Dr. Lee was born in Shanghai, China, and received his college and medical training in the United States. He is fluent in English and three Chinese dialects. He graduated with chemistry departmental honors from Harvey Mudd College. He was appointed president of AOA society at UCLA School of Medicine. He underwent internal medicine residency and gastroenterology fellowship training at Cedars Sinai Medical Center.
Dr. Kulick received his undergraduate and medical degrees from the University of Southern California, School of Medicine. He performed his residency in internal medicine at the Harbor-University of California Los Angeles Medical Center and a fellowship in the section of cardiology at the Los Angeles County-University of Southern California Medical Center. He is board certified in Internal Medicine and Cardiology.
Anticoagulation to prevent blood clots and strokes
Atrial fibrillation is one of the most important causes of stroke in the
U.S. Warfarin (Coumadin) is a blood thinner that prevents the formation of blood
clots. Studies in patients with chronic sustained atrial fibrillation and sporadic (paroxysmal)
atrial fibrillation
have shown that warfarin reduces strokes.
Aspirin
is an anti-platelet agent. Platelets are elements in the blood that are
necessary for blood clots to form. Aspirin can be considered a milder blood thinner
than warfarin, but it is not as reliable as warfarin in preventing strokes
in patients with atrial fibrillation. Some doctors prescribe
aspirin to patients when the risk of
bleeding from warfarin is believed to be too high and to patients who refuse to
take warfarin. Young patients with lone atrial fibrillation who are not at an increased risk for
stroke sometimes are given aspirin rather than warfarin.
Side effects of warfarin. There are some patients who are at increased
risk for side effects from warfarin. Specifically:
Patients with active stomach ulcers can develop ulcer
bleeding while on warfarin.
Elderly patients can experience hemorrhage into the
brain while taking warfarin. The risk of hemorrhage is higher if the patient
also has high blood pressure.
Elderly patients who are unsteady and/or accident-prone are at an
increased risk for trauma that can result in excessive bleeding.
Because of these serious side effects, patients using warfarin must be
closely monitored with clotting tests such as the INR. The INR is a blood test
that measures the degree of blood thinning. (The higher the value for the INR,
the thinner the blood.) In preventing strokes in patients with atrial
fibrillation, the dose of
warfarin is adjusted to achieve a "therapeutic range" of INR. INR
values higher than the therapeutic range are associated with an increased risk
for bleeding, while values below the therapeutic range are associated with a
diminished effectiveness in preventing stroke. Patients who are unreliable or
unwilling to be monitored with regular measurements of INR may be considered for
aspirin treatment rather than warfarin.
The beneficial effect of warfarin in preventing strokes needs to be balanced
against the risk of excessive bleeding if the blood becomes too thin.
Candidates for warfarin. Doctors recommend warfarin to most elderly
patients 65 years of age or older with paroxysmal (recurrent episodes) or
chronic sustained atrial fibrillation. On balance, elderly patients with atrial
fibrillation are more likely to
benefit from warfarin because they are at a particularly high risk for stroke.
Patients younger than 65 with atrial fibrillation, especially those with prior embolic
strokes, significant diseases of the heart,
diabetes mellitus, high blood
pressure, heart failure, coronary artery disease of the heart, or abnormally
enlarged atrial chambers also are candidates for warfarin.
Patients who are not candidates for warfarin. Patients who are not
candidates for warfarin include:
Patients with conditions that increase the risk of
excessive bleeding, such as patients with active ulcers or other bleeding
lesions in the intestines
Elderly patients who are unsteady and/or
accident-prone and who are at an increased risk for trauma that can result in
excessive bleeding
Patients who are unreliable or unwilling to be monitored with regular INR
measurements (for whom therapy with aspirin may be better)
Low blood pressure, also referred to as hypotension, is blood pressure that is so low that it causes symptoms or signs due to the low flow of blood through the arteries and veins. Some of the symptoms of low blood pressure include light-headedness, dizziness, or even fainting if not enough blood is getting to the brain. Diseases and medications can also cause low blood pressure. When the flow of blood is too low to deliver enough oxygen and nutrients to vital organs such as the brain, heart, and kidneys; the organs do not function normally and may be permanently damaged.
Congestive heart failure (CHF) is a condition in which the heart's function as a pump is inadequate to meet the body's needs. A poor blood supply resulting from congestive heart failure may cause the body's organ systems to fail, leading to a weakened heart muscle and fluid accumulation in the lungs and body tissue. There are many diseases that can impair pumping efficiency and symptoms of congestive heart failure including fatigue, diminished exercise capacity, shortness of breath, and swelling. Treatments include lifestyle modifications, medications, heart transplant, and therapy.
High blood pressure, also known as hypertension, is a repeatedly
elevated blood pressure exceeding 140 over 90 mmHg -- a systolic pressure above
140 with a diastolic pressure above 90. There are two causes of high blood pressure, primary and secondary. Primary high blood pressure is much more common that secondary and its basic causes or underlying defects are not always known. It is known that a diet high in salt increases the risk for high blood pressure, as well as high cholesterol. Genetic factors are also a primary cause. Secondary high blood pressure is generally caused by another condition such as renal hypertension, tumors, and other conditions. Treatment for high blood pressure is generally lifestyle changes and if necessary, diet.
Blood clots can occur in the venous and arterial vascular system. Blood clots can form in the heart, legs, arteries, veins, bladder, urinary tract and uterus. Risk factors for blood clots include high blood pressure and cholesterol, diabetes, smoking, and family history. Symptoms of a blood clot depend on the location of the clot. Some blood clots are a medical emergency. Blood clots are treated depending upon the cause of the clot. Blood clots can be prevented by lowering the risk factors for developing blood clots.
An arrhythmia is an abnormal heart rhythm. With an arrhythmia, the heartbeats may be irregular or too slow (bradycardia), to rapid (tachycardia), or too early. When a single heartbeat occurs earlier than normal, it is called a prmature contraction.
Hyperthyroidism is an excess of thyroid hormone resulting from an overactive thyroid gland. Symptoms can include increased heart rate, weight
loss, depression, and cognitive slowing. Treatment is by medication, the use of
radioactive iodine, thyroid surgery, or reducing the dose of thyroid hormone.
Heart attack happens when a blood clot completely obstructs a coronary
artery supplying blood to the heart muscle. A heart attack can cause chest pain, heart failure, and electrical
instability of the heart.
COPD (chronic obstructive pulmonary disease) is a disorder that persistently obstructs bronchial airflow. COPD mainly involves three related conditions, chronic bronchitis, chronic asthma, and emphysema. Symptoms of COPD include chronic cough, shortness of breath, frequent respiratory infections, wheezing, morning headaches, and pulmonary hypertension. Treatment of COPD is focused on the related condition(s).
Mitral valve prolapse (MVP) is also also known as "click murmur syndrome" and "Barlow's syndrome." Mitral valve prolapse is the most common heart valve abnormality. Signs and symptoms of mitral valve prolapse include: fatigue, palpitations, chest pain, anxiety, and migraine headaches. Echocardiography is the most useful test for mitral valve prolapse. Most patients do not need any treatment, however, patients with severe prolapse may need treatment.
Heart rhythm disorders vary from minor palpitations, premature atrial contractions (PACs), premature ventricular contractions (PVCs), sinus tachycardia, and sinus brachycardia, to abnormal heart rhythms such as tachycardia, ventricular fibrillation, ventricular flutter, atrial fibrillation, atrial flutter, paroxysmal supraventricular tachycardia (PSVT), Wolf-White-Parkinson syndrome, brachycardia, or heart blocks. Treatment is dependant upon the type of heart rhythm disorder.
Pulmonary edema (swelling or fluid in the lungs) can either be caused by cardiogenic causes (congestive heart failure, heart attacks, abnormal heart valves) or noncardiogenic causes such as ARDS, kidney failure, high altitude, pneumothorax, pleural effusion, aspirin overdose, pulmonary embolism, and infections. The treatment of pulmonary edema depends on the cause of the condition.
Pericarditis is the inflammation of the pericardial sac that surrounds the heart. The causes of pericarditis include injury from heart attack, heart surgery, trauma; viral or fungal infection, HIV, tumors, mixed connective tissue disease, metabolic disease, medication reactions, or idiopathic. Treatment for pericarditis is generally medication, however, sometimes surgery is necessary.
When a portion of the brain loses blood supply, through a blood clot or embolus, a transient ischemic attack (TIA, mini-stroke) may occur. If the symptoms do not resolve, a stroke most likely has occurred. Symptoms of TIA include: confusion, weakness, lethargy, and loss of function to one side of the body. Risk factors for TIA include vascular disease, smoking, high blood pressure, high cholesterol, and diabetes. Treatment depends upon the severity of the TIA, and whether it resolves.
Rheumatic fever is a disease that sometimes occurs after a group A streptococcal infection of the throat. Symptoms and signs include carditis, polyarthritis, Aschoff bodies, rash, Sydenham's chorea, and fever. Treatment for rheumatic fever involves eliminating the bacteria with penicillin, erythromycin, or azithromycin. Further treatment focuses on alleviating the symptoms brought on by the body's immunologic response to the bacteria.
Heart attacks are the major causes of unexpected, sudden death among men and women. A heart attack is also a significant cause of heart failure. Learn the risk factors for heart attack such as high blood pressure, diabetes, and other heart conditions. Lowering your risk factor, lifestyle changes, and in some cases medication are the most effective way of preventing a heart attack.
Stroke is the third leading killer in the United States. Some of the warning signs of stroke include sudden confusion, trouble seeing with one or both eyes, dizziness, loss of balance, and more. Stroke prevention and reatable risk factors for stroke include lowering high blood pressure, quit smoking, heart disease, diabetes control and prevention.
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