1/Pt w cough for few days, fever, COVID+, post tussive cough w left rib pain. Described by outside facility as ongoing positional chest pain. Fever 103, intubated for hypoxia. EKG below.
#COVID_STEMI
#COVIDPPE
. Given the Variability in PPE recommendation, driven by resource availability, can each of you post a pic (full length) next time you are in full PPE. Would be interesting to see the variability. 1/
Took 4 patients to the lab this week for PE. “Stable hemodynamics” on paper with BP in the 110-130s. All with cardiac index 1.5-1.7. Significant improvement in hemodynamics after clot removal. Need better risk stratification for submassive.
@PERTConsortium
@jameshorowitzmd
#PERT
Alarming numbers in NYC. 4500+ cases. Outpatient testing to stop soon. Per DOH —With the widespread community transmission of Coronavirus in our region, ambulatory patients with fever and cough can be presumed to have COVID disease without testing!!!
STEMI transfer from outside facility. Reported no fever/cough. At our Cath doorstep hesitantly reveals cough for days but attributes it to allergies. CXR suspicious. Upgraded to PUI and primary PCI. we may have created a stigma where patients will be hesitant to reveal cough!!
Patients with stable coronary disease were randomly assigned to an initial invasive strategy with angiography and revascularization if appropriate or to medical therapy alone. The findings were sensitive to the definition of myocardial infarction.
Although many of us have been vocal about PPE availability, the next big issue in the Cath lab is the Donning and Doffing process. Attached is our process. We have the respective steps posted in relevant areas. Please feel free to modify and use as needed
The
#EAPCI
community mourns the sudden loss of Alain Cribier, a pioneering
#IC
known for numerous 'firsts' including the first-in-man
#TAVI
on April 16, 2002. Our heartfelt condolences to his family, friends + colleagues. His wisdom, expertise and guidance will be greatly missed.
And here is the meta-analysis showing very similar 5-year all-cause mortality after left main DES versus CABG. Normally I am not a great fan of meta-analysis, but considering aggregate data is appropriate to assess low frequency non-pre-specified under-powered events.
One thing that was clear in the ACC China webinar was the use of surgical masks by all Heath care workers. Good to see more hospitals implement this. We need to prevent hospitals from being epicenters of infection in the next few weeks!!
Today, my health system took a big step: Notified staff that they're adopting the model described here, with face masks at all times & a health check each shift for even mild ill symptoms. Effective Wednesday. Kudos to
@PartnersNews
@BrighamWomens
@MassGeneralNews
Pt with Medina 1,1,0 distal LM bifurcation. PCI with provisional 1-stent technique - 3.5 mm DES followed by 4.5 mm POT - resulted in high-grade stenosis at origin of LCX. TIMI 3 flow, no symptoms or ECG changes. iFR of LCX performed=0.94. Next steps? Poll to follow.
@JoshuaBeckmanMD
@NephroNinja
@thebyrdlab
We debunked it a while ago.
“Given the equal outcome efficacy+fewer adverse events with ARBs, risk-to-benefit analysis in aggregate indicates that at present there is little, if any, reason to use ACEi for the treatment of HTN or its compelling indications
Since its introduction almost two decades ago, the crush technique for coronary bifurcation stenting has undergone a significant and constant evolution. This paper reviews the technical aspects and outcomes of the variants of the crush technique.
9/ - Both STICH and REVIVED BCIS show that EF improvement is only seen in the minority with revasc
- Relative merits of PCI vs. CABG can only be compared via a head to head randomized trial
1/ Case resolution. Few considerations based on the responses to the poll- The diagnosis is split between myocarditis and STEMI. Highlights the difficulty in instituting lytics first for such patients.
1/Pt w cough for few days, fever, COVID+, post tussive cough w left rib pain. Described by outside facility as ongoing positional chest pain. Fever 103, intubated for hypoxia. EKG below.
#COVID_STEMI
From quadrapelegic to being back in the cath lab:
Dr. Dean Kereiakes courageously shares his journey of chronic and acute spinal cord injury caused by decades of wearing led as a stark warning to young interventional cardiologists who think they are unbreakable ... you are not
1/ Tweetorial on an interesting case. Please answer the poll and based on the highest response I will provide the next information. Patient with prior angiographically normal cors s/p aVR 5 months prior with chest pain since 2 months. Angiogram below.
8/ My take on REVIVED BCIS is the following:
- It is a win for medical therapy, which admittedly was far from optimal when compared with today's standards. Will PCI or even CABG have a mortality benefit over today's standard of medical therapy?
This was fun to work on. Is it time to abandon outdated practices- NPO, shellfish allergy, IV dosing for contrast allergy prophylaxis, holding metformin, ACE. Can we do radial access on those with prior mastectomy and many more.
@SVRaoMD
@drmortkern
@HollandTamis
@DrMauricioCohen
1/ Hemostasis band release after TransRadial Angiography (TRA). Poll suggests majority start releasing 1 hour after diagnostic and 2 hours after PCI regardless of UFH or bival use. A brief evidence review based on our recent publication.
@fischman_david
@evandrofilhobr
If you look at the pyramid of diagnostic accuracy, contrast FFR is in between rest and hyperemia. For such lesions I do resting first—> if negative switch to FFR mode and inject contrast. If negative and the story is discordant (like in your case) would do hyperemic FFR.
1Patient with unstable angina with severe stenosis of LAD. He needs a urological procedure in 2 months. Which of the following is the most appropriate management? (Choice 5 will be medical therapy only). I will post the
#ChatGPT
response in a day.
@fischman_david
@ShariqShamimMD
Perhaps twitter has the answer to this question. An N95 mask blocks at least 95% of very small (0.3 micron) particles. An N100 makes blocks 99.97%. Apart from cost considerations, why settle for N95?
#COVID19
8/ The discordance typically occurs in short lesions supplying a large territory where the gradient at rest is small but results in a large gradient at hyperemia resulting in a potential FFR/iFR discordance.
I hope CDC and others first start with what is best the PPE for health care workers in a ideal situation with no scarcity of PPE and then outline fall backs for limited resource. The guidelines thus far has been the opposite unfortunately.
There is a concern that the CDC guidelines on PPE are not adequately protecting our nurses & doctors.
We're aware of the concerns & we're actively looking into it.
If the guidelines don’t sufficiently protect our health care professionals, we'll put our own guidelines in place.
🆕📚 Presented at
#SIF2024
💡case of recurrent
#ISR
due to severe coronary calcification w asymmetric stent expansion demonstrating the feasibility of
#IVL
along w a “buddy” balloon to treat stent eccentricity.
➡️
@MustehsanMD
@SripalBangalore
Building on our publication to predict normotensive shock in intermediate risk PE, we have now validated the score. Score of 6 has a very high prevalence of shock (60-100%) and outperforms any PE score. .
@PERTConsortium
@jaygirimd
@drandrewsharp
🚀our latest study validating the CPES score for identifying normotensive shock in patients with intermediate-risk PE 📊
@CircIntv
Can the CPES score guide us in identifying patients that may benefit from CBT?🤔💡More research is needed
@SripalBangalore
1/17
How do calcium channel blocks (e.g., amlodipine) cause edema?
I've known since medical school that amlodipine can cause edema, but I’ve never taken the time to examine the mechanism.
The explanation is cool and has implications as the summer heat approaches...
@SVRaoMD
@rwyeh
@ajaykirtane
@KAlaswadMD
@CardiacConsult
@lorenzo2509
If RCTs of stable CAD do not show a reduction in death/MI with revasc, I am not surprised with CTOs. I have a growing CTO program and the ones we do are patients who are symptomatic. In fact, they are more grateful than the STEMI ones as they have suffered long enough.
Here is ours. The comments below are great but pls try to post your pic. So far the ones posted are all outside US and IMO far better with less skin exposure.
1/ Elderly with shortness of breath and cough for 1 month p/w Chest pain for 3 hours. CXR read as b/l consolidation. No fever. EKG below. What would you do.
#COVIDSTEMI
@DrQuinnCapers4
Surprised many are advocating for CTO PCI. I revasc arteries supplying large territories but not CTOs. Our program has come around not to insist and rely on cardiologist to make the decision. The risk of restenosis of a CTOin an ESRD patient is very high, let alone upfront risk
1:2 Pt w anterior MI s/p DES to prox LAD. Develops AF. Apixaban added to DAPT (ASA+clopidogrel). ASA dropped after 2 doses of Apixaban. 3 days later develops stent thrombosis. Haven’t had stent thrombosis w this strategy before. What is your strategy for SAPT+DOAC
@VPrasadMDMPH
Instead of spending so much effort on anti-masking it is better spent on where evidence is— encourage people to vaccinate. The masking debate is short lived once vaccination are available for kids which is only a few months away.
6/ Interestingly, 4-year death with PCI in REVIVED and CABG in STICH are largely similar (~28%) (Extrapolated from CIF plots). The dif in outcome bn the 2 trials, in part, is due to difference in event rates in the MT arm of the trials (REVIVED (~26%) than in STICH (~32%)).
Surgeons at NYU Langone Health recently completed the first-ever combined heart pump and gene-edited pig kidney transplant in a living patient with heart failure and end-stage kidney disease, who otherwise had no options for a better quality of life:
4/ Med therapy in STICH was largely BB and ACE/ARB. REVIVED used BB, ACE/ARB, 57% were on MRA, 37% on ARNI. In addition, ICD use was 18.6% in STICH vs. 54% (cardiac device) in REVIVED. Med therapy significantly better (but not to current day standards) than STICH.
@GreggWStone
Severe prox lesion supplying large territory but short lesion length— this is where the concept of separation coefficient and false negative resting indices apply. Wouldn’t be reassured by just a resting index.
@GreggWStone
Similarly based on the data from FREEDOM follow-on trial, choosing CABG over PCI in diabetics results in extension of survival by 3 months after 8 years of follow up. I wonder how many would choose CABG if presented this way.
@ShariqShamimMD
Non hypotensive shock is a known entity. I have had couple of STEMIs with BP in the 130s, elevated lactate and low CI. I bet we are missing many of these if we are relying on BP alone.
7/ Finally, EF did not improve significantly with PCI when compared with MT in REVIVED. This is similar to the results from STICH where EF improvement >=10% was in 19% in the CABG group and 16% in the MT group (P=0.30).
Fantastic CSRC Cardiogenic Shock II Think Tank
@CardiacSafety
. Help design a future trial in cardiogenic shock: infarct-only PCI vs. multi-vessel CABG (with or without POBA) in patients with MI, multi-vessel CAD, and cardiogenic shock. Survey at: .
Before jumping on the HCQ+Azithro bandwagon, pls read below. We need to wait for results of RCTs. Trumps rhetoric will make trials harder to complete.
#COVID19
Guys. We need to talk about this Hydroxychloroquine + Azithromycin thing. It is out of hand. It all stems from this study that came out today. The study design: Comparative viral eradication on day 6 between HCQ, HCQ + Azithro, and control (not treated) COVID-19 patients.
@SVRaoMD
@mmamas1973
@CMichaelGibson
What a loss. He maybe one of the only EIC who would read every word of the manuscript— more than most co-authors of the paper.