definitely. And so you and I kind of chatted about the different procedural things that you can do for patients. So do you want to jump into a little bit of that? There's a lot of acronyms that get thrown around that people are like, what is that?

Christy Cantey (03:32.014)
Sure. Yeah, right. Yeah, that's right. Exactly. Right, this makes it sound really fun. So the one that started first, right, so in 2011 it was approved, it's called TAVR. And so that's Trans Catheter Aortic Valve Replacement. And so these are patients that have aortic stenosis, typically severe aortic stenosis. They will have their valve replaced using catheters.

instead of open heart surgery. The other ones are trans catheter mitral valve replacement. So these are patients that have already had a surgical mitral valve and their valve is deteriorating and they need a new valve, but maybe they're older and so they can't have surgery. So this is when we do the trans catheter mitral valve replacement and just put that valve inside the one they already have.

And then finally, we have two different kinds of repairs. They can do a mitral valve repair and a tricuspid valve repair. And that is also a transcatheter. That is called a TEER So it's transcatheter edge to edge repair. And so essentially, they're using like a little, it's like a kind of like a little clip or a paper clip in it or a clothespin maybe. And it pulls those two leaflets of the mitral valve and tricuspid valve together.

to reduce the amount of regurgitation that that patient's having. So those are the acronyms. You're gonna hear TAVR, you're gonna hear TEER and then typically TMVR or TIMVR, some people say. So lots of acronyms there that we like to use.

Liz Rohr (they/she) (05:12.977)
Totally, totally. And so when you're, well, a couple different places you get to choose. Choose your own adventure. So one is I would love to talk about the patients who, like guess I'm thinking about primary care and also like if you have any like anecdotes to share from your primary care experience of like who are the patients that, yeah, I guess I wanna, I would love for you to expand on like the procedures of like.

just like kind of drop us into that situation of like somebody is either referred from primary care for certain symptoms or it's like, we definitely know that they need this. Like, what does that look like for a patient? Maybe that's a big question, but kind of like from the start to finish. And I know there's a couple of different procedures, but if we can kind of help, I think it would be really helpful for people to see and understand what it looks like in terms of the preparation and the recovery and like the maintenance from there.

Christy Cantey (05:55.0)
Sure.

Christy Cantey (06:05.216)
Yeah, that's great. And yes, lots of stuff to include in there. So I think initially, when the patient is seen wherever they're found, right, so in primary care, urgent care, ER, a lot of these patients don't realize that they have valve disease, and maybe they relate their symptoms to other things. And so once that patient is identified, and I can go through kind of basic steps of that, if that's something that you want to walk through. Okay.

Liz Rohr (they/she) (06:31.427)
Yeah, actually, maybe let's, yeah, let's start with that. Just kind of break it down a little bit more of like, what are the initial presenting symptoms and when to refer?

Christy Cantey (06:36.342)
Yeah. Yeah. So, so typically what happens is a patient will come in and maybe they are short of breath or they are having fatigue. Maybe they're having some leg swelling. And so those patients present and it's a lot of times it's very, it's vague. It's, it's not sudden. It's kind of occurred over a long time. And so

One of the most important things I think we can do as nurse practitioners is really pull out those symptoms. know all of us have had patients, you come in, maybe they have their spouse or their partner with them and they come in and you're asking, how's it going? How are you doing? And the patient says, great, fine. And you can see the person behind them shaking their head going, no, they are not fine. And so to kind of explore those symptoms, one of my favorite questions to ask a patient

Liz Rohr (they/she) (07:16.945)
Hahaha

Christy Cantey (07:28.46)
instead of doing like the checklist where you say, you have chest pain? No. Do you have shortness of breath? No. Cause they're going to answer no, right? Is, is how do you spend your day? And that's kind of my, my introduction. How do you spend your day? And so a lot of times these patients are going to tell you that, you know, I don't do much. I sit in the chair and watch TV. And so then you can say, why is that? And they may tell you that they're just too tired to do anything else.

Liz Rohr (they/she) (07:34.181)
Right.

Liz Rohr (they/she) (07:38.161)
We love that.

Christy Cantey (07:55.83)
And then sometimes we'll ask the patients, know, what did you do six months ago that maybe you're not able to do now? And so these can be really small changes. Like maybe they were able to get their garbage can all the way down the driveway and now they can't. Now they have their neighbor pull it down because they're just not able to do it. They're too tired. And so kind of digging in on those questions, I think really helps figure out if these patients are truly having a change.

And they'll often relate it to their age, right? Everybody says, I'm getting older, I'm tired. Well, sometimes that's true, but a lot of times we'll have patients like, for example, that have had their aortic valve replaced, they've had TAVR and they'll come back about, you when they visit us again like a month later, they'll say, I didn't realize how bad I felt. And that that was truly a symptom of their valve disease. And so I think just really spending time to pull those symptoms out.

Liz Rohr (they/she) (08:27.558)
Yeah.

Liz Rohr (they/she) (08:43.825)
Mm.

Christy Cantey (08:51.724)
And it may not mean that you know exactly what is happening, but just notice that there's a change over time and that's important for patients with valve disease. Most of the indications are to treat these patients when they become symptomatic and those are the common symptoms. You've got fatigue, shortness of breath, lower extremity edema. Some people with aortic stenosis will experience chest pain and some people syncope and those kind of two are big red

flags to really push those patients through quickly. So yeah, so once you kind of have a patient that comes in with symptoms, then you're going to do your physical exam. And so on that exam, you may or may not hear a murmur. Murmurs are difficult to hear. There was a study back in, I think it was 2015, it was, been about 10 years ago, that they presented at the European Society of Cardiology and it showed that about 35

Liz Rohr (they/she) (09:23.995)
Absolutely.

Christy Cantey (09:47.448)
percent or cardiologists fail to identify about 35 percent of murmurs, advanced murmurs, and then half of basic murmurs. So if the cardiologists are having trouble identifying it, you can imagine that really rolls over into the non-specialty areas.

Liz Rohr (they/she) (09:57.457)
Liz Rohr (they/she) (10:04.953)
I love that you said that because I think it's just so normalizing for people because I think that they're like hearing that it's like not just primary care, it's not just new grads. It's like literal cardiologists who spend years and years and years, you know, doing this. That's so helpful.

Christy Cantey (10:14.196)
Yes, yeah. you just, you know, it could be the patient's body habitus. It could be background noise, lots of different things. And so there's some tools now that we can use to kind of improve that. One of them is a digital stethoscope. And so those stethoscopes have AI enhanced technology. And so it's kind of like a safety net can help you pick up on murmurs and

Liz Rohr (they/she) (10:22.918)
Yeah.

Liz Rohr (they/she) (10:33.606)
Mm-hmm.

Christy Cantey (10:42.818)
I've always thought that would be a really great thing for primary care to kind of have that little extra boost when they're doing their exam. And so that has helped kind of identify more patients, I think, over time. So if you do hear a murmur or if you're just concerned because of the symptoms, it's always something really easy is to get a trans thoracic echocardiogram. So the one on the outside of the chest.

Liz Rohr (they/she) (10:46.949)
Yeah. Yes.

Christy Cantey (11:09.142)
It's not invasive. It's not that uncomfortable for the patient. And it's usually pretty accessible. So that would be the next step would be to get the echocardiogram. And then once you have that report back, then we have to kind of consider, do we need to send them to a cardiologist? And that kind of high level recommendation would be to, if you're concerned about them and you get the echo and say they even have mild valve disease or moderate, I think it's always,

important just to go ahead and send those patients on to cardiology. Even if they're not going to get that procedure, it helps really build that relationship with the heart team. And then also, you know, just a side note is the echo is only good as a person who did it and the person that read it, right? And I don't mean that in a bad way. It's just you're going to have a wide range of the technologists doing the ultrasound and whoever that person is reading the ultrasound. And so

Liz Rohr (they/she) (11:48.187)
Yeah.

Christy Cantey (12:07.84)
it may be read as mild at this one area institution and then maybe you them into cardiology and it's actually moderate. And so it could, yeah, it could potentially change how and when you're gonna treat this patient. So I think it's important just to refer early to cardiology. Now, granted, they don't want to see everything in the world because they're so busy already. I remember sending people over

Liz Rohr (they/she) (12:16.613)
That's really helpful to hear.

Liz Rohr (they/she) (12:23.355)
Definitely.

Liz Rohr (they/she) (12:32.528)
Right.

Christy Cantey (12:34.818)
when I was in primary care that looking back now that I probably shouldn't have sent over and they probably were like, what are they doing? But I think it's always better to err on the side of caution, especially if they're having some sort of symptom that you cannot relate to anything else.

Liz Rohr (they/she) (12:37.873)
Yep.

Liz Rohr (they/she) (12:48.559)
Yes. I love that. that's, yeah, that's really helpful to hear with the echocardiogram, because I think that sometimes we, yeah, just like, I don't know, at least I'll just speak from my experience. Sometimes it's like, well, it's like, it must be, it must be like perfect. And the way that, I mean, with lab interpretation, there's always some errors there too, but it's, that's really helpful to hear, because it's further reinforcement to help us trust our judgment of like, this isn't matching up, this isn't feeling good. So.

Christy Cantey (13:05.826)
Right.

Christy Cantey (13:15.146)
Exactly. And I think even new nurse practitioners, I mean, you have that, you have some intuition. And I think there's nothing wrong with acting on that, especially when that patient's in front of you saying that there's something that has changed. Yeah.

Liz Rohr (they/she) (13:19.845)
Yes.

Liz Rohr (they/she) (13:24.535)
Absolutely. Absolutely. And I love what you said about, I love those questions about like how you spend your day and then also the six month question is just such a tell. Because I like a lot of those insidious, like onset is just it's really hard to appreciate. And yeah, there is so much writing off I think of older adults as well, in terms of like, just getting older, like they do it themselves. And then the system can do that to them too. And then it's like, no, you actually can have a great quality of life. We just have to investigate what the options are.

Christy Cantey (13:38.371)
Yes.

Christy Cantey (13:45.934)
Absolutely. Yeah.

Christy Cantey (13:53.27)
Yeah, and they also will, they'll alter their activity level. So if they're not able to it, then they just kind of slowly alter their activity level. So then they almost don't even notice when they're having a change because they've done these other things to make it more manageable. So it's really interesting once you kind of do that deep dive into the symptoms to see what you can pull out.

Liz Rohr (they/she) (13:58.267)
Yeah.

Liz Rohr (they/she) (14:05.583)
Mm-hmm. Yeah.

Liz Rohr (they/she) (14:16.333)
Absolutely. Are there any, and that makes me think of like with the chest pain and shortness of breath, like I think it's, are there any specific things that like people, the way that they talk about it, like the way that their chest pain hurts in particular with these conditions, or is it kind of just the same as like other, like, it kind of feels like heartburn or kind of feels like, you know, like those kinds of things.

Christy Cantey (14:35.31)
Yeah, I wouldn't say there's any special characteristic. It's definitely, of course, more with exertion. They're going to have more chest pain that will occur with exertion. But anytime you have somebody that has a valve disease with chest pain or syncope or presyncope where they feel like they are about to pass out, those are really kind of our red flags to let us know that that valve is probably, especially with aortic stenosis, probably really narrowed and we need to get them kind of pushed through the system pretty quickly.

Liz Rohr (they/she) (14:40.901)
Mm-hmm.

Liz Rohr (they/she) (15:00.293)
Definitely.

Yeah.

Christy Cantey (15:03.935)
So those are the patients we worry about a little bit more than maybe just fatigue. Yeah.

Liz Rohr (they/she) (15:06.809)
Yeah. Yeah. And so I guess that also brings me to think about, cause people listening to the podcast are all over in terms of accessibility of like how quickly they can get seen. So do you have any thoughts about that in terms of like, I'm, I'm such a fan of cold calling. It's a little bit scary, but it's like, Hey, I have this patient here. This symptoms here's the echo. Can we get them in sooner? It's like, do you recommend any other, do you recommend that first of all, unlike any other things to think about?

Christy Cantey (15:19.576)
Mm-hmm.

Christy Cantey (15:25.378)
Yeah, yeah, for sure.

Christy Cantey (15:35.726)
Yeah, so the really great thing about structural heart is most programs that treat valve disease are going to have a valve program coordinator. That is, it's a, you know, level one indication to send the patient that you think you're going to need to do an intervention on. It's a class one indication through the guidelines to send that patient to a valve program.

Liz Rohr (they/she) (15:44.528)
Mm-hmm.

Christy Cantey (15:57.494)
And so these valve programs have coordinators because there's so much involved with doing these procedures. A lot of times they're nurses, sometimes they are nurse practitioners or physician associates, but that would be a wonderful person to reach out to. I wouldn't, you I would recommend reaching out to them. They know how to triage these patients and they understand, you know, what they're looking at when they read the echoes and they know how to pull out patient symptoms.

So a lot of times for our program, we'll get a referral sent and our valve program coordinators will go through the chart and they'll go ahead and get them set up for the clinic visit and call the patient ahead of time and just let them know, you know, this is what we're going to be talking about. These are some things that might further testing that you may have and just really kind of get to know that patient even before they make it through the doors. So yeah, and there are over 800

Liz Rohr (they/she) (16:49.115)
That's so wonderful.

Christy Cantey (16:52.974)
Valve programs in the United States. So wherever you live, there's one somewhere. I think it was, I think it was Wyoming maybe that just they have I think one site or one or two sites. So but all up the East Coast, West Coast, so many Valve programs and those are really great resources. So if you haven't ever met your Valve program team, I think that's a great great starting point.

Liz Rohr (they/she) (16:55.825)
as

Liz Rohr (they/she) (17:19.625)
I love that. I love that so much. Can you just recap real quick? What are those red flags or reasons that we send to cardiology or structural cardiology?

Christy Cantey (17:28.46)
Yeah, so I think anytime you have a patient with symptoms that you can explain that might be related to valve, so shortness of breath, syncope, chest pain, all those heart failure symptoms such as lower extremity edema, patient may have significant fatigue, palpitations, things like that. Those would be patients to send and then getting that echo ahead of time is an easy thing to do. And so those would be the patients that are, and of course if you hear a murmur, then you

can get the echo that way as well, even if they're saying they don't have a lot of symptoms. So those would be kind of the key indicators to go ahead and send them to cardiology.

Liz Rohr (they/she) (18:06.693)
Awesome. Well, do you want to transition into talking about the procedures in terms of like maybe or even if you wanted to start with like when they get there, it sounds like they are already in touch with the coordinators and then from there.

Christy Cantey (18:11.682)
Yes.

Christy Cantey (18:15.566)
Sure. Yes, yeah. so the coordinators really take care of the patients from end to end. These patients will have testing beforehand. So a lot of the procedures, especially TAVR, there's several tests we do, one of them being a specialized CT scan that helps us be able to size the heart valve and look at the structures, the blood vessels, so that we know we can do this procedure through a catheter.

And the procedure itself is very much, all of them, very much like having a heart catheterization. These patients are mostly going to present the date of the procedure in the morning. They're gonna be prepped and their procedure will take place in the cardiac catheterization lab in most areas. Some sites still will do the procedures in a OR.

but most have transitioned into a cath lab or a hybrid type room. So these patients come that morning, they have their procedure, they're recovered. These patients will either undergo general anesthesia or they may have MAC, which is that monitored anesthesia care. So a little bit like kind of moderate sedation. And then some programs are doing nurse-led sedation. So those are where the nurses, they don't have anesthesia right there in the room, but they are available.

So these patients, depending on what kind of anesthesia they had, they'll have their recovery. And then they often will be up in a few hours, having them walk and monitor them for different heart rhythms that may change, bleeding, things like that. Then the patient will go home typically the next day. The length of stay is usually one to three days, depending on what procedure they had and how they did.

But these patients, they're doing pretty good that next day and most of them are ready to go home. They don't have any type of wounds, open chest, anything like that. They just have two sites on their leg, one or two sites and those just have to be restricted as far as like some sites restrict for driving, some sites restrict for weight lifting. And so the patients will go home typically the next day.

Liz Rohr (they/she) (20:05.446)
Mm-hmm.

Christy Cantey (20:26.54)
And then a lot of the programs will see the patient in a week. And then all of our sites have to see the patients back in 30 days, give or take, and then at one year. And so those patients will also have an echo at that time. And so patients are usually feeling pretty well. I see all of our patients a week later and they're usually doing, feeling a lot better. Some it's very quickly that they notice a change in how they feel. And some it takes a little bit longer to kind of build up that deconditioning that has happened over time.

Liz Rohr (they/she) (20:56.689)
Definitely, definitely. What are some things that aside from those kind of like immediate almost like post-op restrictions, like what are some things to watch out for that primary care could be supportive in, the first, you know, or like, or I guess like between like when they have the procedure and like in that year, like any thoughts for how primary care can be supportive?

Christy Cantey (21:17.122)
mean, typically if we're gonna see any kind of changes in their rhythm, usually it's within the first week to 30 days, but that's always something if somebody comes in and says they're real dizzy or their heart rate's slow, that would be something that would be important to kind of let the cardiology group know, you know, do an EKG, things like that. Over time though, I think the big thing to remember is that all these patients, either if they've had a replacement or a repair of their valve, they have to do the...

endocarditis prophylaxis before dental cleanings and dental procedures for the rest of their life. And that's something that we really try to get across to them, but I think it's good for everyone to know. So any kind of dental work cleaning, they have to take an antibiotic before they go to the dentist. It's just one big dose and then that's usually it. And then these patients typically are gonna at least be on an aspirin, 81 milligrams.

Liz Rohr (they/she) (21:53.23)
Okay.

Liz Rohr (they/she) (22:05.819)
That's great.

Christy Cantey (22:12.342)
And then sometimes the patients have to be on other types of medications like anticoagulants, depending on what kind of valve procedure they had. So those would be, I think, two key things just to know for long term is that those two kind of medicine requirements are needed for these patients. Yeah.

Liz Rohr (they/she) (22:21.147)
Definitely.

Liz Rohr (they/she) (22:29.521)
Definitely. And then in terms of like the patients that are on anticoagulation, for example, like do they typically see cardiology for management of that or do they transition into primary care? I feel like I just hear it's so different site to site and maybe location to location.

Christy Cantey (22:44.856)
think it probably is different site to site. It kind of depends. A lot of times whoever ends up starting it will manage it. We've had some patients that their warfarin was managed by their primary care. And so we just continue that, right? But if it's a new thing or if they are gonna continue to see the cardiologist, which they should if they've had a valve procedure, then we'll just manage it ourselves.

Liz Rohr (they/she) (22:47.024)
Yeah.

Liz Rohr (they/she) (23:09.819)
Totally. And then that's like, and then there's probably an annual check-in, like annual once a year, just in terms of like, if you happen to have a new patient start and checking in on whether or not they've continued their care with cardiology.

Christy Cantey (23:14.146)
Yeah!

Christy Cantey (23:19.414)
Right, that's right. Because not everybody comes back, unfortunately. Yeah, so any kind of valve replacement or pay your transcatheter, typically an annual echo is needed. Just a transthoracic echocardiogram is recommended.

Liz Rohr (they/she) (23:25.263)
I know.

Liz Rohr (they/she) (23:33.386)
okay.

Liz Rohr (they/she) (23:37.594)
Yeah, so I guess, yeah, I guess I'm just thinking about when I've had patients come in and it's like, you should have, no, not should have, the recommendation is that we advise you to have annual check-ins and annual echoes. And then it's like, it's been at least three years. So that's helpful to know for primary care, like starting off like, just get a little echo and maybe get some notes and go from there. So I'm thinking, sorry, I'm just like gonna look at my notes here. How do you feel like it's going so far? Cool.

Christy Cantey (23:47.372)
Yes. Yeah.

Christy Cantey (23:53.696)
Yeah, that's great. Yeah, definitely.

Christy Cantey (24:04.514)
Good. How do you think? Okay, good.

Liz Rohr (they/she) (24:06.725)
Good, no, I think it's great. I think it's be so helpful for people. my gosh. Yeah, what other things would feel good to touch on that you can think of? I mean, if you wanna get into echoes, you're more than welcome to, but I mean, we also don't have to get into that either. I think people feel pretty uncomfortable with echoes, but I think that, yeah.

Christy Cantey (24:14.998)
Okay, let's see.

Christy Cantey (24:25.75)
Yeah.

Christy Cantey (24:31.854)
Probably talk too fast, I suppose.

Liz Rohr (they/she) (24:33.581)
No, no, no, it's totally fine. No, it's no, I think you I think you had a great pace and I think you're very clear.

Christy Cantey (24:38.35)
you

about kind of like resources like where can I go to learn more about this and you know if they want to kind of learn about echoes or learn about the valve procedures but that may be towards the end.

Liz Rohr (they/she) (24:51.577)
right, right, right. Yeah, yeah, yeah. No, I mean, and then I think like if, because it's been about 25 minutes, so I think that that would be good. Like we could definitely transition into the resources. Hold on, let me just double check one.

Christy Cantey (25:00.864)
Okay.

Okay.

Liz Rohr (they/she) (25:09.873)
So you kind of touched on the urgent re-referral symptoms.

Liz Rohr (they/she) (25:21.177)
you know what we could do actually is maybe touch on the counseling around it. So does that sound okay? Like the counseling around like, like just talking to patients about like, this is my, this might be going on. This is maybe what they'll do because like, like touching on that. Yeah. So I guess, so I guess where my mind is going is thinking about patients who, so I just, had another,

Christy Cantey (25:29.271)
about.

Liz Rohr (they/she) (25:49.05)
interview recently and we talked about kind of like, we were talking about, it was an IBS specific one and we were talking about kind of like the almost like before we get into the testing, the kind of expectations because with IBS specifically, it's like, a lot of times it comes up negative, but that doesn't mean that it's nothing, you know? So we're just thinking about pre-anticipatory, like counseling about it. And it's also making me think of patients who either like on that note of like not wanting to follow up.

Christy Cantey (26:05.398)
Right, gotcha. Yeah.

Liz Rohr (they/she) (26:17.837)
or not having access to follow-up, and then also people who may not be interested in sort of interventions around having structural heart disease, but not being interested in intervention. So yeah, I think both of those things tap into the counseling around it, and likely those patients are not gonna go to cardiology to have that conversation. They may, but yeah, what are your thoughts about that in terms of having the conversation around it with patients who are just like, I'm all set. I'm just getting older, I don't wanna do anything fancy, that kind of thing.

Christy Cantey (26:27.786)
Yes, that's great.

Christy Cantey (26:43.191)
Yeah.

Right, yeah, I think it's important because the cardiology, the heart team, they're specialists at what they do. And so I think it's good to talk about it, I think with your patients, because obviously you've built this really big, you know, have a lot of trust with the patient and that kind of thing. But I think it's always worth getting them over to at least have that conversation. We are very much shared decision-making with any of these procedures. And so we do spend a lot of time with these patients going over

not only the risk and benefits, which is more informed consent, but actually, you know, shared decision, what is your goal? And maybe it's that they just want to feel better so they can, you know, do their garden again and things like that. And so we kind of talk about, you know, this is the risk that you would take if to achieve that. And is it worth it to them? And I think the big thing is that we try to get across is

this is a, especially for aortic stenosis, that's kind of the big one, it's a lethal disease. Like it is only going to get worse over time. If we do nothing to these patients that have severe AS, they, and about 50 % of patients will pass away in about one to two years from it. And so I kind of, when I think of it, it's almost comparing to, if you got diagnosed with cancer, you know, most often you'd least want to go have that conversation with somebody. And so,

Liz Rohr (they/she) (27:56.744)
wow.

Christy Cantey (28:09.592)
So just letting them know, not to scare them, but just say, this is a lethal disease and this is really affecting your quality of life. And so going over there and just having that conversation. we never, of course, whatever the patient wants to do, we are 100 % gonna support that. We just wanna make sure that they're informed of all their risk. And just saying, yes, this will hopefully make you feel better. There's patients we have seen that

Liz Rohr (they/she) (28:12.366)
Right.

Christy Cantey (28:36.94)
Maybe they haven't walked in a really long time and they want to know if that's going to affect that. Well, probably not. It may make them less out of breath, but it's not going to change certain things about their clinical status. So I think it's just really important to have the conversation. But from our primary care, just letting them know that there are options out there that are not surgical. I think when you tell somebody that we do these procedures,

under moderate sedation, get to go home the next day, that's appealing to people. The recovery is not like surgery, because I think, you know, I'm sure most people have known somebody that has had surgery and it's a big undertaking. And so just letting them know that there's other options out there to explore, I think that would be a great way to kind of start the conversation.

Liz Rohr (they/she) (29:09.423)
Right.

Liz Rohr (they/she) (29:18.522)
Yeah.

Liz Rohr (they/she) (29:26.949)
Definitely, yeah, and I guess, and clearly they like the time and the knowledge depth that you have to have these conversations with patients is like not replaceable. I guess if you have like a high level of like harm reduction of like, if I really wanna get somebody to go talk to you and have that full conversation, but they're like not, they're not there yet.

What is a high level risks benefits? How would I approach that with a conversation with a patient of they're like, really, I really don't want to. I'm like, OK, that's totally fine. But they're like, me a little bit about it. And you've shared so much already about what those procedures are like. But yeah, if you can share a high level risks benefits, how you start to broach it with patients, how would you go about that?

Christy Cantey (30:13.078)
Yeah, I think really focusing on whatever it is that they can't do, or maybe they've had a lot of hospitalizations. So some of these procedures, especially the TEERs the repairs, they really have been shown to reduce hospitalizations for heart failure and improve their quality of life. And I think everybody is on board with having a better quality of life. And so I think I wouldn't probably go into detail about, know, percentages per se.

Liz Rohr (they/she) (30:17.638)
Mm-hmm.

Liz Rohr (they/she) (30:42.054)
yes, yeah.

Christy Cantey (30:43.01)
But I think just letting them know that, you know, it's proven to reduce hospitalizations, heart failure admissions, improve quality of life and longevity. So I think those are all things that, you know, again, that everybody is interested in, Yeah.

Liz Rohr (they/she) (31:00.145)
Totally, totally. And then I guess, like, what are some of those high level risks of the procedure? Like it just, or any of the procedures, like it's not going to work or, sorry, go ahead.

Christy Cantey (31:06.509)
Yeah!

Yeah, no, that's great. And yeah, of course there are some times where it's not successful, especially with our repairs. They maybe they weren't able to reduce that regurgitation. There's risk, of course, with a procedure, anything you do with the TAVR procedure, the aortic stenosis, these patients are at risk for needing a pacemaker due to where the valve is placed. And so that's a conversation that we have with them because that's can often be a big deal to some people.

And then bleeding, injury to the vascular system, all those kind of risks that come along with a more invasive procedure, but definitely lower risk a lot of times for certain things than surgery. So they do try to kind of go through and compare everything. Often our patients will also for certain procedures see a surgeon as well. And so they're getting kind of the whole broad overview and help them decide what they think is best for

them themselves. Yeah, it's really good teamwork. Yeah.

Liz Rohr (they/she) (32:09.839)
I love that. Awesome. Well, thank you. I love that. That's so wonderful. Yeah, thank you so much for your time. I would love to conclude with resources that people could look to if they want to learn more or feel more confident and also like any other lingering pearls of practice that you have to share.

Christy Cantey (32:32.986)
Yeah, thanks. And really, I think the go-to for resources is the American College of Cardiology. And there are often, all the guidelines are open access. And they often have that key points, like maybe 10 key points. And so it's a lot if you're going to read the whole document, but just kind of having that high level overview is helpful, I think, just to know what's going on. There's so many changes happening quickly with valve disease. And this really kind of helps you understand.

the current guidelines and they also have a lot of webinars and podcasts that are great just to kind of like listen on the go and in other resources. So that would probably be my first one be the American College of Cardiology and then now I don't remember what you say. What was the second? Oh yeah. Okay. Okay. Okay. All right. Okay.

Liz Rohr (they/she) (33:21.009)
That's okay. Any other resources or pearls of practice? Or pet peeves, if you have any pet peeves, get those off your chest.

Christy Cantey (33:31.808)
All right, and then you also asked about pearls of practice. I think the biggest thing is to refer the patient early because they, again, getting them established with the heart team is really important to establish trust among it and then be able to prepare them if they are gonna have a procedure at some point. It's just really helpful. So anytime you have a question, I would refer them if you've gotten an echo and you see maybe moderate.

Liz Rohr (they/she) (33:35.504)
Yes.

Christy Cantey (33:59.82)
valve disease, even mild sometimes, especially if they're having symptoms, because again, it may be worse than recorded. And then reach out to your valve program coordinators. That's an excellent resource. They are very knowledgeable, and they can really help kind of guide your patients through these processes, because it's complicated, but that's what they're there for.

Liz Rohr (they/she) (34:22.469)
That's so wonderful. I have another podcast I'm going to be recording and it's about bleeding disorders. And they have like a bit of a similar thing because it's like, it's a little bit niche, but it's like, it's so hard for it's, it's hard for people. Like, I feel like even myself accessing healthcare can be overwhelming sometimes. it's wonderful. That's great. Well, thank you so much for your time. This has been so, so wonderful. So helpful.

Christy Cantey (34:29.495)
Nice.

Christy Cantey (34:38.354)
yes, for sure it is. That's a lot. Yep. Yes, thank you. Thank you so much, Liz.

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