Assessing Chest Pain: New Red Flags & Risk Factors - Interview with Jennifer Carlquist, PA

Aug 22

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Show notes:

I’m SO envious of Jennifer Carlquist’s knowledge. She’s a cardiology Physician Associate who has worked in outpatient, ED, and inpatient cardiology for 17 years, and before that, worked for 13 years as a paramedic 😮.

When I was a newer NP, I remember wishing I could plug my brain into my supervisor’s brain and download all the clinical knowledge they knew. Honestly, I still feel that way. I wish I could download every little bit of cardiology knowledge from her!

In primary care, we have to hold so many pieces when it comes to the specialties, we simply cannot keep up with all the new developments that happen with each one.

Since she’s in cardiology, she gets to delve into not just guidelines, but new papers on developing evidence and is really on the cutting edge of practice.

This interview is absolute gold. There are so many things to talk about in cardiology— we decided to focus on assessing chest pain and what new developments are happening.

In this episode, we talked about:

Assessing cardiac versus noncardiac chest pain
Assessing risk for MI and when to send patients to the ED or not
What EKG findings to watch out for, and how to learn more to build your ekg reading confidence (and what’s new!)
What we can do for patients to assess and manage heart disease risk, including labs and tests to check in primary care
Further resources to learn if you’re in cardiology or interested in making the switch from primary care

I would ADORE to have her back on the podcast, so stay tuned and hopefully we can all learn more from Jen!

Key takeaways from this episode:

Consider both cardiac and non-cardiac causes of chest pain, especially in female patients with atypical symptoms.
Take a detailed history, including risk factors and family history, and be aware of red flags that may indicate a more serious condition.
Recognize the limitations of certain diagnostic tests, such as EKGs and troponin levels, and consider a CTA with FFR for outpatient testing.
Collaboration between primary care providers and the ER is crucial, and concise reporting of findings is key to effective communication.
Differentiating between hyperkalemia T-waves and hyperacute T-waves can be challenging, but hyperkalemia T-waves are pointy and hyperacute T-waves are more blunted and broad-based.
Inverted T-waves in leads other than AVR and V1, especially if they are symmetric, can indicate the need for urgent evaluation.
Q-waves can form within an hour of an infarction, and a small Q-wave in lead III without other abnormalities may be a normal finding.
When learning EKG interpretation, it is important to start with understanding what a normal EKG should look like and then focus on high-risk findings.
Inflammation is a significant risk factor for heart disease, and non-traditional risk factors such as psoriasis and early menses should be considered.
Lab tests such as the coronary calcium score, LPa, and homocysteine can provide valuable information in assessing heart disease risk.
Magnesium supplementation can be beneficial for patients with palpitations and hypertension, but the specific type and dose should be tailored to the individual.
Primary care providers play a crucial role in assessing heart disease risk and can collaborate with cardiologists to order appropriate tests and make informed decisions.
The three-day EKG challenge and the Cardiology Fundamentals Mentorship program are valuable resources for learning and advancing in cardiology.
The importance of fostering a supportive and collaborative environment in healthcare to provide the best care for patients.

Resources mentioned in this episode:

If you liked this post, also check out:

Assessing Chest Pain: New Red Flags & Risk Factors - Interview with Jennifer Carlquist, PA
Liz Rohr (they/she) (00:00)
thank you for being here. This is so wonderful. I finally get to have you on the podcast. So can you introduce yourself for the people? If they don't know you.
Jen (00:07)
Absolutely. Yes, absolutely. My name is Jen Carlquist and I am a physician assistant. I primarily, my entire career have worked in the emergency room and outpatient cardiology, but recently made a switch to exclusive inpatient cardiology. And prior to that, I was a paramedic for 13 years. So that is my medical career in a nutshell. In my spare time, I lecture around the country on
Liz Rohr (they/she) (00:28)
my gosh.
Jen (00:36)
cardiac and EKG topics. And then of course, I also do something virtually that's geared towards new learners that need to get a good foundation. And that kind of stems from when I was learning EKGs, it wasn't so user friendly. And so that just, we created an environment where the new folks could come and not be hazed and feel supported as they learned in their journey.
Liz Rohr (they/she) (00:53)
Yeah.
Love that. I'm so grateful for you and all of your work that you do. It's just so wonderful. And you have such a wealth of experience. The paramedic to PA, like, amazing. So good. So there are so many things that we could talk about today. And before we started recording, we chatted about, like, there's so many cardiology topics. And maybe we can have some more chats. But I think maybe a place to go with our conversation is we wanted to focus on chest pain, how to, like, assess it in clinic, and
Jen (01:12)
Thank you.
Liz Rohr (they/she) (01:31)
just helping people feel prepared, especially newer clinicians, but also this really applies to experienced clinicians as well. I think chest pain is a really uncomfortable thing for most people in outpatient practice. And then we also talked about touching on the new STEMI guidelines and some risk factors that are new. So yeah, so maybe a place to start is when it comes to chest pain, and I'm just looking at my notes here, what are like...
I guess maybe the place to start is how do you think about chest pain? How would you recommend people to think about chest pain? New clinicians, whether nurse practitioners, PAs, things like that.
Jen (02:04)
Honestly, so I would tell anybody new that take the guidelines on how they want us to look at chest pain with a grain of salt because there's sort of this push to us determining early on in the workup, is it cardiac or non -cardiac chest pain? And there's sort of a shift in really how we're supposed to be documenting about it as well, where we used to use terms like typical and atypical.
They really want us to just decide is it cardiac or not cardiac. And I think that the problem with that is that after really being on all sides of the curtain, so to speak, you know, seeing these cases coming in the ER now and taking a STEMI all the way to the cath lab and realizing that, you know, we can't really hang our hat on pretty much anything anymore. and just to illustrate this point, I had a female who was 68 years old.
Liz Rohr (they/she) (02:54)
Mm.
Jen (03:00)
who had chest pain for a year. It was sharp. She felt like there was some air in her chest. She had a normal EKG. She had a normal echocardiogram and she had a normal nuclear stress test. She had some risk factors, hyperlipidemia and diabetes. And her family came in with her and said, you know, I understand you're telling me all the tests are normal, but my mom has been having chest pain for a year and I just don't feel satisfied. And you know,
they were advocating for her. So really at that point, the decision was, well, there isn't any more testing your insurance is going to pay for because everything's normal. So they opted to get a calcium score, which is a test I absolutely love and recommend clinicians to think about for prevention also. But she ended up getting a calcium score and it was one of the highest I'd ever seen. And she ended up needing a cabg a bypass. So, you know, we're taught sharp,
Liz Rohr (they/she) (03:51)
Wow.
Jen (03:59)
a pain for a year, it's musculoskeletal, you know, she was a field worker, so she was doing heavy labor. And you could have been justified by saying non -cardiac, unlikely cardiac, right? But, and with all the information you had, but the thing is, is that with multi -vessel disease, it will sometimes on the nuclear stress test, it will cause what's called balanced ischemia.
Liz Rohr (they/she) (04:05)
Wow.
Jen (04:27)
and it will basically be normal. And that's not the first time I've seen that. So when I first got into being a cardiology PA I thought, you know what? You know, I know treadmills aren't that accurate, but nuclear stress tests, you know, those are pretty accurate. And then I found out, well, no, they're not. A lot of times they're wrong. And so then I realized, okay, well, what's next as far as like, what can I really trust? The closest thing to an angiogram,
Liz Rohr (they/she) (04:45)
Yeah.
Yeah.
Jen (04:56)
that I can trust. If you said to me, Jen, you get one test and one test only, it would really be a CTA with FFR, which stands for fractional flow reserve. And I've talked to my interventional guys and I've, you know, I've asked them like, how close is this once you're getting in the angiography suite and doing the cath, how close is this test matching? And they're like, it's so close. It actually is almost nearly exactly what I see when I go in. And so
I think that that test is one that holds the most weight with me as far as outpatient testing. So going back to your original question of how should we think about testing, we should be ready for anything and we should expect, we should expect people to present with not the classic symptoms, especially if they are female. So females will say things like fatigue, they'll say things like indigestion, you know,
Liz Rohr (they/she) (05:31)
Mm -hmm.
Yeah.
Jen (05:55)
really anything for the female. I have a low threshold to do an EKG. And that's the reason that, you know, women have worse outcomes is because they present later or they're taken seriously later in the course. So we just have to have that on our radar, right? That the females, we got to think about them a little differently. but, but also going back to that, that chest pain, how we think about it as a new provider.
Liz Rohr (they/she) (06:13)
Totally.
Jen (06:23)
I think the best thing to do to keep yourself safe is always think worst first, because if you do that, you won't get burned. And then, so like,
Liz Rohr (they/she) (06:30)
Yeah, I mean I think people are going in and just being like everybody's having a heart attack. I think most clinicians are going in with that thought. So yeah, go ahead.
Jen (06:35)
Bye.
Yeah, and that's a safe thing. And you know, it is a hard attack till it isn't, because then you're not going to get burned. You know, the other thing I would say is really take a detailed history of their risk factors. And you know, I think the scores that we use are great, but they're tools. So we really got to factor everything together. How, what's, what is their age? You know, what are their risk factors? What is their family history? And I always ask, has anybody had any young?
either cardiac arrest because that makes me think about inheritable things like Bergata or Hocum. But also I want to know has anybody had any heart attacks early in the family because then the threat level for me goes way up with that patient. And then there's some other risk factors that are not really talked about a whole lot and should be just for everybody, not really sex dependent, but getting an LP little A on people is crucial at one point in their life.
because that is very atherogenic. It can also lead to early aortic stenosis. We should also be thinking about stress levels. And I know that especially in primary care, we don't have a whole lot of time in primary to open that bag of worms, right? Open that can of worms. But one way to do that successfully without getting into the details, right? Because you only have a certain amount of time.
is you can say, how is your stress? Not, how are you feeling? How is your stress? Because you really want to focus on taking that into consideration because it creates inflammation. And then the other thing would be a homocysteine level. So homocysteine is something that can also lead to elevated blood pressure. And it's not really routinely checked in labs. So if you have somebody that you're concerned about, or you maybe has
Liz Rohr (they/she) (08:21)
Mm -hmm.
Jen (08:36)
come into you for, my dad just had a heart attack or my brother just had a heart attack. And you really want to get a complete look at what's going on. I highly recommend there's a lab called Boston Heart. And they give you, I think it's called a Cardia Map. They give you the fibrinogen, which can lead to clotting. They give you the homocysteine. They give you insulin levels, which can actually predict diabetes way earlier than what we're using, like hemoglobin A1C.
or fasting blood sugar. They even do C -peptide. They give you the molecule or the particle size. They also add an Lp little a in. And so you're looking not only at the particle sizes, but also the other inflammatory markers like CRP. Like you're getting a full well -rounded look at their actual risk. So.
Liz Rohr (they/she) (09:26)
Totally, totally. Well, so many places I wanna go with this. So I think, yeah, so maybe if we can like zoom back for a second. So if we have somebody in primary care who's pretty brand new, they're so terrified that everybody who comes in has chest pain. I definitely wanna talk about those tests. But I guess maybe to start with that, like, so before it used to be like atypical, typical, like, what is that like kind of like one -on -one place of like, I have somebody with chest pain.
Jen (09:31)
Yeah.
Hehehe
Liz Rohr (they/she) (09:55)
Like, what are just, like, just kind of like keeping in mind with people who feel so stressed, it's like hard to, it's hard. We, I try to keep it like real basic of like, how do we bring it down to like, okay, I'm going to do an AKG. I'm going to ask some questions. Like what, what is that like starting place? Like what, what do you, how do you conceptualize that? Like what kind of differentials are you thinking about? And like, what are the things to document? Cause we talked a little bit about like specific things to document. Cause everyone's like, I know how to do an AK, like I know how to order an AKG.
Jen (10:16)
Okay, yeah. Yeah.
Liz Rohr (they/she) (10:22)
I'm also uncomfortable interpreting it. It's like it's so many things, right? So, yeah, start from there.
Jen (10:24)
So many things. Bring me back to the EKG part, but I'll go back to what you start with. And this is what I learned when I was a baby medic. You learn the PQRST, and that's really true for any pain complaint. But that PQRST is gonna help you really start to form the picture, is this cardiac or not? So part of that PQRST, if somebody were to say, exertion provokes, you're automatically, it's cardiac, it'll prove otherwise.
Liz Rohr (they/she) (10:29)
Totally.
Jen (10:53)
Sharp is less so, but still possible as we found out, right? And then, you know, quality. People, you know, we're taught, they're going to say it's a heaviness, but it's what's interesting is when you're asking, people will correct you and they are very particular about how they describe their pain. They'll say, no, no, no, it's not a pain. It's just a discomfort. And then whatever they say for their quality, keep
reiterating that back to them because that makes them feel hurt. If you don't, if you say, okay, let's go back to your chest pain, it really causes a divide and you'll notice that. So it's really true. The other thing would be the radiation. If they have radiation, that's more likely cardiac, but while you're there, okay, where is it radiating? Because if it's also going to the back and it's ripping and tearing and their blood pressure's through the roof, that's a red flag for AAA. So
Liz Rohr (they/she) (11:27)
I love that.
Jen (11:49)
This is why that PQRST helps guide you. There was a long time ago this like mantra that I was taught. if pain goes to the right, you're fine. And that's actually not true either. They found that like a bunch of people ruled in and had pain that went to the right. So we can't use that anymore. And then, you know, the severity, a lot of people will say, you know, a 12 on a 10, you know, and you have to take that with some
Liz Rohr (they/she) (12:02)
Yeah.
Jen (12:18)
you know, some pause because, you know, just the other day, just an example, I had a gentleman who had a very low trip on in an EKG that was barely abnormal, but he was like, I'm a 12 and a 10, I'm a 12 and a 10. So it can still be something that even with very benign EKG changes. So really listening to that is, is critical. And then time. So the time piece, it really doesn't matter for clinic work because
you know, even if they say a year, it can still be someone who needs a cabbage. So, you know, you document it, it's part of your documentation, then you do your PCARC. Then I like to document my red flags and my risk factors. So red flags, we talked about the ripping and tearing for AAA. If I notice that my patient, they say, you know, you ask them, what makes it better and makes it worse? well, when I lay flat, my pain's worse. That's a clue that you might be dealing with pericarditis talking about differential.
Liz Rohr (they/she) (12:52)
Yeah.
Jen (13:16)
If that's the case, you're going to see widespread ST elevation with no reciprocal changes, and you're going to possibly hear a rub. And they'll most likely have had some sort of recent cardiac procedure that usually is what precipitates it. And then also documenting equal pulses, thinking about that AAA. And anybody who says to me, this feels like it did before my last heart attack.
Liz Rohr (they/she) (13:44)
Oof. Yes.
Jen (13:44)
you have my attention, you have my attention. So the keys would be really knowing those hot button words and triggers to just not keep your patient in the clinic. Now the other thing I know that happens with primary and honestly any clinic where you work and it's happened to me because I've been on both sides. I know that there's some hesitation because primary care, first of all, you don't want to overwhelm the ER and you also.
Liz Rohr (they/she) (14:04)
yeah.
Absolutely not. It's such an agonizing decision and there's people who don't have insurance. Like it's so, people talk about it all the time. So yeah, it's like, do I send them, do I not? It's so hard. Go ahead. Yeah.
Jen (14:12)
Yes, yes, yes. But there's so many layers. That insurance piece, I didn't even put it. But yeah. But then there's also the phone call that has to be made. And I know that that person on the other end of the phone is oftentimes going to be fairly quick and it could be interpreted as gruff. And then, you know, what we also, we don't set our providers up to make that call because we teach them
Liz Rohr (they/she) (14:33)
Yes.
Yes.
Jen (14:42)
We say, hey, you know, give the report like this. I have a 65 year old male, the past medical history of this, there's complaining of this, their grandmother had the ear like, and like ER folk, and I can say this because I am one, like we have ADHD and we do. It's why we function so well in that environment. So like we need like the nugget and that's it. We need the nugget. Like 65 year old male, I think there was a STEMI, I've given aspirin, they're five minutes away, vital stable.
Liz Rohr (they/she) (14:50)
Mm -hmm.
Yeah.
Get to the point. Yeah.
Jen (15:12)
Like, so, so not, you know, that's how to not get a bad experience when you call knowing kind of what to expect. And then also knowing that this is the bottom line for anybody knew anybody. Okay. It doesn't, it doesn't matter if we're overloading the ER. Okay. And I can say that being both sides. The only thing that matters is what is right for our patient. Period. And you know,
Liz Rohr (they/she) (15:12)
Yeah.
Jen (15:41)
I have a low threshold for sending people because here's the thing, then the primary care person can say, well, you know, they don't want to go to the ER, there's cost, there's this or that. Maybe it's nothing. So I'll just get a troponin.
Liz Rohr (they/she) (15:57)
Yeah, oof. Can you talk about that? I have some feelings about that. Go ahead. So yeah, so they're trying to keep them here and they're like, I'll just order a troponin just to check on them because they can't go or whatever. So yeah, go ahead. I have some feelings. Go ahead. Well, I was gonna say, and totally check me if this is off, but it's like, you can't.
Jen (15:59)
Yeah. Yeah.
Yeah. And the thing, well, why don't you tell us your feelings? They're probably the same.
Liz Rohr (they/she) (16:15)
You can't check, it's not a one time thing. Troponins are something that you trend over time. And it's like, what are you going to do when you get that result? And what are you going to do when you need to check it again and see what the trend is? And then they need intervention. That's like enormous liability for that patient. Right? I mean, I don't know. I don't know. You tell me.
Jen (16:32)
Yeah, yeah. And there's been cases actually where providers have been sued because they ordered the troponin and the patient died that night and they got the troponin the next day. So it's just not a good recipe. And on that note, also a D -dimer. Like if you're concerned about a pulmonary embolism, let's talk about that for a second, because that's a cause of chest pain. That's like a total lethal thing to miss. Okay. So D -dimers are fairly inaccurate.
Liz Rohr (they/she) (16:52)
Yeah. Yeah, yeah. Go for it.
Jen (17:02)
I've had PEs who have had negative D -dimers. And really the only time I'd ever reach for one is if I want to prove it's not in the ER, because I'm going to get it back. So going back to what a PE may present like, okay, their PQRST their is going to be, it's sharp. It's right here. It doesn't move when, or doesn't change when I move, because you always want to ask, does it change when you move or breathe? And they'll have some risk factors, you know, it'd be blood birth control or previous blood clots.
Liz Rohr (they/she) (17:09)
Yeah.
Jen (17:31)
recent COVID, recent travel, smoking and birth control and or yes, I do like the wells. Yes. So good. So good. But also I think we need to also factor in cancer. So just a little quick case to kind of illustrate this and to give you a nugget about tachycardia. Okay. So if you ever have unexplained tachycardia in a patient,
Liz Rohr (they/she) (17:35)
I use the Wells criteria. I don't know if you feel how you, what you feel about the Wells criteria, but I can link to that down below. That's like a helpful checklist of risk factors for PE. Go ahead.
Yeah.
Jen (18:00)
And you've done, you know, they're not just nervous, like they came in and they have high heart rate. You've done a couple heart rate checks, even at the end of the visit and they're still tachycardic and you can't explain why. PE should be at the top of your list. And yes, it's a board question that they like to torment us with, but it's actually true. And I had this patient who was late fifties had been diagnosed with ovarian cancer and I think she was like stage four and oncology referred her to us for persistent tachycardia and they
They gave her a beta blocker that she didn't take. She said, I'm going to go to cardiology. So when she came in, I looked at her EKG and she had that infamous S1 Q3 T3. Now there's a lot of debate about this because people are like, it's not really that accurate or specific, but it is something that you can have when you have a PE. You can also have it when you don't have PE, but I document that I looked for it.
because it shows my medical decision making that I thought about it. I'm also looking at their legs. I'm documenting no unilateral edema because usually DBTs progress on up to PEs. But she was the first visit in the office and I was like, and her heart rate was 124 persistently. So I asked the questions, have you had any volume loss? Are you anemic, anything like that, right? And I had her labs, I think. So I ended up telling her, I said, ma 'am,
I'm really sorry, I know you and I just met, but you better go to the hospital." And she ended up having a massive PE that somebody wanted to give her beta blockers for. So we don't just mask, we need to know why. And if you always, as a provider, ask why is this happening, you will stay safe.
Liz Rohr (they/she) (19:43)
I love that. I love that at guidance because I think that's people talk about that a lot for abdominal pain. Like, we don't treat abdominal pain if we don't know why. It's like, so I can see that so easily happening. It's like, they're just tachycardic. Just give them something. Love that.
Jen (19:56)
Yeah, yeah, yeah, yeah, true. And abdominal pain can also be in the upper gastrointestinal, it can also be cardiac. We have to think about that. I can't tell you how many times that we've put someone in the hallway in the ER for we suspect a gallbladder or some GERD, and maybe they even got a GI cocktail and felt better. That doesn't rule them out. Unfortunately, we've had people who've had GI cocktails, I feel better, but they're having, you know, an N STEMI for example. So yeah, be careful with the belly pain stuff.
Liz Rohr (they/she) (20:02)
Totally.
Yeah.
Totally.
Totally.
Absolutely. Absolutely. So yeah, so we sort of talked about like the kind of the one on one of like, what are the where you're asking and you're documenting the red flags, the risk factors, you're thinking specifically about PE symptoms versus heart attack symptoms versus other things. And I guess like, when it comes to I think that I think that there's this I'm just thinking of like the brand new grads, especially it's like you go in, you're asking the questions, you're kind of on the fence, you do an EKG.
Jen (20:26)
high risk.
Liz Rohr (they/she) (20:55)
and maybe it looks normal or they're comparing it to the last one and it seems the same. Yeah, I don't know, what are your thoughts about that? I mean, you said you had a pretty low threshold of sending them to the ER, but yeah, I don't know, do you wanna say more about that kind of scenario?
Jen (21:08)
Yeah, absolutely. I think if you can't talk yourself out of the fact that it's cardiac, then they have to go. And it's just as simple as that. And you don't have to feel bad about it. If anybody gives you static about it, the easy answer is this. well, as you know, there's a lot of atypical presentation. I'm going to use that word because I personally like it. And because of that, and I can't do a troponin in the clinic.
Liz Rohr (they/she) (21:30)
Yeah.
Jen (21:35)
They can do a troponin there and I'll tell the patient too, I'll say, you know, listen, you'll maybe spend four hours there. They'll do, you know, two back to back troponins, right, for a trend. And if everything looks good, they might send you home, but at least we'll get our answer today and we'll take that worry off our plate. We won't be wondering and worrying. And here's the other thing which makes me feel less bad about sending to the ER, because let's just say.
Liz Rohr (they/she) (21:55)
Yeah.
Jen (22:02)
Even if I'm working in cardiology, okay, I think I have somebody that has a cardiac issue and I put in the referral to for echo or even stress test. So if you think about the mechanics of it and you touched on insurance, I want to go back to that because it drives us, okay, drives our decisions. And, you know, like, let's say you have a PE in the office and also you were tempted to just do a CTA, you're not going to get it authorized anytime soon.
Even if you put stat, because the authorizations are always so backed up, and then they have to schedule it, you don't schedule a PE study, right? So then the same thing is true, you know, if you're, even if I'm in cardiology and I could wave all my magic wands, and I think I was in a cardiac, I still send them to the ER because I know that nothing's going to happen fast. And, you know, the last thing on that is when those new providers are looking at that EKG and it says something on the top that everybody should be
Liz Rohr (they/she) (22:35)
Yeah. Yeah, no.
Jen (22:59)
afraid of, okay, seasoned and new. If it says non -specific STT wave changes, that is rarely ever non -specific. And there are a lot of really bad things that live in that, that you need to be able to pick up that are lethal. And like a lot of people see that and they're like, you know, non -specific, that's okay. I can refer to cardiology. It's so not, like I've seen it be non -specific maybe like two times.
Liz Rohr (they/she) (23:21)
I know it sounds so benign.
Yeah. Wow.
Jen (23:29)
out of all the times, it's usually what the machine doesn't know. And that's where that, that collision happened because there was an article that was published in the journal of American necrology cardiology. It was November 15th, 2022. And I remember that because that's the day that, that I think it changed things forever for us, because that was the day that I wanted to stand up on top of any soapbox I could and tell providers.
that you have to read the article. It was called Consensus Pathway on Treating Chest Pain in the ED. And here's the thing. So if you are not in the ED, you didn't read it. Or even if you were in the ED, it was Thanksgiving. You probably didn't read it. All right, let's just be honest. And they outlined all these new STEMI equivalents in there. They're just as applicable to us and wherever we work. In urgent primary cardiology, they're just as applicable to the ER. And those findings are labeled non -specific. Things like...
Liz Rohr (they/she) (24:12)
Yeah.
Jen (24:27)
Welland's warning. Things like hyperacute T waves, things like dewinters. These are probably foreign terms, right? And the machine is never going to print that out because it doesn't know those terms. But two of those things are now STEMI equivalents. And in that article, there's a table and it lists the five STEMI equivalents that they've now sort of elevated. And that's an article worth digging into and reading up on.
Liz Rohr (they/she) (24:35)
you
Yeah.
Yeah, and I can definitely share that. We can definitely share that for sure. Yeah, it's really helpful to think through. Yeah, I mean, I keep putting myself back into the new people. I think that there's so much terror. And I guess I want to say now that, I mean, we'll mention it more when we wrap up, but that you have resources to help people feel more confident with EKGs because most people are like, I'm sorry, what?
Jen (24:59)
Okay, great.
Hehehehe
Mm -hmm. Yes.
Liz Rohr (they/she) (25:23)
So you definitely have some resources to share about EKG interpretation that you can help people with.
Jen (25:25)
Yes, yes, yes, yes. You know, the other thing too is I got when I was very new, I got burned by not looking at the skin. Because another differential would be shingles. Always look at the skin. If it's a belly or chest complaint, before you CT that abdomen for nappy, right? Make sure you look at the skin. And I've been burned a couple times by not doing that. And so
Liz Rohr (they/she) (25:34)
Say more.
I love -
do I? Yeah.
Yeah.
Jen (25:54)
with chest pain, look at the skin, it's super important. And actually you need to do that anyway. You need to lift up the shirt to listen on the skin for those murmurs and lung sounds. But while you're there, just take a peek at the skin, make sure there's no blister like rash.
Liz Rohr (they/she) (26:01)
Yes.
Love that. I love that. And I want to go back to what you said about the sending to the ER of like, yeah, maybe people want to like order a troponin outpatient or they want to order a CT outpatient. Like to your point, I remember being a new grad and trying so hard to keep somebody out of the ER. And I was like, I'm going to do stat this, this, and this. And I was like, wait, that's what they do in the ER. And like, so like, hopefully, like I think that that was definitely a moment. And I remember in my mentees, there's been moments where they're like, that does mean the ER. I guess, is there anything that would help facilitate that? Because.
Jen (26:24)
You hear it?
Liz Rohr (they/she) (26:35)
I really love that you have the ER experience because I just want us to collaborate better in terms of ER versus the primary care. Are there any things that you have aside from the kind of concise reporting that would be helpful in terms of like, are there things that ER providers like wish that primary care did when sending somebody for chest pain, for example?
Jen (26:56)
You know, that's a good question because I think that having better collaboration is important. But other than an EKG, there's really nothing else you need to do. And it's funny because the ER doesn't really want to know a lot. They just want you to send them. They don't want to know. And the background on that, yeah. And if you have an EKG, that's great. And even better if you can speak to the findings intelligently because eventually,
Liz Rohr (they/she) (27:05)
Yeah.
Yeah, I get that impression. Like we're going to do it over anyway, it's fine.
Jen (27:25)
As you keep calling, they'll be like, that's the one that knows what they're talking about when you use the proper terminology. And, you know, I know a lot of new providers will say, like when they're talking about a T -Wave, for example, right. And we'll say, the T -Wave is depressed. If you say that, your instant credibility is just done. Because, you know, it's that, so even the basic terminology really matters because you have to speak a language. It's like when we talk to any of our consultants, we have to sort of know their language and
Liz Rohr (they/she) (27:29)
Yes. Totally.
Yeah.
Jen (27:55)
That makes primary care so much harder because you have to be able to speak all the languages, right?
Liz Rohr (they/she) (27:59)
Yeah. Totally. Well, I think that one take home that I got from a dermatologist one time, I think it might've been in school, in grad school, but they were basically like, don't try to be fancy. Just if you don't know the words, don't try. Or like not to be discouraging, but it's like, don't try to sound fancy about EKG interpretation talk. And tell me what you think about that, but it just seems like it can cause more ruffles and friction than it needs to.
Jen (28:11)
Yeah.
Yes. Yeah.
Liz Rohr (they/she) (28:25)
So it's not about using the terminology, it's about using it correctly. So it's totally fine. At least this is my perspective. Maybe the ER feels differently, but it's totally fine to send somebody with an EKG and I'm concerned about it. They have chest pain. I can't really speak to all the findings. I've been on my own in the clinic as a provider and not feeling 100 % confident about how the way that I talk about the EKG findings. But it's like, I'm going to send them. I'm going to send the previous one. I'm going to give the history. And then they take it from there.
Jen (28:30)
Mm -hmm.
Yeah. Yeah. And that's, that's reasonable. also you can describe what you're seeing too. Like you can say, you know, I'm sending them because I'm noticing that the T waves don't look right or, you know, just giving them a clue and really, you know, what, what they're thinking, just to give you kind of their perspective, they're thinking they've got a full beds, right? And there's no empty beds and they're, they want to know, do I need to move the guy out of room 20 who I'm about to do?
Liz Rohr (they/she) (28:55)
Yeah.
Yeah.
Yeah.
Jen (29:18)
a paracentesis on, right? Like, do I need to move him for your guy? And they're shuffling, they're juggling like so many things. They're like acrobats. And there's so much noise and just bells and people yelling and screaming and it's like chaos all the time. So that's why they want like the minimal info. And you could knock it out of the park with saying very little, which actually is a relief because you don't have to have, but here's the thing, you're going to get one of those docs. Like I had one.
Liz Rohr (they/she) (29:25)
Yeah. Yeah.
Yeah.
Jen (29:47)
who it never failed. He wanted to know like the grandmother's shoe size. He wanted to know all the things. And if he answered, I was like, I wasn't ready for him. I was ready for everybody else. But you know, have some semblance of an idea of, you know, their history, anything they may ask you, but it's better to give less than more because they tend to drown. You lose them. They're not hearing you.
Liz Rohr (they/she) (29:56)
Yeah.
Yeah. Yeah. Yeah. Yeah. And that's right. I mean, I love that painted picture of context of like, wow, it really is just insanity. And we're trying to shuffle a paracentesis patient. Like that's a lot. So it's helpful to hear that context of like, get to the point. Get it as concisely as possible. Yeah.
Jen (30:28)
Otherwise, yeah, because you take it personally. Otherwise, I mean, honestly, I even took it personally, having worked both at the same time, like when I would call, I'd be like, Hey, why are you so rough? But I know, you know, it's not a personal thing. It's just, they're, they're drowning. They really working in the ER, you're always going to have a drowning rat. And so it's just, you're just trying to climb up onto the boat. Yeah.
Liz Rohr (they/she) (30:46)
Totally.
Totally, totally. Well, I'm thinking about, so I guess, I'm looking at my notes here. So, yeah, so I guess, do you wanna touch on the guidelines and you're talking about the risk factors, the kind of newer risk factors? And like, just like really like 101 level, like so if somebody's just graduating and like they touched on chest pain but they're like, what guidelines, by who? And you know what I mean? Just like, if we could bring it back to that.
Jen (31:07)
Yeah. Yeah, so there's...
Liz Rohr (they/she) (31:20)
That would be awesome.
Jen (31:21)
Okay. So there's a couple of things to talk about there. A couple of articles. We'll have to link them for you, but basically the STEMI STEMI hasn't changed. Okay. It's still the, I think 2018 guidelines. And that's just talking about the criteria. And that's just talking about like how many millimeters and what lead is going to make you qualified for STEMI. Okay. that, that hasn't changed, but what has changed is that article in Jack where they've given some new STEMI equivalents and
Liz Rohr (they/she) (31:26)
Yeah, yeah.
Jen (31:52)
What they said was, and basically this table is basically split up into two. The top are semi -equivalents and the bottom are things that should have urgent, urgent catheterization to look for revascularization means basically. So the two that we are not familiar with, and I would get really familiar with on the top of the list are hyperacute T waves. And then also de -winters T waves. So hyperacute T waves are just T waves that are too big.
in relationship to the QRS that they are assigned to. And so one of the little tips and tricks with this is that I think of the P as the mom, the QRS is the dad and the baby is the T wave. And when you think about it this way, when you see those T waves, they're going to look like teenager T waves because they're really tall. And you know that teenagers can be problematic, right? A little bit more problematic than the regular babies.
Liz Rohr (they/she) (32:49)
I love that.
Jen (32:50)
So that's the way I look at it. But then the question is always going to come up for people that they'll say, okay, well, okay, that T wave is big. And so is the one next to it, contiguous leads, right? And they're going to say, well, maybe it's hyperkalemia because they look very similar, the peak hyperkalemia T waves and the hyperacute. So here's a little pro tip. Okay. When you're looking at them, the hyperkalemia T waves are going to be very pointy.
Liz Rohr (they/she) (33:05)
Hmm.
Jen (33:18)
They would hurt your booty if you sat on them. But the hyperacute ones are a little more blunted and they would not hurt you. Okay. And they're also going to be, the hyperacutes are going to be more broad based. And the problem is in this article, they don't give you like the definition of hyperacute. They just say, it's bigger than it should be. It's a relative proportionality. And that's not like us in EKG world. We are so specific down to the millimeter, but this one finding, okay, it's a quite problematic.
Liz Rohr (they/she) (33:37)
Hmm
Yes.
Jen (33:47)
So I would say, I mean, I obviously have a class that teaches that and we can help you with those findings. We go over it in detail, but if not, you can look it up. And what I recommend is practicing it. And once you identify the pattern, what it looks like, go hunt for it on Real EKG. And then when you feel a little bit more comfortable with it, then go teach one of your.
people that you work with. Hey, I just learned this new thing and I'm going to show you because when you're teaching it to somebody, not only are they benefiting, but you're learning it. So I think it solidifies it for you. And it's funny because hyperacute T -waves for a long time, I've been teaching EKGs forever and I used to teach that they are pre STEMI and now they've upgraded them. And there's some other things that they have upgraded to on the bottom that should go urgently.
Liz Rohr (they/she) (34:27)
I love that.
Jen (34:43)
And those are inverted T waves. So if you just remember on the EKG that for A, VR and B1, the T waves are supposed to be inverted. Everybody else is supposed to be upright. So if one of those other guys is inverted, they've actually said that's now someone that should potentially go to the cath lab. Because especially if they're symmetric, that's the key. If the T waves are symmetric. So there's lots of different, well, so
Liz Rohr (they/she) (35:08)
What do you mean by, what do you mean by symmetric?
Jen (35:12)
If you have a T wave that's upside down and it completely looks like this versus one that looks like a reverse check mark, right? Like the reverse check mark one is going to be from hypertension that's been poorly treated. It's LV strain, but the inverted symmetric, a T wave that you could put a cue ball in. Yeah, you could, it's not going to go anywhere. If you put a little cue ball, that's the dangerous one. So keep those on your radar as well.
Liz Rohr (they/she) (35:21)
Yeah.
I understand what you're saying. Yes. okay.
Jen (35:41)
And those are just going to be read. They'll say, machine will say things like, consider ischemia, consider lateral ischemia. And then of course, Q waves you have to keep on your radar as well because, you know, we're taught about Q waves and we're taught, they mean old MI. But, but Q waves can form within an hour of an infarction. And they never really tell us that part. And they don't, they don't also tell us that, you know, a Q wave
Liz Rohr (they/she) (36:07)
Yeah.
I'm sorry.
Jen (36:11)
that is just hanging around in lead three with nothing else that's kind of small, that can be a normal thing, right? And they don't tell us that, well, if you have a cue, you should make sure it's not part of the pattern like the S1Q3T3 pattern. So there's a lot of details and nuances, I think, and it intimidates people, right? Because there's so many nuances, but...
Liz Rohr (they/she) (36:31)
yeah.
Jen (36:35)
I think they're really the way to start. And if I could go back in time and teach myself, like instead of learning access and vectors, which made me almost want to just quit like literally, okay. That's not the place to start. And I've had some people argue with me and I'm like, friend, you can think what you want. That's great. But when you're new and you're trying to conceptualize vectors, that is not necessary. Okay. I have PTSD.
Liz Rohr (they/she) (36:45)
Yes, yes.
Yes.
Yeah, no, no.
Jen (37:05)
I would say like really just learn what a normal EKG should look like. Learn the waves, learn the segments. And then, you know, if you have limited time and all of this do, the next thing I wish I would have learned was like the high risk stuff. Because if you think about it, right, they're spending all this time teaching us PAC, PJC, wandering neutral pacemaker. Is that going to kill anybody? No. But these other things are not even teaching us.
Liz Rohr (they/she) (37:24)
Yeah. Yeah.
Yeah.
Jen (37:34)
And those are killers. So it was like, I don't know. So that's, I made a workshop actually just dedicated to like, let's just get in for three hours and let's just teach you those non -specific things, the five things that it could be, right? Bad things. And let's just really then give you some hands on practice with real EKGs, not the ones out of the books. Cause they're always all like beautiful and no artifact and right.
Liz Rohr (they/she) (37:34)
I know.
yeah, no. In the real world, it's like, what am I looking at here?
Jen (38:01)
And they also teach us like one at a time STEMI. And then when you have someone who's having like both two arteries, two or three arteries affected, you don't know what to do. You're like, I don't know what this is. I know it's bad, but I don't know. Cause no one taught us. So you need to be exposed to having two at once. You need to see what it looks like. You need to be able to understand how the slap paper corresponds to the 3D anatomy. And then it starts to make sense because you realize that
The heart is trying to tell you what's wrong with it. It's sending signals and it's like Morse code. We have to learn and the LAD in particular, I have so much affinity for the LAD, the most important artery because she tries to tell us like five, there's five ways she'll try and tell us she's sick. The RCA is like elevation and bradycardia, but like the LAD has all the things and I call it the most dumb.
Liz Rohr (they/she) (38:49)
Yeah.
Mm.
Jen (38:58)
She's the drama llama artery, because she's always trying to. But like, it's also beautiful because she advocates for herself. We have to listen, right? We have to know, like, what is she saying? So that's where those high risk findings really come in.
Liz Rohr (they/she) (39:10)
I love that. I love that. I love that so much. And I think I really appreciate that approach of like, let's like, yeah, I just, I was always frustrated with PACs, PJCs, like all those extra things. I'm like, okay, when are we going to get to the scary things? You know, so I appreciate your focus on the, like the real heart of it. And also just making it fun, right? Of like, it gets to be fun. It gets to be whatever we want it to be. It doesn't have to be like, you know, sitting down in a classroom and blah, blah, you know, just having this.
Jen (39:31)
Hehehe.
Liz Rohr (they/she) (39:40)
Visualizations are really helpful. Yeah, so do you want to talk about risk factors? There are some risk factors that you want to touch on.
Jen (39:45)
yeah. So one other thing that's kind of come up is, really the new, there's a new paradigm shift in the way we think about, risk factors in heart disease. And it's funny because I first read an article, it was in like this super sciencey magazine. I don't remember the name of it. It was a long time ago, but like maybe 12 years ago. And they were like, inflammation is the new.
It's coming you're gonna hear more about it and I was like, I got on my radar right and now you're starting to hear what is it 12 years later? They're talking about how inflammation is the key. So Think about this and I've asked why all the time. I'm always asking why I'll see these people who come in and their LDLs are to goal below 70 and they're having massive MIs Because that's not the full answer inflammation
Liz Rohr (they/she) (40:35)
Yeah.
Jen (40:41)
is a risk factor in itself. Okay. So that's a paradigm shift and kind of on that psoriasis, right? If you think about it can be a risk factor. And I had somebody who I've done had the most procedures done on who had a really bad uncontrolled psoriasis because he kept basically plaquing up every artery. And he needed it. He's like, every time I see you, you tell me something bad. And then he finally got on, I think it was co -syntax and got it controlled and he stopped plaquing up everything. But
You know, we don't think about that. We don't put it in any of our risk scores. And then the female risk factors, there's new data, I think came out somewhere in the last two years where they've said, you know, having early menses can be a risk factor for heart disease, having gestational diabetes, having hypertension and pregnancy, having late menses. All these things are just things that we are now taught and at least where I work.
to ask, it's actually in a hard stop in epic now. And it's because we have a wonderful female physician who is leading the charge in our entire state. And she's like, no more, we are going to stamp out heart disease in women. And this is, we're going to do it by, you know, asking these questions and addressing, you know, realizing that their risk is really more elevated than we thought. So those are the two new things that I would put on that in your radar as well, as far as risk.
Liz Rohr (they/she) (41:43)
Wow.
Wow.
Absolutely. And so are these kind of like studies that have been posted after the guidelines have been updated? So are there any consensus statements? I guess maybe we can talk after the episode about links and stuff like that. Because a question that a lot of people ask me are like, where can I read more about that? Or what specifically is that from? And then they can also cite themselves when they're backing up their medical decision making. So that's really great.
Jen (42:22)
Yes, absolutely.
yeah.
Yeah. Yeah. And you know, one thing that is also going to happen too is there's the gut, when they update the guidelines, they're going to start incorporating something called occlusion MI and you're going to hear that eventually. So I'm probably the first time you're hearing it, but, there's a lot of things that are not STEMI that are bad. There's a lot of ways that EKG will show us that the arteries occluded.
That's what they're starting to focus on. They've sort of done that in this new paper, that consensus pathway. They've said, hey, start looking for things that are not STEMI, that are signs of OMI. But it's going to completely, I think, kind of head that direction because we used to just throw everything in STEMI and STEMI, but they've learned that that's dangerous to do that because, for example, NSTEMI, hyperacute T -waves, right? No, that's actually...
Liz Rohr (they/she) (43:02)
Yeah.
Yeah.
Jen (43:27)
still Cath lab right now. So we really do need a change. It's coming. I don't know when, but it's going to change and it's going in that direction. It's a good thing though.
Liz Rohr (they/she) (43:28)
Yeah.
Definitely, definitely. And that kind of reminds me of when we first started the conversation talking about different labs. So I think that there's a context of somebody comes in, in primary care, they have chest pain, you're assessing them, do they need to go to the ER or not? And then you also have the people who are, you're just thinking about heart disease in general, or maybe they've had an MI. I guess, and it's a big topic, I know, but what are some, I guess I know that people...
Jen (43:55)
Mm -hmm.
Liz Rohr (they/she) (44:04)
want to feel more comfortable with the lab tests that you mentioned, and then coronary calcium scoring, or any other imaging. So we had one other episode, and I can link to this below, where we talked about the different types of stress tests. Like there's so much in cardiology for people to know, right? And so we won't get into the stress testing aspects necessarily. I mean, you mentioned, well, anyway, I have so many thoughts, so many things I want to share with people. But maybe I guess starting from there, if we're thinking about heart disease in general, assessment, do you want to touch on some of those kind of like?
Jen (44:10)
Okay.
Mm -hmm.
Liz Rohr (they/she) (44:32)
you know, questions, risk factors, maybe the coronary calcium in some of those labs for people just like, you know, starting from the beginning. Cause some people are familiar. Some people are like, what is LP little a go ahead.
Jen (44:38)
Sure. Yeah. Yeah. So, you know, you get someone who comes in that they're concerned that they're at risk. That happens all the time, or maybe you're concerned they're at risk. So, getting the good family history and knowing that we're genetic carbon copies of our closest relatives. So, if someone had disease, you're, I'm automatically thinking about a calcium score with them. Young family history, get a calcium score. if they have
hyperlipidemia and I'm going to get it and they don't want to take a statin, I'm going to get a calcium score because if it's anything over zero, then I have justification for them to take the statin because it'll help prevent progression. The other thing I always kind of throw in my consideration of the lipids is are their numbers, they're LDL over 190 or total cholesterol over 290 because those numbers make me think about camellial hyperlipidemia.
And those people have a tendency to have severe disease early, severe coronary artery disease early, like in their 20s and 30s. And so, you know, a lot of people will say, well, do I need to do any scoring? Do I need to do any, you know, Dutch assessments, all these things? No, you just need to get them on a statin if you can and get them to cardiology because they need more advanced drugs. They are not going to get to go on a statin.
They are not going to get to go on a diet. And I think that the whole lipid conversation is another piece, but really those patients need aggressive reduction with multiple agents and they automatically qualify for things like rapathia or progulant and even Lyckvia just with having familiar hyperlipidemia. So going back, so you're just looking at them. They're coming in. So you run basic lipid panel. I mean, if you could also throw on, you know, a particle size.
That would be great if you're not doing the Boston, right? If you could throw in an LP level A, if they've never had one before, that would be super beneficial. And you also want to check, believe it or not, vitamin D levels and a thyroid level, because the thyroid can affect lipid levels. And also the vitamin D level is going to play into the potential for myalgias with a statin, if they are under 40 on their vitamin D.
Liz Rohr (they/she) (46:40)
Okay.
Jen (47:07)
So I like to get all of those and then a CRP could be considered as well. And if you can get it, and then mostly you can, a homocysteine. Because probably that patient also has hypertension. And on that note, the homocysteine can really help, you can manage that really easily with supplementation and then potentially help your blood pressure too.
But on that note, the other thing I'm asking about on pretty much everybody is I'm looking at their body habits and thinking about sleep apnea. And in primary care, I feel like we're not doing a good enough job because I'm diagnosing it in cardiology. And there's a lot you can do before they come to cardiology. And I'm not saying you have to, but if you're talking about being collaborative and like doing the best thing for the patient, like get those basic labs, get the EKG and get a
Liz Rohr (they/she) (47:48)
I agree. Yeah.
Jen (48:05)
get screened them for sleep apnea because nine times out of ten that hypertension referral that's coming my way that's young it's like sleep apnea. So and that could be avoided if we just go back to our why like why is a 32 year old on four drugs like why right and so before we're adding more drugs we're bringing out that question why why yeah so i think that that would be a great like starter
Liz Rohr (they/she) (48:19)
Mm -hmm. Yeah. Absolutely.
I love that.
Jen (48:34)
for somebody and then when they get referred to us, you know, we can pick up the ball by ordering the calcium score. But I think primary does have access to order calcium scores too. So if you do great, literally so much information on the calcium score. Sometimes we even find incidental things like fatty liver will show up, right? Like all sorts of things will show up on the calcium score that you just didn't plan on finding. So it's helpful in many different ways.
Liz Rohr (they/she) (48:34)
Totally.
Yeah, well.
That's helpful. Yeah. And I guess, cause I, cause I think there's like this balance piece of like in specialty care, we get a little bit more time with the patients and then in primary care, it's like, we might not have the access to that. So it's kind of this balance of like, what is the, what is the must do of primary care and like, what could we do if we have the time, but also acknowledging that, you know, there's more time. So, so it sounds like, I guess, just to recap, it's sort of like, we definitely want to look at cholesterol, like a basic cholesterol panel, looking at the LDL.
Jen (49:22)
Yes. Good question.
Liz Rohr (they/she) (49:33)
Greater than 190 or total greater than 290 is big concerns there. And would you say that most cardiologists are going to order the LP little a, homocysteine, and some of the other labs that you order? No, that's not a typical thing. They're really just looking primarily for the lipids with maybe a particle size? OK. Yeah.
Jen (49:46)
No, it's not. It's
Yeah, maybe. Honestly, yeah, it's at least the cardiothoracic. Yeah, it's gonna start happening, but I guess it is more cutting edge. But honestly, if you're talking about being new and really wanting to start earning your stripes early and coming out of the gate like that is going to like that person, wow, they really know what they're doing.
Liz Rohr (they/she) (49:59)
More and more, yeah.
Yeah.
Yeah.
Yeah, totally.
Jen (50:18)
And I think it's important when you're new to earn that confidence from your people you work with early, both patients and the providers that supervise or collaborate with you. And you can do that easily with that set of labs. They'll be like, wow, you really have a handle on this. And then, yes, send them to cardiology. But it's also not wrong to just do the basics too, depending on what you have access to and the time and what is the patient going to be.
Liz Rohr (they/she) (50:24)
Mm -hmm.
Totally.
Totally.
Yeah.
Yeah.
Jen (50:47)
If you're seeing somebody, you're getting all the rest of the labs anyway. You're getting a hemoglobin A1C. That's another thing I'd add on. You're getting your CVC and your CMP, but just adding those other two things on because you're already sending them to the lab anyway. But from a primary care standpoint, you have to think about how are you going to get that vitamin D covered because you can't order it to see if they're going to be at risk for myelges, right? So yes, there's also that piece. Yeah. Yes.
Liz Rohr (they/she) (51:01)
Yeah.
Yeah, yeah. It's a justification there. Yeah, totally. Totally. Could you do a brief 101 of LP little a and homocysteine? Not to put you on the spot, but if somebody's like, I don't even know what those tests are.
Jen (51:27)
Yeah, so, LP little a is just a special type of particle that's, a cholesterol particle and it's just super atherogenic and basically goes in and like scars up the walls and implants itself. And if you have a high level, the bad thing is that you can't do anything about it yet. I mean, okay, let me back up. You can do niacin, but.
If you've ever put a patient on myosin, the drama and the trauma for them and you and your inbox. Okay. And I don't use that. It's not really that great of a drug to be honest. There's better things out there, but there are drugs that are coming for LB little A. They're coming down the pike, I think probably next year at the earliest. But that is a risk factor that we, you know, you can't die a airway out of it.
Liz Rohr (they/she) (51:58)
Yeah. Yeah.
Because of the flushing, is that the main thing that you've seen with people? Yeah.
Yeah.
Jen (52:26)
The homocysteine is, I'm not sure if it's a hormone or if it's, I'm not sure how it's classified. No, but I'd have to, I'd have to look at it, but it's, it's a marker of inflammation. And sometimes it actually, if it's high, it also means you have a certain genetic deficiency, MHTFR. And that's something.
Liz Rohr (they/she) (52:32)
And not to put you on the spot, totally. This is like just very, you know, basic overview.
Jen (52:52)
that's not to deep dive too much, but that's something that they can correct with like proper B supplementation. And when they fix that, they fix the homocysteine and then that oftentimes fixes blood pressure. But while we're in this like, kind of like over here in the tide pool part, I also wanted to put a plug in about magnesium and yeah, because magnesium is another thing we can do for people who have palpitations and more hypertension. And it's a very like,
Liz Rohr (they/she) (52:56)
Mm -hmm.
Yeah, go for it.
Jen (53:22)
low cost thing they can do. And a lot of people who are like, I'm not going on pharmaceuticals, do something else. Magnesium. And there's the problem is there's like seven flavors of mag. And, you know, if you think about it, we give mag citrate for constipation. So mag citrate is not the one I'm grabbing for the palpitations. You know, like glycinate and mag oxide is very hard in the stomach too. But it's one of the only ones that I think we can actually prescribe. So I don't think you can prescribe the other ones.
Liz Rohr (they/she) (53:28)
Yeah.
Yeah.
Yeah, totally. Mag oxide. Yeah. Yeah.
Jen (53:51)
but it's hard on the stomach. So the best one for palpitations is taurate, T -A -U -R -A -T -E, but also well tolerated is glycinate. And the only two like contraindications are if they have like kidney failure basically, or they have like really bad loose stools, you're not going to be their friend if you're giving them magnesium. But half our patients are constipated and they have palpitation and they can't sleep. And magnesium is like beautiful for all of those things.
Liz Rohr (they/she) (54:21)
Do you have a standard dose that you're recommending? Are you doing lab tests? Like it's not, go ahead.
Jen (54:24)
So no, no, I mean, honestly, you're checking the lab, it's you're checking extracellular magnesium. And so it's not like really super accurate.
Liz Rohr (they/she) (54:32)
Yes. And most of it is stored. Like most of magnesium is stored, so we can't really tell by blood tests anyway if it's low, correct? Cool. So.
Jen (54:41)
Yeah, like really low. So I don't use it to like base whether I'm going to give it or not. I just, the only time I check mag anymore is when somebody comes in with AFib or if they have testing issues, I'll check the mag or palpitations, but in the inpatient setting. But anyway, so it depends on what flavor they're using. Honestly, they can just follow the instructions on the bottle of whatever they choose for that.
Liz Rohr (they/she) (54:47)
Yeah.
Jen (55:10)
dose. But there is actually this, there's one supplement that I recommend. It's called Magne MAGNE5 and it's by the Natural Heart Doctor. And he has a website with some supplements. That's a good one. Also in that realm, if you run into patients, because I know everybody does, who doesn't want to take a statin, I want something else. He also has something called OptiLipid. OptiLipid is
I'm really good at reducing cholesterol naturally. It's supplement based. So that's a really helpful thing. And then there's one other thing that's by Designs for Health that is good for people who have plaque but don't want to take a statin and it's called arteriocell. And you can get all of them without a prescription. And so, because I had so many people in my practice who were like, I'm not doing pharmaceuticals, get me something else. And so I would do food and I would do supplementation.
because that's what they wanted to do. I would try to encourage them to statin, but then you could also sometimes get around the statin and give them something else pharmaceutical that didn't have any side effects like the statins if they failed two statins. So, and that's a whole nother topic, but another rabbit hole.
Liz Rohr (they/she) (56:24)
Yeah, totally. Absolutely, absolutely. Totally. Well, thank you so much for that. I guess just to recap, when it comes to the heart disease prevention side of it or concerns about it, excuse me, so we're doing those kind of like a, we're doing risk factor, family history, we're doing some labs, coronary calcium score.
Jen (56:37)
Mm -hmm.
Liz Rohr (they/she) (56:51)
I don't actually know, like what has your experience been with insurance, with getting that covered? It's still not, okay, because I haven't had it covered, so I just didn't know if there are other places. Okay, so that's a thought, but it's helpful if they do have, so if they have a calcium, corner calcium score, and they're already on statins, and they have risk factors, is that just like decision -making material for cardiology to decide like, hey, we're gonna go do a cath to do some exploration? Okay.
Jen (56:55)
They don't cover it. No. No.
Mm -hmm. Mm -hmm. Yeah, because I mean, so a lot of times too, there's a lot of different ways to use that tool. So someone doesn't want to do a statin, you do it. If they have anything, you put them on statin. If they have chest pain, but a normal stress test and normal echo, I'll often use it to see if there really is something because I found a lot of disease that way. And then I'll also use it if, you know, if I find someone who has over 400.
they're absolutely going to get a stress test and even potentially an angiogram. So, and the other thing it shows you is the distribution in the arteries. It'll show you like, I like heavy burden in LAD, you know, severe plaque LAD and where it is. And that also, like, if I were to see that in the left main, I'm not going to Pasco and collect 200 because
that patient I'm going to stop, drop and roll and be like, hey, cardiologists, we need to, you know, we need to do something right now. And, you know, a lot of times what people don't know is that cardiologists have cath days that they're allowed to do the procedures in. So sometimes, you know, that means the patient waits a week or two till they have an opening on their day in that lab. So sometimes, you know, they may have to go more urgently and that calcium score can sometimes tell us that. And if that's the case, we can either
get permission to bypass them and get a different cardiologist to do it. So it does really help us make decisions on a lot of different levels. And I don't think they've anywhere I've ever worked, it's never been more than $179 cash pay. And they do that because, well, here's the thing, it's been out for more than 10 years, but they still say the insurances say, it's,
What's the word? Like not exploratory. Experimental. Yes. When actually it's like one of the best tests we have, but they do that so they don't pay for it. But then the institution, well, it's like a $1 ,400 test. They'll discount it severely so patients can have access to it, which I like. And there's really no reason not to get one. I mean, I wouldn't blanket statement, hey, let's expose everybody to the radiation that walks through our door. But man, when you're talking about, you really want to know someone's risk.
Liz Rohr (they/she) (59:08)
Experimental.
Yeah.
Jen (59:37)
going to help a lot. Here's the thing. Okay. I have had like one or two false positives where the calcium was outside the vessel. It doesn't always get that right. But when you do that other test, CTA with FFR, it does tell you if it's inside and it does tell you if it needs a step with like certain accuracy. It just, it's a really good test. So
Liz Rohr (they/she) (59:37)
Yeah.
Yeah, that's awesome. And that would probably be, I'm thinking of the questions from the people, is that that's typically something that people would order, like the cardiologist would order, excuse me, because I think that some people, I need to know all the tests and how to order them all. And it's like, okay, hold on a second. It's okay. We can like cardiology, help us with that. And also we can call cardiology if we have limited access and see, is this an appropriate test? Is there a way to order it? Like, I'm not going ahead and ordering that kind of test, but like,
Jen (1:00:08)
Yeah.
Yeah. Yeah.
Yeah!
Liz Rohr (they/she) (1:00:25)
I'm just thinking of the people who are out there who like, I want to know all the things.
Jen (1:00:28)
But also I think it's good that you do all the things just because when you get that patient back and you from the specialist visit and you see the reports, knowing what they mean, I think can really help because here's the thing as primary, you're like the quarterback and you're the one they trust. They're going to come back to you and be like, I don't know. They said this and this, but I don't know what it means. And then you have to like be the interpreter. So that's a, that's a really another point to know what the tests mean, but.
Liz Rohr (they/she) (1:00:32)
Yeah.
Totally.
Yes. Yeah.
Totally, totally. Yeah.
Jen (1:00:58)
But you're right as far as ordering them. When I worked primary for three months when I got out, three months, that was all I could do just because I realized this, no, here's why, okay? I'm gonna be honest, sports physicals is what drove me out. No lie, okay? And they are so high risk, so high risk and you have like two minutes to do them and everybody's like pressuring you to sign the form, right? I was like, I'm out, I'm out, I'm done.
Liz Rohr (they/she) (1:01:04)
I'm outta here.
All set.
Jen (1:01:28)
yeah, I do have some, some tips and tricks to navigate that if we ever want to talk about that.
Liz Rohr (they/she) (1:01:31)
I love that. I love that. Well, thank you. I'm mindful of our time. I really, I'm so grateful for all that you shared. You just, you know so much stuff and yeah, I just really appreciate you being able to go in between the like brand new person and the, you know, I really want to specialize into cardiology and it's so fun to hear from you, like how lit up you are by it because I think that's really something that people enjoy seeing is that like people are just happy in their careers and they love what they do. Especially like you've been in medicine for so long. So.
Just thank you so much for sharing and I will definitely be sure to share all of the links and all of your resources. But yeah, if you maybe we'll wrap up by saying, where can people find you and learn more? And like I said, we'll share links, but what do you want to share?
Jen (1:02:13)
Well, the big thing is, find us in the three day EKG challenge. It's a free thing we do every month. We're actually doing night two today. but the recording stay up in the group. It's a great place to get some fundamentals for free and be in a supportive community where it's there's no dumb questions and it's super fun. And then when you're ready to learn more of the high risk things, we have a program called the 30 day EKG challenge where we give you six months access and you get access to multiple coaches.
Lots of mentoring and ability to ask questions as you're learning. It's self -paced and live, a combination of, and that's a really fun thing. And then if you do want to specialize in cardiology or thinking about transitioning, we do have a program called the Cardiology Fundamentals Mentorship. And that's going to open again in September. There's limited spots, but we do it every few months. My partner Erin Lee and I, she's an NP and I adore her. We do it together and it's a really intimate space where we.
Liz Rohr (they/she) (1:02:55)
Yes.
Peace.
Jen (1:03:10)
like basically foster new providers and give them a place to ask questions. Everybody gets their own time. So if you're interested, we can hook you up.
Liz Rohr (they/she) (1:03:19)
I love that. I love that so much. I'm so thankful that you have all of these resources. So yeah, any last thoughts or pearls of practice or words of wisdom to share?
Jen (1:03:31)
Just thank you for having me. I'm honored and it was a pleasure.

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Liz Rohr