Transcript: Ask A Cardiology Nurse Practitioner

​Liz Rohr:
Thank you so much for sharing because I know that a number of people, which we'll get to, wanted to ask about getting into cardiology or if they're already there. So it's really helpful to hear that you did family nurse practitioner and then you ended up here because sometimes I think about specialties and I'm like, "What specialty would I do?" and it's just encouraging to hear that there are people that are doing that.
 

Well, hey there. It's Liz Rohr from Real World NP and you are watching the Real World NP YouTube channel. We make weekly episodes to help save you time, frustration, and help you take the best care of your patients.

I am so excited to share this episode with you. This is an interview with Scott Pasquale. He is a cardiology nurse practitioner, family nurse practitioner by training, and we talked about so many things. All the questions primarily came from the community, Real World NP community, but of what we would like to ask a Cardiology NP and vice versa, what Cardiologists and Cardiology NPs would like us to know in primary care.

So we talked about pre-referral testing, atrial fibrillation, heart failure, all the different types of imaging which is just so good so I hope you really enjoy it. One quick note though is that we didn't get into in-depth like different medications. Things like guideline directed medical therapy, anti-hypertensive medications, what to choose when and how to change them, titrate them, etc.

So just so you know, there's two resources I have to share. One is that we already did a video on the channel and a podcast episode about heart failure guideline directed medical therapy overview of care of heart failure patients. And then, the other thing is we actually have a full on course called the Diabetes, Hypertension, and CKD: Managing Those Conditions course and we talk about all of those aspects of hypertension management, what meds to start, all the pharmacology behind it, how to titrate it, frequently asked questions, all of that good stuff. So if you need any support with that, head over to realworldnp.com/courses. Without further ado though, I'm going to share my interview with Scott Pasquale and I hope you enjoy.
Thank you so much for being here. Can you introduce yourself?

Scott Pasquale:
Yeah. My name is Scott Pasquale. I'm a nurse practitioner. I work in an outpatient cardiology office just outside of Boston.

Liz Rohr:
Awesome.

Scott Pasquale:
In general cardiology so we see a little bit of everything. Pretty much, my whole career background has always been in cardiology. I worked as a nurse on a telemetry med-surg floor and then a cardiac surgery step-down unit and then my first nurse practitioner job, I did some in-patient cardiology and now, I'm on the in-patient side of things.

Liz Rohr:
That's awesome. How long have you been an NP for?

Scott Pasquale:
I have been an NP for about six years now and a nurse for 12.

Liz Rohr:
Awesome, awesome. Very cool. What kind of program did you do? Did you do adult JRO or family nurse practitioner or acute care? If you don't mind sharing that.

Scott Pasquale:
I did the FMC route because I really wasn't sure what I wanted to do and I figured that would give me the most options when I finished. It just so happened that I worked in cardiology while I was in school and I had my foot in the door and really liked that population and everything we so I just stuck with it. Yeah.

Liz Rohr:
That's awesome. I was going to ask you, how did you choose cardiology? Was it that you were in that area and you're like, "Wow, I really like this," or did you think more about it beforehand? What was your approach to it?

Scott Pasquale:
Yeah. That's a great question. I just fell into it. I really didn't know what I wanted to do. It was a tight job market when I got out of school. My first job was at a rehab nursing home but it was when I went to a telemetry med surg floor from there where I really started to like the cardiology stuff. Actually, in school, I was not a big fan of cardiology stuff. It was very confusing to me. And so, it's kind of full circle. I ended up going back to what I found challenging.

Liz Rohr:
Totally. I love that and thank you so much for sharing because I know that a number of people, which we'll get to, wanted to ask about getting into cardiology or if they're already there. So it's really helpful to hear that you did family nurse practitioner and then you ended up here because sometimes, I think about specialties and I'm like, "What specialty would I do?" and it's just encouraging to hear that there are people that are doing that.

Scott Pasquale:
Yeah.

Liz Rohr:
Cool. So first question I usually ask for specialist interviews is what is it that you wish that primary care providers knew that something that comes up either all the time or just in general or any pet peeve you have to share? This is really your opportunity to have a primary care provider soapbox so go for it.

Scott Pasquale:
I'm going to just preface this with the fact that in my practice, I do not see new consults. They would have been referred to us. They've been seen by one of our doctors first, our cardiologist first, and I'm not a substitute for a cardiologist. I'm not a cardiologist. I'm in addition to, part of the team. That being said, common things I do here when new patients are referred to us is a lot of times, people just get referred to us for symptoms and there's been no workup whatsoever or a chest pain referral and it's like, "Okay. Well, do we have an EKG? Have they ever had a stress test?" There's some things that primary care can do to get the ball rolling before they get to us.

Especially as with any specialty, there's limited resources and we're not always able to get people in as soon as you hope for. So just getting the ball rolling on workup and actual treatment too is important if these patients are going to have to wait for a while. And then, in that same vein, knowing who really is an urgent referral versus something that's a little bit more back burner, someone who has a markedly abnormal stress test and a convincing history, yeah, we're going to want to see that right away versus a 32-year old old with an asymptomatic murmur that they've had all their life. It's not as urgent. So definitely indicating on the referral, if there's any way your system has that where they can basically, how worried are you about this patient? Do they need to be seen yesterday or can this wait?

Liz Rohr:
Totally. That's super helpful and that's definitely some of the questions we're going to get into. I think there's a huge... This applies to most specialties too from primary care perspective is how much do you want to work up? So maybe let's get into that one first because I think that there is, yeah, there's a lot of questions and so I feel like maybe the place to segue into is talking about imaging and testing. There are so many areas we could go with this but I think that specifically if we can start to break it down, and let me know what your thoughts are, but if you want to break it down into ordering a stress test. Maybe let's start there because I think there's a lot of confusion there about the different types of stress tests, when you would expect to order them, when you would hope to have them done, things like that. Anything you want to add or talk about with that?

Scott Pasquale:
Yeah, definitely. Stress testing is a great one to start off with just because I feel like there is a lot of confusion. Even when I first started working in cardiology, I had a lot of confusion about the different stress tests. So it's helpful if you break it down into A, "What are we stressing the person with?" and B, "What kind of information are we going to get?" Stress exercise is the typical one. When you hear stress test, you have someone walk in the treadmill and some stress labs, they'll use a bike. The stress lab that we have, we use the treadmill. Usually a Bruce protocol.

Liz Rohr:
You said Bruce protocol?

Scott Pasquale:
Yeah.

Liz Rohr:
Okay.

Scott Pasquale:
That's just a standard treadmill protocol that I think most stress labs will probably use but it's just important to know how we're going to stress this patient. Are they suitable to be on a treadmill or not?

Sometimes we do get patients who use a walker or they have an amputation and they don't have a prosthetic. It's like, "We're not going to get very far if we order the treadmill." So just knowing how you want to stress the patient and also looking at their other medical issues. Certain medications are tougher to use, different medications to stress. So yeah, typically with stress we use either exercise.

The second most common kind is lexiscan or regadenoson which is a vasodilator. And then, dobutamine is the other common one that we use. So start with the most basic exercise stress test. You're stressing with exercise. You're asking the person to work more, increase their cardiac demand, and you're getting a continuous EKG tracing and you're looking for a lot of things. But most commonly, if it's a chest pain workup or a shortness of breath workup, you're looking for ischemic changes and you'll see that usually with some ST, depression different places.

So that's the most basic. It's just an exercise with the treadmill. If you want to do any sort of imaging, you can still do the exercise portion and then most common imaging would be with a nuclear scan or an echocardiogram. We use the nuclear scans a lot more. You might hear these called MIBIs or Myoviews. A lot of different names, I think, just adds to the confusion. But basically, same principle, you're having someone exercise, at their peak exercise, you're injecting them with a nuclear tracer and that tracer gets brought to the heart muscle wherever the blood is going to bring it and it sticks to the heart muscle and afterwards, we get pictures.

The tracer glows underneath the camera and the pictures look funny when they glow. They look like, depending on what view, they look either like little peanuts or donuts. But basically, you're looking to see if there's any areas that aren't glowing quite as bright or as much or at all as other areas. If the stress pictures show that everything looks fine and dandy, then that's fantastic. If there's something that looks abnormal, we take resting images as well and compare the two to see if this is something that is just induced with stress or if this is something that is there at baseline and that's how you tell the difference between ischemia versus infarct. And so, those are the nuclear ones.

The echo ones. You also can do with exercise and same idea, you're looking to get the heart rate up, you're seeing their exercise tolerance, and then you're getting echocardiogram images at their peak exercise to see if there's any... Usually, you're looking for wall motion abnormalities if you're looking to diagnose ischemia.

These can be a little bit more challenging because it's a tough test. You're having these people go on the treadmill and they're working pretty hard for us to consider it a diagnostic heart rate. To rule out a ischemia, you're looking to get to 85% of their age predicted maximum which is a pretty good workout. So you're having these people run up the hill on the treadmill and then to get good echo pictures, they need to be perfectly still holding their breath lying down. So it's like this weird thing where it's like run, run, stop. All right. Hold your breath. It can be a pretty uncomfortable test so we tend not to use those as often.

The other way to do a stress echo is just dobutamine so it's a infusion of dobutamine which keeps the heart rate so you can get to a targeted heart rate that way as well. Yeah. So basically, there's different ways of stressing, different ways of getting information from that.

Liz Rohr:
Yeah. I love that and I love those explanations. Those are really helpful especially from a visual perspective. I feel like you've probably had practice explaining this to patients. That was just so easy for you. In terms of... I have a follow-up question about the nuclear. So what are some of the names, especially for newer providers, Myoview, what are some of the other names for the nuclear scans?

Scott Pasquale:
Yeah. So you might hear it called it MIBI or a sestamibi or nuclear scan, a Nuke, Myoview , all fairly synonymous. You're using nuclear images to look at the blood flow of the heart muscle. I guess a good way to explain this and we use it with patients, this is not an analogy I came up with, I'm stealing it, but it looks at how well the lawn is watered so to speak versus cardiac catheterization with an angiogram, you're actually looking at the major arteries, you're looking at hoses and sprinklers. This, you're looking at the lawn. Is there any area that's a brown spot that suggests it's not getting a lot of water is one way to look at it and explain to people.

Liz Rohr:
I love that. I love that explanation. And so, just another recap. So basically, if we take a couple of steps back. So if you have a patient who has, in their 50s, cis male patient has chest pain with activity and they are ambulatory, they can walk fine, they don't use a walker. So for that person, typically, in your office, would you be ordering a regular exercise stress test, treadmill stress test to start, and then you add the-

Scott Pasquale:
Yeah.

Liz Rohr:
The fancier ones later or how does that work for you in terms of choosing between them?

Scott Pasquale:
Yeah. So if they have no history and you're just looking for an initial evaluation, an exercise stress test or exercise tolerance test, used interchangeably, different names. But basically, having a person walk on a treadmill and getting an EKG tracing, you won't really be wrong going that way as part of the initial workup. Where you might want to start with something more involved like a stress or nuclear stress test would be if the patient's baseline EKG is abnormal. Because with the ETT, the exercise tolerance test, with just the EKG criteria, that's really all we have to go on as objective evidence of ischemia.

So if someone has a baseline EKG that's abnormal and it's harder to say, is this change an ischemic change with exercise or is this sort of their baseline abnormality that's just getting exaggerated as they exercise? So if someone has a perfectly normal EKG to start, they're suitable to go on a treadmill, just a plain exercise stress test is good enough to start with. It's the people who have the baseline abnormalities or if they can't exercise, you're going to need some sort of imaging agent.

Liz Rohr:
So let's play with some examples. So if you have somebody that same profile has an abnormal EKG, you're probably going to do something like the nuclear stress test, and correct me if I'm wrong because I get so turned around with all the different stress tests myself, is it basically just exercise and nuclear or is there another category that I'm forgetting about?

Scott Pasquale:
So with the stress modalities, you can do it exercise or you can do it medication. And then medication-

Liz Rohr:
Oh, I see.

Scott Pasquale:
The more common one is-

Liz Rohr:
Oh, right.

Scott Pasquale:
The lexiscan or the dobutamine.

Liz Rohr:
I see.

Scott Pasquale:
They work a little bit differently so-

Liz Rohr:
Which does not have the nuclear imaging part. It just has the medication and EKG.

Scott Pasquale:
Right. You can use exercise with just the EKG. You can use exercise with the nuclear and you also get the EKG along with the nuclear or likewise, you can do exercise with the echo. If someone's not exercising, you need to have imaging because you can't just get still EKG and look for changes that way. You're going to want some imaging evidence with the echo or the nuclear.

Liz Rohr:
Oh, that's really helpful because I think that's one of the main concerns of primary care providers. They're like, "I don't want to order the wrong test and so, I'm going to just send them to cardiology," but then you get to the situation like you were saying with cardiology is like, "Well, what tests have been done so far?" so that's really helpful.

Scott Pasquale:
Yeah, and in most patients, if they have no history, their baseline EKG is normal, you wouldn't be wrong to start with an exercise.

Liz Rohr:
Yeah. But if they were non-ambulatory with a normal EKG, would you go straight for chemical-

Scott Pasquale:
Yeah.

Liz Rohr:
Okay.

Scott Pasquale:
Yep. In that case, I'd probably would order a nuclear test and typically, we order nuclears more than the echoes just because-

Liz Rohr:
Oh yeah.

Scott Pasquale:
Patients tolerate them better. The medications we use mostly for the nuclear scans is the lexiscan or regadenoson is the other name for that. It dilates the coronary arteries. It's super short acting. It's inside our system in a minute or so. Most people, they feel a little short of breath with it but by the time they start to feel poorly, it's out of their system or they have no symptoms at all. So that one, we can do with relative ease and get nuclear pictures. If you want to go the echo route, you would've to use dobutamine which is, I think in my experience, not as well tolerated. People have issues with ectopy and blood pressure and makes them feel really crappy and takes longer. And so, typically we see the nuclears more often than the echo. It's in limited circumstances that I would order a stress echo.

Liz Rohr:
Totally. And then, just to dig one last time on all of these tests. So if you have somebody who's non-ambulatory and an abnormal EKG a baseline, straight to nuclear basically is what you're saying?

Scott Pasquale:
Yeah, yeah. That would be your only option. Yeah. You'd have to do either a dobutamine echo which, like I said, is not ideal. So a nuclear test would be better tolerated and people do have concerns about radiation exposure and it's obviously something we're all concerned about with any sort of test that we're ordering. I've been told by our stress lab tech that the amount of radiation that they use for a nuclear stress test is very low. So if you want to tell people for frame of reference, it's about as much radiation that you would get if you were to just sit on a cross-country flight, the background radiation of the plane, so it's a very low amount.

Liz Rohr:
That's wonderful. That's really great to hear. Thank you. Yeah. I think in terms of primary care's role, aside from initial assessment and testing, I think is that preparatory counseling as much as we can do in primary care before they get to a specialist because I feel like that communication piece of what to expect really goes a long way regardless of where they're going to so I really, really appreciate all of that. So can we touch a little bit more on just another testing one before we move on to the other topics is about Holters?

Scott Pasquale:
Yeah.

Liz Rohr:
I feel like there's so much struggle with different Holter monitors and arrhythmias and stuff like that. So I can ask some pointed questions or you can just give me what you got, your thoughts on that?

Scott Pasquale:
I think the biggest thing when determining what type of monitor you want to have a patient wearing, there's all sorts of options. There's Holters, there's patch monitors, event monitors, implantable loop recorders so you got to know why are we doing it first off. Is it we're working up with symptoms or did someone have a stroke or we're looking to screen for AFib or something like that? If it's a workup of a symptom, it depends on how often they're having the symptom. If they're having episodes two, three times a day, then a 24-48 hour Holter is probably going to be more than enough. If it's something that people have once a week, you might want to do a patch monitor that's a week or two long to ensure you're capturing weather symptoms you're looking for or obviously, if symptoms are even more infrequent, you could do 30-day monitoring. But typically, if it's for something like ruling out Afib, [inaudible 00:20:03] of a stroke, or a TIA or something, you're going to want at least 30 days of data.

The other thing to consider too is what are we doing with the information? When you get a rhythm monitor, is this someone that we're concerned about that if they do have something pop up, we're going to want to do something about it right away or is this just a routine? I'm having palpitations here and there, it's been going on for months, let's see what that's all about because there's different turnaround times on the testing too.

A Holter can come back and get read same day or next day. The issue more so is with the different patch monitors that people can wear for a week or two. They're very convenient because they're easy. They stick out right on the chest and people just throw them in the mail. But the company, depending on where it goes and where you're practicing and everything in regards to that, it could take a couple weeks to a month to get the results back. So if you're looking to see if someone has new AFib or if someone might need a pacemaker, not the ideal test because when you get the results, it's going to be a month later.
For [inaudible 00:21:12] like that you're going to want more like a 30-day event monitor that can notify the office in real-time if they're having any actionable arrhythmias, like a new AFib that you'd want to anti-coagulate them for or high grade AV block or something that they need to be considered for a pacemaker.

Liz Rohr:
Cool. That's super helpful. So just to recap, so the patch monitors, do you get... So if anyone listening or watching has not seen those, I've personally had experience with them and it's just like this little patch in your chest and a little sticker and it comes in a kit, you put it on and there's some rules about how to prepare your skin and how long to leave it on and how to take care of it. And then, you pop it back in the mail and then it gets delivered. And then, so you're saying, so for the patch monitors, those are only for a week and you can do 30 days for that, it's just a longer turnaround time?

Scott Pasquale:
So the patch monitors, you can go up to two weeks.

Liz Rohr:
Okay.

Scott Pasquale:
So any timeframe in there. It's just a turnaround time is-

Liz Rohr:
Oh, I see.

Scott Pasquale:
The benefits is that they're super easy. You can just have them on the office, you go home with it, you throw it in the mail. But just the downside is if you're looking for something potentially that is time sensitive, it's less ideal.

Liz Rohr:
And so, that's the event monitor which is hooked up at the office and then they have real-time feedback to the office.

Scott Pasquale:
Right. So we can notify the patient if we're seeing something that we need to do something about.

Liz Rohr:
Oh, that's so cool. And then, in terms of the one-day monitors, that would be a patch as well or is it site dependent?

Scott Pasquale:
It might be site dependent where we are with for one day, 24 or 48 hour monitoring, we do the Holters. That's for if we are working up symptoms that are happening multiple times a day or on a daily basis, that's usually an adequate amount of time and the turnaround should be pretty quick on those. Another kind we do just 24 hours worth of monitor and say if someone has AFib and we want to assist their overall rate control, if we see them in the office, their heart rate's like 98 but are they anxious or they just because they're here are their heart rate really borderlines so it's helpful to get an overall 24-hour trend, stuff like that.

Liz Rohr:
I see. And then, the Holters, are those the ones that you're hooking them up to all the leads in the office, they go home with that little fanny pack of a monitor, and then they bring it back in the next 24 to 48 hours?

Scott Pasquale:
Yeah, yeah. Usually, yeah, we set them up in the office. It's usually a few leads. The devices may vary, some of them might be bigger than others. I remember it as really tiny. Yeah. Typically, they just drop it off the office the next day or two days later.

Liz Rohr:
Does that have real-time information being sent as well or is it just the event monitor that has the real-time notification?

Scott Pasquale:
That's a great question. I want to say it's just the event monitors that will have the real-time. I could be wrong though.

Liz Rohr:
Yeah. I was going to say probably the most common one that you've seen in the office at least is getting that information sent in because it's a longer period of time but that's super, super helpful. I can't tell you because the main... So I've never worked in a cardiology office and especially me in primary care and I'm trying to work up a patient, I'm doing my due diligence, it's like you want to monitor their rhythm and it's like, "Okay, but what are all the options?" and then you also have your referrals department. It's like, "You put the order in wrong," and I'm like, "Well, how do I put it in? This is what I want."

Scott Pasquale:
Yeah. It can get very confusing very quickly. Yeah.

Liz Rohr:
Totally. I love that. So maybe we'll take, come back to echo a little bit but I want to come to the other topics. Okay. This is the question of the ages. So people, new grads, experienced people ask about EKG learning resources. Do you have any thoughts about EKGs in general? Do you feel like you have any pearls of practice to offer or resources to offer or what are your thoughts about EKGs? I think everyone hates them and-

Scott Pasquale:
Yeah. I'm-

Liz Rohr:
Primary care and they want to do even better and they always ask me for courses and I'm like, "Okay. This is really complicated," but what are your thoughts? What are your thoughts?

Scott Pasquale:
It's just practice and no matter how long you're doing it, you're going to have ones that are challenging. I frequently will go to the doctors I work with and be like, "What's going on here?"

Liz Rohr:
Totally.

Scott Pasquale:
But I think to start is just to make sure you have a systematic approach. That way, you're less likely to miss everything. If you have this mental checklist or if you actually write it down a physical checklist, things to look at. Most important, identify the rhythm, look at the rate, and then just go further on down from there. Worry about getting the rhythm and the rate and stuff before you worry about particular blocks and left access deviation and all those things like that.

So typically, there's the seven plus two thing is what I was taught. With EKGs, you're going to identify the rhythm, identify the rate. What's the conduction look like? Is the intervals normal? Is it prolonged? What's the axis? And then, you're looking at the morphologies of the different waves. So the P-wave morphology, the QRS, and the SD and then you're going to compare it to the previous one if there's anything to compare it to and then the last piece is what's the conclusion-

Liz Rohr:
Hmm. I love that. I love that. I guess just from my own perspective as an experienced NP and having spent a lot of time trying to learn EKGs, and please let me know if you agree with this, but I think that there is, like you said, there's a process, there are some red flags to watch out for. Also, at least in the resources that I've learned from, it's like, well, you can have 20 cardiologists look at an EKG and have different answers on one day and then you can ask them about the same EKG, the same group of people and they will probably still have different answers the next day.

Scott Pasquale:
Yep.

Liz Rohr:
Thank you for validating that. I just want to share that with the people because it is really complicated and I think that there are definitely resources out there. Do you feel like is there a course or a book or is it just experiential practice? What do you feel has... Anything you can shout out there for people to take a look at?

Scott Pasquale:
Obviously, definitely a course is going to be a really good focus, all the content all at once. Just the more you do it, the more you get comfortable with doing it.

Liz Rohr:
Totally.

Scott Pasquale:
ECGPedia is a website that has tons of information. It's a wiki so anyone can submit content to it but that can be super helpful.

Liz Rohr:
Cool.

Scott Pasquale:
The other thing with the EKG that I just want to mention is don't always trust what the computer says is going on-

Liz Rohr:
I was just going to ask you that. Thank you.

Scott Pasquale:
Yeah. We see that all the time. Part of that too is common sense. Is what the computer telling you there, does it actually make sense with what's going on with the patient? The most frequent ones where the computer reads it wrong, it'll would be like if there's a two to one atrial flutter and it's reading it as a sinus tach because the atrial flutter waves, that first one blends in with the T and then the next one looks like a normal P wave.

So if someone gets read of sinus tach and 133 beats per minute but they're not febrile, they're not sick, they're not in pain, they're not anxious, not bleeding, why do they have sinus attack at 133? What's the more likely explanation? So just taking everything into the clinical context is important too and that'll help you determine what's going on with the rhythms.

Also too, just common sense. Sometimes you'll see stuff that gets read as an accelerated junctional rhythm but what's more common, an accelerated junctional rhythm or AFib? AFib can be way more common. That was one that I've seen that someone who was saying, "Oh, they're an accelerated junctional rhythm." I'm like, "Oh, it could be but what's more likely?" So just using the context of the whole situation can be helpful.

Liz Rohr:
Totally. Yeah. I actually have a quick question that came up a bunch in the questions from the community about AFib. In terms of somebody, for example, if you have a patient who is a new onset AFib, you do the CHA₂DS₂-VASc Score, all the numbers and letters one, and you start into coagulation, maybe they're rate controlled, you start something like metoprolol, beta blocker, something like that. I personally feel like as a primary care provider, I'm like, "I think they're covered but I still want them to see cardiology." What are your thoughts about that? Do you feel like is there any other things that a person would do in a case like that or what are your thoughts about somebody with a new AFib that's hemodynamically stable and you've already gotten those pieces going for them?

Scott Pasquale:
Yeah. That's a great question. I think definitely, really, if anyone has any sort of cardiac condition, it's reasonable to have them see a cardiologist.

Liz Rohr:
Cool.

Scott Pasquale:
But yeah, I think what you touched on was the most important thing is like so this is after you get the first things done. If they're an anticoagulation candidate with a higher stroke risk, don't wait for cardiology to start on anticoagulation. That's something that's well within the scope of practice in primary care. So yeah, that's something where you have someone... And they're hemodynamic stable, you get the rate controls, you get them anticoagulated, that could be a routine referral to cardiology and we could talk about rate control, rhythm control. Do we want to go in arrhythmic? Does this person want to explore ablation? That sort of thing. So just getting them the basics in terms of getting them anticoagulated and rate controls would be step one. That might be all we do with them too but-

Liz Rohr:
Yeah. But you have more of the-

Scott Pasquale:
You don't have to wait to do it. Yeah.

Liz Rohr:
But you don't have to wait and then also, there are... I think I always forget that because so often, my patients just end up on that same regimen but there are other options. Like you said, there's ablation, there's rhythm control, there's all these other things so that's super helpful. So that brings us into anticoagulation very nicely.

So yeah, let's talk about anticoagulation. So I'll give you a little scenario that I typically see in primary care and I know a lot of other people do too. But it's basically like I have a new patient that comes from a hospital follow up and they had a PE, it's the first time they have that, they were started on... There's some sort of anticoagulant whether it's a low molecular weight heparin transitioning to another agent. In my clinic, I see a lot of warfarin just because of the, I don't know, cost and population, stuff like that. But yeah, I remember when I was new I was like, "Okay. How long are we going to anticoagulate this person who's not..." AFib aside, AFib is its own thing but if we're talking about things like PEs and DVTs and stuff like that, yeah, do you have any comments about that? Do you have any thoughts about resources or do you see that a lot in cardiology or yeah, tell me what you're thinking.

Scott Pasquale:
I mean, we do obviously see people with PEs. I think, in general, the guidelines are six months in anticoagulation after a PE or DVT. That being said, we don't do a whole lot of anticoagulation management for PE or DVT. We mostly just manage it with AFib or an LV thrombus or something like that.

Liz Rohr:
I see.

Scott Pasquale:
So I actually usually defer to the PCP for the most part with-

Liz Rohr:
To the what? Sorry, I missed that.

Scott Pasquale:
I actually defer to the PCP on how long anticoagulation-

Liz Rohr:
Oh.

Scott Pasquale:
[inaudible 00:32:44] DVT and PEs because it's a weird-

Liz Rohr:
It's not really your wheelhouse.

Scott Pasquale:
Yeah, yeah.

Liz Rohr:
Even as I asked the question, I'm like, "Wait, that's not really cardiology." It kind of is but it's kind of not. I think it also depends on your setting too because I think that there are anticoagulation clinics specifically that deal with a lot of different things so maybe that's the one that I'm thinking of. But yeah, it's a little tough. I mean, I think that, yeah, there's definitely some guidelines and we can link to a bunch of resources down below. Cool. Thank you for that. So I want to jump... Go ahead.

Scott Pasquale:
I just want to say anticoagulation clinics are incredible to have that resource for people who are on warfarin. It's so helpful to have those people available so-

Liz Rohr:
Definitely.

Scott Pasquale:
Definitely use all the resources you have.

Liz Rohr:
Yeah. I think that one of the challenges unfortunately is that... I mean, this is a challenging situation. I think fortunately, in our community, we have people who are in rural medicine. Sorry, I'm having a hard time talking today but rural medicine. And so, they have limited access to resources or they're underserved populations so I think that's where a lot of the questions and the challenges come in. But I think I'm... Actually, I love to hear your opinion about this but I am one for cold calling where I'm like, "Hey, I'm a primary care provider. I have a question about this patient. Are they appropriate for you? Blah, blah, blah, blah." Do you ever take cold calls or are those usually the physicians or how does that work for you? Is that something you're down for as a specialist or annoying you?

Scott Pasquale:
Yeah. No, anytime there's increased communication between the team, I'm all for it.

Liz Rohr:
Amazing.

Scott Pasquale:
I would rather work with people in primary care who are proactive and want to do things and are helpful with patients in terms of facilitating stuff that needs to get done for them. Yeah. We get messages or phone calls, a lot about questions of what to do, and that's what we're here for. I do the same thing with the PCPs for the non-

Liz Rohr:
Yeah. That's awesome.

Scott Pasquale:
We're there to help each other for the patient.

Liz Rohr:
Absolutely. I think it's so important for people to hear that because I think that, especially newer nurse practitioners, I don't know if you've experienced this yourself but it's like there's so much imposter syndrome and there's so much not wanting to bother people. I think it's like because you ask a thousand million questions a day but yeah, it is really important. It's interdisciplinary collaboration and cross specialty so I love that. So yeah. So we have a couple other questions. So coronary calcium scoring, scanning, all that stuff. Do you have any thoughts you want to get into with that? People are kind of-

Scott Pasquale:
Yeah.

Liz Rohr:
I think a general gist... Well, you start and I can say it. It can follow-

Scott Pasquale:
Yeah. I'll preface this with it's not typically something I order in our practice because we're seeing patients with well-established heart disease so it's-

Liz Rohr:
Oh, that's true.

Scott Pasquale:
So we're not really... I would say it's used in primary care more than I use it in my practice. That being said, I know it can be helpful in those borderline cases when you're deciding how aggressive do we need to be with risk factor modification. Let's say you have a 60 year old with a high cholesterol but it's really not terrible, treated hypertension. Do we need to really get you on a Statin or a stronger Statin or is this good enough? That's where that calcium scoring can come in. If they have no calcium, then you feel pretty good about being a little bit more relaxed. But if they have calcium, then it may change your management to offer a stronger Statin or be more aggressive with other things.

Liz Rohr:
Totally, totally.

Scott Pasquale:
Yeah. It's really only if it's going to change your management... As with any, if it's not going to change anything you're doing, it's probably not that important. But if it's going to change what you're doing, that's where the testing can be helpful.

Liz Rohr:
Totally. I love that. I love that. So I think one thing that comes up a bit in primary care is, you and I chat a little bit before the call about hypertension management and there are beautiful guidelines that are super helpful. But I think that one of the challenges of real life application is when you have the algorithm of choices, you have all the evidence of which one to choose when and what conditions but then you have patients who have multiple medication side effects. So like the gingival hyperplasia with some of the calcium channel blockers or something like that. How do you deal with that in your practice when it comes to like, "Okay. Well, they're having this side effect with ACE inhibitors, this side effect with thiazides," yeah, how do you approach that with your patients?

Scott Pasquale:
Yeah. That can be really challenging. You have people who either don't tolerate things because of side effects or full blown actual allergies, angioedema reactions with ACE inhibitors and stuff. First off is I always believe the patient if they're having side effects or whatever, validate what they're experiencing, and then tease it out. Is this something that happened before you started the medication? Is it after? Do some more exploration, if this is actually something that's related to the medication or not because a lot of times it's not and you find something else to fix and you can actually keep people on their medications if they're not actually causing the problems.

But yeah, if things are actually causing problems, I just talk with patients, "Here's what we have in our toolbox to use. Here's what this class of medication will be helpful for. This one would be helpful for," and I do a shared decision. "We've done X, Y, and Z, what do you think about doing this at this dose and we'll just keep a close eye on it?" so getting input from them too. I feel like if the patient feels like they're empowered as part of the decision-making process, they're more likely to be okay with whether it goes well or not, they're most likely to be okay with what you recommend rather than just telling them point blank, "You need to be on this."

And then, two, the other thing with blood pressure is so many of them you can do two birds with one stone. So if there's more than one thing that you can cover, they're diabetic, you can get them on an ACE or an ARB or if they have frequent PVCs or PACs or palpitations, maybe a beta block being it too full in that way. So thinking about everything else that's going on too can help put your order priority of what class of medication you're going to want to use.

Liz Rohr:
Totally, totally. Oh, I love that so much. So cool. I think probably our next towards the wrap up question is we had a lot of nurse practitioners who either were students interested in going into cardiology, primary care who went into cardiology and they're like, "Wow, I'm overwhelmed," or people who are currently in cardiology and they would love to know but do you have resources or recommendations especially for new nurse practitioners who did not do the traditional cardiac step down ICU in the hospital setting, that type of thing? Getting into cardiology, first of all. And then, the second of all is what are the resources that you recommend for cardiology specifically?

Scott Pasquale:
There's tons. So if you want to get into it and you have no cardiology experience, you can just reach out, like you said, cold call people or ask and say, "Hey, this is my name. This is where I work, I'm interested in this. Would it be okay if I came and shadowed you for a half a day or a day?" And so, just reaching out. I mean, the worst they can say is no or just no response.

Shadowing can be a great tool both for seeing if it's something that you would be interested but also if it is, getting your foot in the door and having a name to a face and stuff. The other thing that can be really helpful in terms of education and networking is conferences. There's a ton of cardiology specific conferences. The ACC does a big one every year. There's one at Harvard Medical School and MGH puts on a big cardiology conference that's a few days every fall in Boston. So going to a conference is another good way to get involved.

Liz Rohr:
I love that. So any other kind of parting pearls of wisdom you want to share or anything we didn't get to yet that you want to talk about?

Scott Pasquale:
Yeah. I guess one big thing I just wanted to mention too is with our heart failure patients, particularly the-

Liz Rohr:
Oh my god. We didn't even talk about heart failure. Let's talk about... Hold on. Before we wrap up, let's talk about heart failure. I can't believe we didn't talk about that yet. Go ahead. Go ahead. Tell me about heart failure.

Scott Pasquale:
Yeah. So particularly the reduced ejection fraction heart failure patients, with all the medications we use, the guideline directed medical therapy, we can, as in the cardiology office, we only have the bandwidth to see people so often. Anytime they're seeing any other provider or primary care or another specialty or if they happen to be hospitalized for another reason is an opportunity to always fine tune these patients.

The very, very few people with reduced ejection fraction are actually on target doses of their guideline directed medical therapy. So that would be your beta blocker, your ACE or ARB or Entresto and MRA and SGLT2 inhibitor. So really any chance that you can get involved to get these people on more of their medications and just provide more education with... Because it can be a hard sell if someone's feeling fine. "Okay. I want to add this medication," or, "I want to double the dose of this," like, "Why? I'm feeling fine."

Just explaining all these things help target different things in heart failure that helps improve quality of life and outcomes. So if you see someone in primary care with an EF of 35 and their blood pressure is 142 over 90 and they're on 10 of Lisinopril, don't be afraid. That's plenty of room. Get them on 20. This is great. So don't be afraid to get involved in and where there's clearly room to push medications, if their blood pressure and renal function allow, don't be afraid to get involved because I think you need every opportunity you can to fine tune these really complicated patients.

Liz Rohr:
Totally. I guess I was going to add too. So I had this all the time in primary care, especially at my first job, we had so many patients with heart failure and I was pretty overwhelmed with all of the medicines and I think the diuretic titration. So I have a question but just to recap for people who are not familiar, GDMT is that, like you said, guideline directed medical therapy and it's basically an algorithm of a package of medicines that people who have heart failure with reduced ejection fraction are recommended to take because like you said, improves outcomes, morbidity, mortality, quality of life. And so, all those categories of medicines, they have their own guidelines, I actually have an episode I can link to down below for heart failure management and primary care.

But yeah, I think that one of the struggles I think in primary care is getting comfortable with that whole algorithm of what are the meds which is something that is so learnable. It's like you just practice that and you're like, "Oh, okay. I can rattle off all the medication categories." But then, the next piece I think is the diuretic management. So many people with heart failure primarily, well, I think both reduced and preserved ejection fraction need diuresis. My take is that it is an art more than a science but what pieces of wisdom do you have about diuresis in general and especially the collaboration between your office and primary care. Because like you said, they only see you every so often, every three months, six months, one year, things like that.

Scott Pasquale:
Yeah. Definitely. So just getting comfortable with the frequent ones we use and the typical doses of them and assessing a patient. If you think that they're volume up, their weight is up a few pounds, they get some swelling, they get some crackles, don't be afraid to increase the diuretic. First order of business should always be get them out of heart failure so it may be a few days until we can see them so get them out of heart failure as soon as possible. That's always call number one. We typically use loop diuretics and if they're already on one, typically, they get a decent response. The general rule of thumb is you have to double the dose. I switch people over to Torsemide a lot as they get on escalating doses of Lasix, especially if they still have a lot of edema. Torsemide tends to be a little bit more effective-

Liz Rohr:
I think it's-

Scott Pasquale:
Absorption.

Liz Rohr:
I think it's a longer duration of action too, isn't it? Torsemide? Yeah.

Scott Pasquale:
Yeah.

Liz Rohr:
Maybe... Go ahead.

Scott Pasquale:
I think it's a little bit better absorbed too. So if you're struggling with Lasix, switching people over to Torsemide is something I do frequently.

Liz Rohr:
Totally. I think maybe one barrier to keep in mind is it might be a little bit more expensive, the Torsemide. I think Furosemide tends to be more cheap. I think that's why people sit with that one but-

Scott Pasquale:
Yep.

Liz Rohr:
Yeah. Tell me if you hate this, so you actually work with one of my former mentors so I used to call her at that office and I would ask like, "Hey, can I do this?" and usually, it would be a complicated case though. It would be like, "Okay. Well, they're still edematous, they have all these signs but their blood pressure is a little bit on the lower side and all of these factors." So do you ever have primary care calling you about that? Is that an acceptable thing to call?

Scott Pasquale:
Yeah. I would rather they did than just sweeping under the rug and be like, "I don't know. Call your cardiologist." I'd rather them reach out to us-

Liz Rohr:
Totally.

Scott Pasquale:
Figure out a game plan.

Liz Rohr:
Totally.

Scott Pasquale:
Like I said, more communication so these people don't fall through the cracks. Especially these complicated heart failure patients, they're high risk.

Liz Rohr:
Totally.

Scott Pasquale:
They're frequently hospitalized. So really anything you can do to use all your resources.

Liz Rohr:
Totally.

Scott Pasquale:
Yeah.

Liz Rohr:
Yeah. Yeah, because I just-

Scott Pasquale:
[inaudible 00:47:13].

Liz Rohr:
I guess I just want to add that because so often, we learn about stuff in this textbook realm of here's what heart failure is, here are guideline directed medical therapy. And then, you have the real world where you have somebody who has diabetes, pulmonary hypertension, they have chronic kidney disease, and you're just like, "Okay. I think I need some help here. I just want to make sure I'm keeping all these pieces together. I'm not going to harm them," so let's-

Scott Pasquale:
Right, right. Yeah. So use the resources that you have. I know I do it with the doctors and other NPs and PAs that I work with too. I'll often bounce things off of them because these patients can be pretty complicated and it can be nice to have another point of view or someone to just say, "Yeah. No, actually I agree with... What I think you're doing is pretty good."

Liz Rohr:
Totally.

Scott Pasquale:
So yeah, don't be afraid to ask for help.

Liz Rohr:
Awesome. Well, any other things that we haven't covered or anything else you want to share?

Scott Pasquale:
No, I don't... Nothing urgent I don't think. Yeah.

Liz Rohr:
Cool, cool. Well, I think one thing I wanted to share from our conversation before we even got to this interview was you were talking about how much time you have in specialty practice compared to primary care so I think that's also maybe something to share to keep in mind that you get an hour for patients or just 30 minutes?

Scott Pasquale:
Yeah, yeah. We're really lucky so for our regular patients with office follow-up, we get a half hour and for our post-hospital follow-ups for heart failure patients or MI patients, we have an hour and that's huge. It's such a benefit for us with our workflow but more so for the patient because we have all that time to decompress. After someone has their first issue with an MI or a new diagnosis of heart failure, first off, it's terrifying but often, it's a pretty busy admission with a lot of testing and a lot of people in and out and there's just not a lot being absorbed. So to have that extended visit to debrief, go over, A, what has happened, B, where things are now, and C, here's our plan to have you feeling better or get better or whatever the case may be. So having that time is huge and another reason where if someone has a documented heart problem, have them see us. Yeah.

Liz Rohr:
Yeah. So much education and coordination and I love that.

Scott Pasquale:
Yep.

Liz Rohr:
Oh. Well, thank you so much. I really appreciate it.

Scott Pasquale:
Yeah. You're welcome.