Podcasts about ccta

In this industry-sponsored episode, host Praveen Ranganath, MD is joined by Yader Sandoval, MD and Jonathon Leipsic, MD, MSCCT, the chair and co-chair of the recently published inter-society roundtable document on CCTA for PCI planning. Conversation topics include the origin of this expert roundtable, the benefits of and evidence supporting CCTA for PCI planning, a deep-dive into heavily calcified and bifurcation lesion planning, and insights on how to tackle current barriers to adoption. Coronary Computed Tomography Angiography to Guide Percutaneous Coronary Intervention: Expert Opinion from a SCAI/SCCT RoundtableThis episode is sponsored by Heartflow. References to a specific product, process, or service by speakers in this podcast episode do not constitute or imply an endorsement by the Society of Cardiovascular Computed Tomography. The views and opinions expressed in do not necessarily reflect those of the Society of Cardiovascular Computed Tomography.

In this episode of the Smarter Not Harder Podcast, Dr. Abid Husain joins Dr. Scott Sherr for a masterclass on cardiovascular health — from cholesterol myths to mitochondrial truth. They explore what truly drives inflammation, plaque formation, and cardiovascular risk, while dismantling the outdated “cholesterol = heart disease” narrative. Whether you're a clinician or simply someone trying to make smarter choices for your heart, this episode offers insight into testing, interventions, and personalized strategies that go beyond basic lipid panels. Join us as we delve into: + Why LDL alone doesn't tell the full story of cardiovascular risk + How mitochondria, hormones, and inflammation intersect with lipid metabolism + The real role of CCTA scans, plaque imaging, and particle size analysis + Advanced medications and peptides that support vascular and metabolic health This episode is for you if: - You've been told to fear cholesterol but want the full picture - You're a practitioner looking to personalize cardiovascular treatment plans - You've heard of statins and PCSK9s but don't know when or why to use them - You're curious about GLP-1s, NO precursors, and other precision tools for heart health You can also find this episode on… YouTube: https://youtu.be/npYvJS2cpGc Find more from Dr. Abid Husain: Boulder Longevity: https://boulderlongevity.com LinkedIn: https://www.linkedin.com/in/abid-husain-md-facc-abaarm-00874419/ Find more from Smarter Not Harder: Website: https://troscriptions.com/blogs/podcast | https://homehope.org Instagram: @troscriptions | @homehopeorg Get 10% Off your purchase of the Metabolomics Module by using PODCAST10 at https://www.homehope.org Get 10% Off your Troscriptions purchase by using POD10 at https://www.troscriptions.com Get daily content from the hosts of Smarter Not Harder by following @troscriptions on Instagram.

Save 20% on all Nuzest Products WORLDWIDE with the code MIKKIPEDIA at www.nuzest.co.nz, www.nuzest.com.au or www.nuzest.comThis week on the podcast, Mikki speaks to Dr. Matt Budoff – a world-renowned cardiologist and researcher who has spent decades at the forefront of cardiovascular imaging and prevention. Known for his pioneering work in coronary artery calcium (CAC) scoring and computed tomography angiography (CCTA), Dr. Budoff has helped transform how we detect and assess heart disease risk.In this conversation, we explore what first sparked his interest in cardiovascular imaging and how his views on lipids, plaque, and heart disease risk have evolved over time. We dig into his recent research on lifestyle interventions—particularly low-carbohydrate and ketogenic diets—and how they affect LDL cholesterol, atherosclerosis, and overall coronary health.We also discuss the implications of his KETO study, which found no direct correlation between elevated LDL-C and plaque burden in lean, metabolically healthy individuals following a ketogenic diet.Dr. Matthew J. Budoff is a distinguished cardiologist and professor of medicine at the David Geffen School of Medicine at UCLA. He holds the Endowed Chair of Preventive Cardiology at Harbor-UCLA Medical Center and serves as the Program Director and Director of Cardiac CT in the Division of Cardiology Renowned for his pioneering work in non-invasive cardiovascular imaging, Dr. Budoff has significantly advanced the use of coronary artery calcium (CAC) scoring and computed tomography angiography (CCTA) to detect and monitor coronary artery disease. His research focuses on early detection methods for cardiac disease, aiming to identify high-risk patients and implement preventive strategies Dr. Budoff has authored or co-authored over 50 books and book chapters and more than 2,000 articles and abstracts. His contributions have been recognised with numerous awards, including the Gold Medal Award from the Society of Cardiovascular Computed Tomography and designation as a Master of the Society Matt Budoff https://profiles.ucla.edu/matthew.budoffLMHR https://www.jacc.org/doi/10.1016/j.jacadv.2024.101109  Curranz Supplement: Use code MIKKIPEDIA to get 20% off your first order - go to www.curranz.co.nz  or www.curranz.co.uk to order yours Contact Mikki:https://mikkiwilliden.com/https://www.facebook.com/mikkiwillidennutritionhttps://www.instagram.com/mikkiwilliden/https://linktr.ee/mikkiwilliden

This podcast is the first in a three-part series on integration of responder disciplines during an active threat with subject matter experts Jeff Borkowski, James Sellers, and Sam Shurley. In this episode, we discuss effective pre-planning and pre-incident communication, identifying key stakeholders, and barriers to building strong relationships between agencies.This series references modules or topics taught in LSU NCBRT/ACE's Active Threat Integrated Response Course (ATIRC) and Critical Decision Making for Complex Coordinated Terrorist Attacks (CCTA) class. Find more information on the ATIRC training here, and learn more about the CCTA course here.

This is the second of three episodes on active threat integration with Jeff Borkowski, James Sellers, and Sam Shurley. In this episode, we talk about what integration actually looks like during active threat response, including the challenges agencies may face and the roles/responsibilities of staging managers.This series references modules or topics taught in LSU NCBRT/ACE's Active Threat Integrated Response Course (ATIRC) and Critical Decision Making for Complex Coordinated Terrorist Attacks (CCTA) class. Find more information on the ATIRC training here, and learn more about the CCTA course here.

This is the final episode in our three-part series on active threat integration with Jeff Borkowski, James Sellers, and Sam Shurley. This episode covers the reunification stage of an integrated response to a threat, including the importance of communication with the public, potential challenges during the reunification process, and how agencies can prepare for this stage ahead of time.This series references modules or topics taught in LSU NCBRT/ACE's Active Threat Integrated Response Course (ATIRC) and Critical Decision Making for Complex Coordinated Terrorist Attacks (CCTA) class. Find more information on the ATIRC training here, and learn more about the CCTA course here.

Neste episódio do DozeCast, Mateus Prata e Raphael Rossi recebem novamente o Dr. Silvio Póvoa, um dos maiores nomes da cardiologia do esporte no Brasil, para discutir um tema polêmico e cada vez mais relevante: doença arterial coronariana (DAC) em atletas de endurance.

KHK in der Familie aber Koronarkalk: Dann hin und wieder ins CT und schon nehmen die Plaques ab, wird das Leben länger? Eine Episode vom EvidenzUpdate-Podcast über einen echten CAC-Score.

Mit einer neuen SCOT-HEART-Publikation liegen jetzt 10-Jahres-Daten vor. Im neuen EvidenzUpdate-Podcast schauen wir, was sie für die CCTA bei V.a. KHK bedeuten. Wir reden über die Zukunft der NVL. Und jetzt neu: Scherers Soundmaschine.

Coronary CT angiography-guided management of patients with stable chest pain: 10-year outcomes from the SCOT- HEART randomised controlled trial in Scotland Michelle C Williams, Ryan Wereski, Christopher Tuck, Philip D Adamson, Anoop S V Shah, Edwin J R van Beek, Giles Roditi, Colin Berry,Nicholas Boon, Marcus Flather, Steff Lewis, John Norrie, Adam D Timmis, Nicholas L Mills, Marc R Dweck, David E Newby, on behalf of theSCOT-HEART Investigators* Summary Background The Scottish Computed Tomography of the Heart (SCOT-HEART) trial demonstrated that management guided by coronary CT angiography (CCTA) improved the diagnosis, management, and outcome of patients with stable chest pain. We aimed to assess whether CCTA-guided care results in sustained long-term improvements in management and outcomes. Methods SCOT-HEART was an open-label, multicentre, parallel group trial for which patients were recruited from 12 outpatient cardiology chest pain clinics across Scotland. Eligible patients were aged 18–75 years with symptoms of suspected stable angina due to coronary heart disease. Patients were randomly assigned (1:1) to standard of care plus CCTA or standard of care alone. In this prespecified 10-year analysis, prescribing data, coronary procedural interventions, and clinical outcomes were obtained through record linkage from national registries. The primary outcome was coronary heart disease death or non-fatal myocardial infarction on an intention-to-treat basis. This trial is registered at ClinicalTrials.gov (NCT01149590) and is complete. Findings Between Nov 18, 2010, and Sept 24, 2014, 4146 patients were recruited (mean age 57 years [SD 10], 2325 [56·1%] male, 1821 [43·9%] female), with 2073 randomly assigned to standard care and CCTA and 2073 to standard care alone. After a median of 10·0 years (IQR 9·3–11·0), coronary heart disease death or non-fatal myocardial infarction was less frequent in the CCTA group compared with the standard care group (137 [6·6%] vs 171 [8·2%]; hazard ratio [HR] 0·79 [95% CI 0·63–0·99], p=0·044). Rates of all-cause, cardiovascular, and coronary heart disease death, and non-fatal stroke, were similar between the groups (p>0·05 for all), but non-fatal myocardial infarctions (90 [4·3%] vs 124 [6·0%]; HR 0·72 [0·55–0·94], p=0·017) and major adverse cardiovascular events (172 [8·3%] vs 214 [10·3%]; HR 0·80 [0·65–0·97], p=0·026) were less frequent in the CCTA group. Rates of coronary revascularisation procedures were similar (315 [15·2%] vs 318 [15·3%]; HR 1·00 [0·86–1·17], p=0·99) but preventive therapy prescribing remained more frequent in the CCTA group (831 [55·9%] of 1486 vs 728 [49·0%] of 1485 patients with available data; odds ratio 1·17 [95% CI 1·01–1·36], p=0·034). Interpretation After 10 years, CCTA-guided management of patients with stable chest pain was associated with a sustained reduction in coronary heart disease death or non-fatal myocardial infarction. Identification of coronary atherosclerosis by CCTA improves long-term cardiovascular disease prevention in patients with stable chest pain.

Can CT Angiography Be Used to Track CAD Regression?   Guest: Eric Williamson, M.D. Host: Stephen Kopecky, M.D.   Listeners to this podcast will learn about the role of coronary CT angiography (CCTA) in preventative cardiology. CCTA enables early detection and characterization of coronary plaque before significant cardiovascular events occur. It non-invasively visualizes both calcified and non-calcified plaques, allowing for a comprehensive assessment of coronary artery health. These early insights can inform lifestyle modifications and targeted therapies, ultimately reducing the risk of heart disease.   Topics Discussed: What is the role of coronary CTA in the assessment of coronary atherosclerotic plaque? What recent technological advancements have occurred to improve the characterization of coronary plaque? How is AI playing a role in plaque assessment using CT? What future developments will advance our use of CT for plaque assessment in the near future?   Connect with Mayo Clinic's Cardiovascular Continuing Medical Education online at https://cveducation.mayo.edu or on Twitter @MayoClinicCV and @MayoCVservices. LinkedIn: Mayo Clinic Cardiovascular Services Cardiovascular Education App: The Mayo Clinic Cardiovascular CME App is an innovative educational platform that features cardiology-focused continuing medical education wherever and whenever you need it. Use this app to access other free content and browse upcoming courses. Download it for free in Apple or Google stores today! No CME credit offered for this episode. Podcast episode transcript found here.

Today's show is brought to you by MYOXCIENCE.  In this episode, heart surgeon and best selling author Dr. Phil Ovadia discusses the foods and lifestyle factors driving a new wave of early-onset heart disease. Sponsored by MYOXCIENCE: Support your Intermittent Fasting lifestyle with the Berberine Fasting Accelerator by MYOXCIENCE: https://bit.ly/berberine-fasting-accelerator Use code podcast to save 12% Link to full show notes and articles: https://bit.ly/3uKRKMC Connect with Dr. Ovadia: https://ifixhearts.com/quiz/ Show Notes: 0:00 Intro 1:30 Up to 95% of people with cardiac disease are insulin resistant. 4:45 Processed foods and high carbs are the two primary drivers of metabolic disease, the primary driver of heart disease. 6:53 Insulin resistance damages blood vessels. 11:18 Exercise is indirectly helpful in preventing atherosclerosis. 13:10 The better you can maintain muscle as you age, the better you can deal with the aging process. 14:30 It is possible to reverse atherosclerosis. 16:30 Tests: coronary artery calcium scan (CAC) and coronary CT angiogram (CCTA). 18:30 People in their 30s and 40s now end up on the cardiac operating table. 20:30 High LDL may not be dangerous in a person who is metabolically healthy. 21:00 The quality of your LDL particles is important. 22:54 90% of adults are metabolically unhealthy, so their high LDL is likely dangerous. 24:05 Statin use for over 10 years increases your risk of developing insulin resistance and type 2 diabetes, primary drivers of heart disease. 26:30 Inflammation is an important part of the development of heart disease. 27:40 High blood pressure root cause is insulin resistance/metabolic disease. 31:41 Ferritin testing measures total body iron stores. It is also an inflammation marker. 35:50 Linoleic acid LDL oxidation hypothesis 37:30 Plant-based diets 40:25 Lowering your intake of omega 6 improves your omega 3 index. 41:10 Low vitamin D 42:00 Sun exposure has been misunderstood. 44:10 Triglycerides is a higher risk than LDL. 48:30 Bioidentical hormones are superior to synthetic. 50:03 Low testosterone is a risk factor for heart disease. 53:10 Heart surgery does not fix the underlying problem.      

In this episode, Jian'an Wang examines a study on the predictive power of integrating fractional flow reserve computed tomography (FFR CT) and its local gradient in assessing future coronary events in patients. The findings suggest that this combined approach significantly enhances risk prediction, offering valuable insights for more informed clinical decision-making in managing coronary artery disease.

In this episode of Hart2Heart, Dr. Mike Hart welcomes back Dr. Kyle Gillette, a board-certified family medicine and obesity medicine physician. Together, they dicuss the fascinating realm of peptides, exploring their various forms, applications, and potential benefits. They also discuss the nuances of testosterone therapy, the importance of spiritual well-being, and the practice of forgiveness. Guest Bio and Links: Kyle Gillett, MD, a dual board-certified physician in family medicine and obesity medicine and an expert in hormone optimization and human performance.  Listeners can learn more about Dr. Kyle Gillett on IG @kylegillettmd Episodes Mentioned: Dr. Mike Hart and Kyle Gillett, MD  TRT, Heart Health, and Hair Loss with James O'Hara Dr. Anish Koka on The Vax, Blood Markers, and Daily Asprin Use All You Need To Know About The Controversial Oreo vs. Statin Study | Dr. Nick Norwitz Show Notes: (0:00) Welcome back to the Hart2Heart Podcast with Dr. Mike Hart    (0:15) Dr. Hart introduces Dr. Kyle Gillett to the listeners (0:30) Dr. Kyle Gillett's background (1:45) Exploring BPC 157 peptide (7:30) Eastern European peptides (10:00) Peptides and traumatic brain injury (15:30) Testosterone Therapy - when and how to get tested (17:00) Four stages of puberty  (20:00) Topical testosterone - absorption and application (26:30) Increasing androgen sensitivity (30:00) Testosterone and cardiovascular risks (36:00) Ways to increase and decrease androgine sensitivity  (42:00) Cholesterol testing - the best approach (49:00) Cholesterol lowering drugs - alternatives and considerations (51:30) Triglycerides and their impact on health (56:00) Nattokinase - a potential game changer (59:30) Mental health and spirituality - the power of forgiveness (1:03:00) Daily routines and final thoughts --- Dr. Mike Hart is a Cannabis Physician and Lifestyle Strategist. In April 2014, Dr. Hart became the first physician in London, Ontario to open a cannabis clinic. While Dr. Hart continues to treat patients at his clinic, his primary focus has shifted to correcting the medical cannabis educational gap that exists in the medical community.  Connect on social with Dr. Mike Hart: Social Links: Instagram: @drmikehart Twitter: @drmikehart Facebook: @drmikehart  

Dr. Gillett & James O'Hara react To Ken Berrys most recent lab results. 00:00 Intro01:02 Elevated CRP can be seen in individuals with metabolic dysfunction, even without a cold or flu.03:42 Exercise Factor: An A1C of 5.5 is seen in active individuals with low insulin levels.08:16 Cholesterol Levels: LDL particle numbers and small particles are high12:55 Cardiac Scanning: importance of advanced cardiac assessments like CCTA when standard tests return ambiguous results.21:59 Copper Levels: Liver consumption does not lead to copper toxicity; levels remain in the normal range.23:21 It's important not to overemphasize a single homocysteine level due to potential inaccuracies related to sample handling.25:12 A balanced omega-3 and omega-6 profile is desirable. 25:53 Low vitamin C isn't causing connective tissue issues or scurvy symptoms, contradicting common concerns.27:54 Serum vitamin C level isn't a sole indicator of scurvy; clinical signs must match.28:09 An accurate iodine status requires 24-hour urine collection rather than serum measurement.30:27 A coronary CT angiogram is suggested to check for subclinical atherosclerosis regardless of a zero calcium score.31:27 OutroCarnivore Diet Lab Results of Dr Berry & Nurse Neisha - 2024:► https://youtu.be/bFKs65QsugA?si=6s5WGQsJNu9GKaDyFor High-Quality Labs:► https://gilletthealth.com/order-lab-panels/For information on the Gillett Health clinic, lab panels, and health coaching:► https://GillettHealth.comFollow Gillett Health for more content from James and Kyle► https://instagram.com/gilletthealth► https://www.tiktok.com/@gilletthealth► https://twitter.com/gilletthealth► https://www.facebook.com/gilletthealthFollow Kyle Gillett, MD► https://instagram.com/kylegillettmdFollow James O'Hara, NP► https://Instagram.com/jamesoharanpFor 10% off Gorilla Mind products including SIGMA: Use code “GH10”► https://gorillamind.com/For discounts on high-quality supplements►https://www.thorne.com/u/GillettHealth#reaction #carnivore #diet #podcastAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy

Prediction models vs clinical judgement, CCTA quantification of atherosclerosis, AF ablation plus LAAO, atrial shunt devices, and HF medical therapy are topics John Mandrola, MD, covers this week. This podcast is intended for healthcare professionals only. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I.Clinical Prediction Models vs Clinical Judgement Did Statin Decision-Making Just Get Harder?  https://www.medscape.com/viewarticle/did-statin-decision-making-just-get-harder-2024a1000egl Colunga-Lozano and colleagues https://doi.org/10.1016/j.jclinepi.2023.10.016 Aug 02, 2024 This Week in Cardiology Podcast https://www.medscape.com/viewarticle/1001429 II. CCTA Quantification of Atherosclerosis Atherosclerosis Quantification and Cardiovascular Risk: the ISCHEMIA Trial https://doi.org/10.1093/eurheartj/ehae471 Circulation ISCHEMIA sub study 2021 – Severity of CAD and Outcomes https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.049755 ISCHEMIA Trial https://www.nejm.org/doi/full/10.1056/NEJMoa1915922 III. Combined AF Ablation and LAAO Review from Mills and colleagues https://doi.org/10.1016/j.tcm.2023.11.003 Link to CMS Rule on AF Ablation and LAAO https://hrs2.informz.net/z/cjUucD9taT05MjU3ODgyJnA9MSZ1PTkwMDQ2MTk4MCZsaT04NTU1OTQxMg/index.html IV. Atrial Shunt Devices No Net HF Benefit for Interatrial Shunt Device https://www.medscape.com/viewarticle/no-net-hf-benefit-interarterial-shunt-device-2024a10006kk Original REDUCE-LAP-HF-II https://doi.org/10.1016/S0140-6736(22)00016-2 Two-year results of REDUCE-LAP-HF-II https://doi.org/10.1016/j.jchf.2024.04.011 Apr 19, 2024 This Week in Cardiology Podcast V. Optimal HF Therapy Rao and colleagues; CHAMP HF https://doi.org/10.1016/j.jchf.2024.05.026 You may also like: The Bob Harrington Show with the Stephen and Suzanne Weiss Dean of Weill Cornell Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact news@medscape.net

I read these for a living. Does a coronary CT angiogram show soft plaque in the arterial wall? Cardiologist who read CCTA and calcium scores explains. Why CT angio can miss soft plaque. https://dralo.net/links

In this bonus episode, Dr. Joel Kahn interviews Dr. James Min, founder and CEO of Cleerly Health. Cleerly Health is revolutionizing heart diagnostics with their software, which analyzes coronary CT angiograms (CCTA) using AI to detect and evaluate heart plaque. Not all plaque is equal, and Cleerly Health focuses on identifying non-calcified or "soft" plaques, which are the most dangerous and most likely to be reversible.  This cutting-edge technology has been employed hundreds of times at the Kahn Center, offering a new paradigm in heart health assessment and treatment.

Menopause and age raise our cardiovascular disease risk. Athletes and highly active people also tend to have a higher prevalence of coronary artery calcium and atherosclerotic plaque (though it tends to be the benign kind). But what does that all mean? How can we know what's really going on in those coronary arteries of ours? To find out, host Selene Yeager had a Cleerly-enabled coronary computed tomography angiography (CCTA), which uses AI-enabled software to help characterize coronary plaque composition and cardiovascular disease risk. This week, she sat down with Anita Vadria, MS, PA-C, who is the Director of Medical Science Liaisons and Clinical Education at Cleerly to go over her results, talk about plaque and heart disease risk, and how technology is helping advance our understanding of our personal risk. Anita Vadria, MS, PA-C, is the Director of Medical Science Liaisons and Clinical Education at Cleerly. She is a Board Certified Physician Assistant with a focus in Cardiology. She received her undergraduate degree in Molecular and Cell Biology and received her Masters in Physician Assistant Studies from Western University of Health Sciences in Los Angeles, CA.ResourcesImpact of atherosclerosis imaging-quantitative computed tomography on diagnostic certainty, downstream testing, coronary revascularization, and medical therapy: the CERTAIN study, hereAtherosclerosis Imaging Quantitative Computed Tomography (AI‐QCT) to guide referral to invasive coronary angiography in the randomized controlled CONSERVE trial, hereCoronary Artery Calcification Among Endurance Athletes “Hearts of Stone”, herePhysical Activity and Progression of Coronary Artery Calcification in Men and Women, hereMost heart attack patients' cholesterol levels did not indicate cardiac risk, here Lipid levels in patients hospitalized with coronary artery disease: an analysis of 136,905 hospitalizations in Get With The Guidelines, here2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic AdultsA Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, hereHeart attacks with no obvious risk factors on the rise, hereSubscribe to the Feisty 40+ newsletter: https://feistymedia.ac-page.com/feisty-40-sign-up-page Follow Us on Instagram:Feisty Menopause: @feistymenopause Feisty Media: @feisty_media Selene: @fitchick3 Hit Play Not Pause Facebook Group: https://www.facebook.com/groups/807943973376099 Join Level Up - Our Community for Active Women Navigating the Menopause Transition:Join:...

Welcome Dr. James Min, founder of Cleerly, an AI based software that evaluates the presence, type, and amount of plaque in heart vessels using images from a coronary computed tomography angiography (CCTA). This revolutionary approach is being used by providers to assess their patient's risk for heart attack and to provide personalized treatment recommendations. In this episode we are discussing the following topics and more: The inspiration behind Cleerly and its role in detecting and predicting heart disease (00:00 - 09:47) The science of plaque and heart disease (09:48 - 14:23) Overview of coronary computed tomography angiography (CCTA) and its role in detecting coronary artery disease. (14:24 - 18:05) How does Cleerly work with CCTA images to assess heart disease risk, including the analysis of plaque type and amount (18:06 - 21:00) Who should get a Cleerly analysis? (21:00 - 39:00) As always, thanks for watching! *****Learn More about Cleerly: https://cleerlyhealth.com/ *****Click here to subscribe to my channel:   https://www.youtube.com/channel/UCM2Jjqb7MqtZ7VDIuRjguLA/?sub_confirmation=1     *****Connect with me on Instagram: https://www.instagram.com/doctorjones_doctorjones/     *****Connect on Facebook: https://www.facebook.com/GregJonesNM

Today Stephen dives into his story about his heart health. In November, 2023 he had a major heart scare that put him in the emergency cardiac floor for four days and has changed his outlook on life and on his health forever. We discuss symptoms of a heart attack, and preventative action steps to take to learn more about our own heart health. Resources discussed on this episode: https://www.heart.org/en/health-topics/heart-attack/warning-signs-of-a-heart-attack https://my.clevelandclinic.org/health/diagnostics/22770-troponin-test website about CAC vs CCTA testing: https://www.kahnlongevitycenter.com/blog/coronary-artery-calcium-score-vs-coronary-ct-angiogram-what-they-are-and-what-they-show Huberman Lab podcast w/ Dr Sara Gottfried: Jan 30, 2023 @2:25:00 Rich Roll podcast w/ Simon Hill: Jan 1, 2024 Living proof 10 Truths PDF: https://theproof.com/longevityscore/ https://cleerlyhealth.com/ https://www.insidetracker.com/ -- Join the TKM Reflections Group: www.thekineticman.com/signup Subscribe to our newsletter (The MENifesto): www.thekineticman.com/newsletter Get a monthly email with 3-minute videos from every podcast guest we have on The Kinetic Man Podcast that answers the most impactful action they have taken to Level-UP in their home & in their business: www.thekineticman.com/levelup Join our New Kinetic Man Facebook Group: https://www.facebook.com/groups/thekineticman

Answering questions from X (Twitter). XQ Can you take Mounjaro and Ozempic together?Does Victoza becoming generic matter? (liraglutide generic)Does LDL Particle Size Matter?How does a cardiologist assess CVD risk?When would you order an ECG, Echo, Stress, CAC, CCTA?If I do everything right, does Lp(a) still matter?Why do surgeon medfluencers comment on medical topics?Should we stent asymptomatic 65% lesions in coronary arteries? https://dralo.net/links

Einem Herzinfarkt geht fast immer eine zunehmende Verengungen eines oder mehrerer Herzkranzgefäße voraus. Wie können diese frühzeitig erkannt werden? Welchen Stellenwert hat dabei die Computertomografie der Koronarien, kurz CCTA? Ausführliche Infos dazu gibt es in dieser Episode.

Today we dive into three cardiology papers with important insights for cardiac care. STUDY #1: We explore an analysis that compares Coronary CT Angiography (CCTA) with stress modalities like SPECT-MPI. We see if CCTA has the potential to reduce the need for invasive angiography, and how it stacks up against other testing strategies. Zito, A, Galli, M, Biondi-Zoccai, G, et al. 2023. Diagnostic strategies for the assessment of suspected stable coronary artery disease: A systematic review and meta-analysis. Ann Intern Med. 6: 817–826. (https://www.acpjournals.org/doi/10.7326/M23-0231) STUDY #2: We discuss the approval of a dual-chamber leadless pacemaker system by the FDA. Although this study supports the efficacy of this innovative approach in certain scenarios, it also raises important concerns.  Knops, RE, Reddy, VY, Ip, JE, et al. 2023. A dual-chamber leadless pacemaker. N Engl J Med. 25: 2360–2370. (https://www.nejm.org/doi/10.1056/NEJMoa2300080) STUDY #3: We look at a comprehensive retrospective study that evaluates aggressive management of hypertension in hospitalized adults. What are the ramifications of minimizing the use of BP-lowering agents, particularly intravenous ones, in certain inpatient scenarios? Anderson, TS, Herzig, SJ, Jing, B, et al. 2023. Clinical outcomes of intensive inpatient blood pressure management in hospitalized older adults. JAMA Intern Med. 7: 715–723. (https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2805021) Join us as we dissect these studies, unpacking their methodologies, outcomes, and the intriguing questions they raise.  For show notes, visit us at https://www.medmastery.com/podcasts/cardiology-podcast Learn more with these courses: Pacemaker Essentials: https://www.medmastery.com/courses/pacemaker-essentials Pacemaker Essentials Workshop: https://www.medmastery.com/workshops/pacemaker-essentials-workshop Coronary Angiography Essentials: https://www.medmastery.com/courses/coronary-angiography-essentials

Novel AI Technology to Improve Risk Stratification of Patients Without Obstructive Coronary Artery Disease Undergoing CCTA: The Oxford Risk Factors and Non-Invasive Imaging (ORFAN) Study (AHA 2023)

Die CCTA soll für manche beim V.a. stabile KHK zum Goldstandard werden. In der Kardiologie sind einige besorgt. Ein EvidenzUpdate über Interessen, Konflikte und die Prätestwahrscheinlichkeit.

IADC Speaks podcast Host Rebecca Weinstein Bacon interviews IADC's 2024 Corporate Counsel Training Academy Chair Nicole Brunson and Corporate Counsel College Dean Amy Sherry Fischer about this year's programs held in Chicago, April 10 to 12. Take a listen for an inside look at what to expect with this year's programs. Learn more and register on www.iadclaw.org.For tips on what to do in addition to the CCC and CCTA when you are in Chicago, revisit the "My Kind of Town: Chicago" episode: https://www.spreaker.com/episode/my-kind-of-town-chicago--57906336

This week in the HotBox, we chat with Jeremy Smith, the Director of Government Relations for the Canadian Cannabis Tourism Alliance (CCTA). We discuss the significance of cannabis tourism and on all sectors of our economy. Canada has the opportunity to become the world's number one cannabis tourism destination if done right. The CCTA is doing the hard work to make that happen. Follow the CCTA on IG @CannabisTourismCanadaSupport the show

Heart Surgeon and best selling author Dr. Phil Ovadia discusses the foods and lifestyle factors driving a new wave of early-onset heart disease. Sponsored: Support your Intermittent Fasting lifestyle with the Berberine Fasting Accelerator by MYOXCIENCE: https://bit.ly/berberine-fasting-accelerator Use code podcast to save 12% Link to full show notes and articles: https://bit.ly/3uKRKMC Connect with Dr. Ovadia: https://ifixhearts.com/quiz/ Show Notes: 0:00 Intro 1:30 Up to 95% of people with cardiac disease are insulin resistant. 4:45 Processed foods and high carbs are the two primary drivers of metabolic disease, the primary driver of heart disease. 6:53 Insulin resistance damages blood vessels. 11:18 Exercise is indirectly helpful in preventing atherosclerosis. 13:10 The better you can maintain muscle as you age, the better you can deal with the aging process. 14:30 It is possible to reverse atherosclerosis. 16:30 Tests: coronary artery calcium scan (CAC) and coronary CT angiogram (CCTA). 18:30 People in their 30s and 40s now end up on the cardiac operating table. 20:30 High LDL may not be dangerous in a person who is metabolically healthy. 21:00 The quality of your LDL particles is important. 22:54 90% of adults are metabolically unhealthy, so their high LDL is likely dangerous. 24:05 Statin use for over 10 years increases your risk of developing insulin resistance and type 2 diabetes, primary drivers of heart disease. 26:30 Inflammation is an important part of the development of heart disease. 27:40 High blood pressure root cause is insulin resistance/metabolic disease. 31:41 Ferritin testing measures total body iron stores. It is also an inflammation marker. 35:50 Linoleic acid LDL oxidation hypothesis 37:30 Plant-based diets 40:25 Lowering your intake of omega 6 improves your omega 3 index. 41:10 Low vitamin D 42:00 Sun exposure has been misunderstood. 44:10 Triglycerides is a higher risk than LDL. 48:30 Bioidentical hormones are superior to synthetic. 50:03 Low testosterone is a risk factor for heart disease. 53:10 Heart surgery does not fix the underlying problem.      

En este capítulo, Pacho llegó muy feliz al programa y le dedicó un acróstico al productor, y también, estudiantes de dos universidades se hacen tendencia en redes sociales. Lo acompañamos a donde quiera con este pódcast tan coquette.

Episode 2435 - On this Friday's show Vinnie Tortorich welcomes back Dave Feldman to discuss Citizen Science and its LMHR study, and more. https://vinnietortorich.com/2024/01/citizen-science-with-dave-feldman-episode-2435 PLEASE SUPPORT OUR SPONSORS   YOU CAN WATCH THIS EPISODE ON YOUTUBE - Making Noise Dave explains a recent double-blind study and the recent data shared with him. (5:00) He defines an LMHR (Lean Mass Hyper Responder) as high LDL, high HDL, and low triglycerides. He explains his background to folks unfamiliar with him. (7:00) Dave is an engineer and noticed a pattern or system. He shares the study with LMHR was about and some of its challenges. Awareness of LMHR is growing, so it should be studied even further. Funding such studies is difficult; however, the low-carb community has stepped up. The study analyzes how much LDL independently induces a high rate of atherosclerosis (lesions on the artery walls). (23:00) The participants are part of a year-long study that will measure plaque volume and soft plaque progression. The majority of studies done are on people who already have various diseases. (32:00) Dave would like to see a larger percentage of studies done on healthy populations to find a common baseline of biomarkers. Dave shares some information about Dr. Matthew Budoff's presentation that may be more useful to view on YouTube. To view the slides go to Vinnie's YouTube channel for this episode to view the discussion. (36:00) It discusses the quantifying of atherosclerosis with CCTA. Dave goes through the slides and explains the findings. A total plaque sore is discussed. (48:45) LDL cholesterol does not correlate with the progression of plaque. The caveat: this is preliminary data and more information needs to be collected. (56:50) Both Dave and Vinnie hope that the funding they have received for projects will help people learn and be empowered. (1:01:00) You can help fund such studies through Citizen Science at . [the_ad id="20253"] PURCHASE BEYOND IMPOSSIBLE (2022) The documentary launched on January 11! Order it TODAY! This is Vinnie's third documentary in just over three years. Get it now on Apple TV (iTunes) and/or Amazon Video! Link to the film on Apple TV (iTunes):  Then, Share this link with friends, too! It's also now available on Amazon (the USA only for now)!  Visit my new Documentaries HQ to find my films everywhere: REVIEWS: Please submit your REVIEW after you watch my films. Your positive REVIEW does matter! FAT: A DOCUMENTARY 2 (2021) Visit my new Documentaries HQ to find my films everywhere: Then, please share my fact-based, health-focused documentary series with your friends and family. The more views, the better it ranks, so please watch it again with a new friend! REVIEWS: Please submit your REVIEW after you watch my films. Your positive REVIEW does matter! FAT: A DOCUMENTARY (2019) Visit my new Documentaries HQ to find my films everywhere: Then, please share my fact-based, health-focused documentary series with your friends and family. The more views, the better it ranks, so please watch it again with a new friend! REVIEWS: Please submit your REVIEW after you watch my films. Your positive REVIEW does matter!  

Why the latest results on CAC scores and CCTA don't add anything meaningful to the LMHR theory. What should they have checked instead? In fact, the new CAC results actually muddy the waters and confuse those who don't know any better. https://dralo.net/links

Deep dive into imaging modalities that can actually show soft plaque. A deep dive into invasive and non invasive techniques. Comparing CT angiograms CCTA, calcium score CAC, coronary angiography cardiac cath, intravascular ultrasound IVUS, optical coherence tomography OCT, 3D vascular ultrasound 3DVUS, versus lipid levels. PESA, PRECAD, CARDIA trials. https://dralo.net/links

Mike reached out to Dr. Baker to share his transformative health journey over the last seven years. From childhood, he experienced chronic stomach issues and anxiety related to his condition. Despite being an active athlete in college football and rugby, his gastrointestinal problems persisted into his 30s. As a Firefighter/Paramedic, he faced challenges due to his morning routines caused by these issues. After numerous medical tests and a late diagnosis of ulcerative colitis in his late 20s, Mike turned to dietary changes for relief. Transitioning from gluten-free to paleo, then to keto, he eventually found significant improvement by following a diet inspired by a Joe Rogan podcast, focusing on red meat and eggs.  Timestamps: 00:00:00 Trailer and introduction. 00:05:26 College linebacker struggled with weight and migraines. 00:07:59 Bathroom troubles, embarrassment, doctor visits, unchanged diet. 00:10:12 Quit drinking alcohol, did Whole30, lost weight. 00:15:06 Disastrous gut reactions led to lifelong medication. 00:17:36 Same outcomes, debates, cholesterol, no statins. 00:22:02 Bringing own skillet, overcoming obstacles, stomach issues. 00:25:14 Butter, salt on fish; no soy sauce. Wife's dietary changes for hormone health. 00:26:58 Limited vegan options in department meals. 00:32:55 Carnivore and keto diets gaining popularity. 00:34:25 Fruit sugar tasted amazing, then inflammation and pain. 00:38:58 Carnivore diet for health issues. 00:42:20 High obesity rates. 00:45:21 Limited food options at wedding, ate beforehand. 00:49:41 Uphill battle, impact people. 00:52:18 Encouraging study on CCTA angiography. 00:54:12 Where to find Mike. See open positions at Revero: https://jobs.lever.co/Revero/ Join Carnivore Diet for a free 30 day trial: https://carnivore.diet/join/ Carnivore Shirts: https://merch.carnivore.diet Subscribe to our Newsletter: https://carnivore.diet/subscribe/ . ‪#revero #shawnbaker #Carnivorediet #MeatHeals #HealthCreation   #humanfood #AnimalBased #ZeroCarb #DietCoach  #FatAdapted #Carnivore #sugarfree  ‪

Take Home Points: A CCTA is an anatomic test to determine if a patient has normal coronary arteries, non-obstructive disease, or obstructive disease. The warranty period for a CCTA is anywhere from 3-10 years depending on the characteristics of the plaque.  A nuclear stress test is a functional study that allows for ischemia-driven management. The ... Read more The post REBEL Core Cast 111.0 – Cardiac Testing appeared first on REBEL EM - Emergency Medicine Blog.

Is there any way to really see soft plaque? Yes, there is. What do calcium scores mean and why do we have calcium score? What about coronary CT angiogram (CCTA)? What about the Cleerly Heart Scan? https://dralo.net/cholesterol https://dralo.net/links

Early coronary artery disease detection may just save your life or the life of somebody that you love and luckily, it's a lot easier today than ever before. Dr. John Tighe discusses CCTA and HeartFlow.

Host Praveen Ranganath is joined by Dr. Vinit Baliyan, assistant professor of radiology at Massachusetts General Hospital, to dissect his research and thoughts on the routine performance of coronary calcium CTs immediately before coronary CTAs. Tune in and enjoy!

Cleerly is a digital healthcare company. Their AI-based digital care platform works with coronary computed tomography angiography (CCTA) imaging to help clinicians precisely identify and define atherosclerosis earlier, so they can provide personalized, life-saving treatment plans for all patients throughout their care continuum. James K. Min, MD is the Founder and CEO of Cleerly. Previously, Min was a Professor of Radiology and Medicine at Weill Cornell Medical College and the Director of the Dalio Institute of Cardiovascular Imaging (ICI) at NewYork-Presbyterian. He is a board-certified cardiologist with a clinical focus on cardiovascular disease prevention and cardiovascular imaging. Sharonne N. Hayes MD is Professor of Cardiovascular Medicine. She founded and maintains an active clinical practice in the Mayo Clinic Women's Heart Clinic. As a non-invasive cardiologist with a focus on prevention and equity, Dr. Hayes has long advocated for the advancement of women's health and sex-based medicine within the field of cardiology and other areas that affect women's health and well-being. Dr. Hayes research interests include sex and gender-based cardiology, cardiovascular conditions primarily affecting women, spontaneous coronary artery dissection (SCAD), fibromuscular dysplasia, pericardial diseases, health equity, participation of women and minorities in medical research, healthcare workforce equity, and the utility and optimal role of social media in clinical practice, medical research and health education.

An aging population, physician shortages, and industry fragmentation are making cardiology the “new darling” of private equity investment. The question is – can private equity coexist with the quadruple aim? On MedAxiom HeartTalk, host Melanie Lawson talks with Ann Honeycutt, executive director of Virginia Cardiovascular Specialists, Larry Sobal, CEO of Heart and Vascular Institute of Wisconsin, Dinesh Pubbi, MD, a founding member of First Coast Heart and Vascular Center, Rick Snyder, MD, FACC, an interventional cardiologist at HeartPlace Dallas, and Joe Sasson, executive vice president of Ventures at MedAxiom. They discuss the influx of private equity in cardiovascular healthcare and how one size does not fit all.Guest Bios:Ann E. Honeycutt, MSN, is the executive director of Virginia Cardiovascular Specialists (VCS), a private practice based in Richmond, VA. In her role, Ann has been actively involved in developing strong partnerships with local health systems and managed care organizations and has strived to ensure VCS remains a leader in the transformation of healthcare and clinical cardiology. She also serves as vice chair of MD Value Care, an ACO comprised of 90 primary care physicians and 350 specialists. Ann is also the only practice executive serving on the Richmond Academy of Medicine Board. She received a Master of Nursing, Community Health and Education from the University of Washington. Over the course of her nearly 40-year career, she has held various leadership roles in the areas of community health, home health care, acute care, ambulatory services and physician practice management. She has in-depth experience with financial management, strategic planning, business development, talent acquisition and leadership development.Larry Sobal, MBA, MHA, FACMPE - CEO of the Heart and Vascular Institute of Wisconsin in Appleton, WI. - Larry is an innovative, results-driven senior healthcare executive with a diverse background in medical group leadership, hospital leadership, and insurance. Effective communicator with the ability to engage others to create a vision for change and translate that into strategy by analyzing critical business requirements, identifying deficiencies and potential opportunities, and developing innovative solutions. Respected decision-maker who delivers value and trust through strong relationships with colleagues, physicians, staff, and the community. His areas of expertise include strategic planning and implementation, leadership and management, and operations improvement.Joe Sasson, PhD - executive vice president of Ventures and chief commercial officer, MedAxiom - Joe is a tenured member of the MedAxiom team and brings with him a wide variety of perspectives on healthcare operations and market access strategies. As chief commercial officer and executive vice president of Ventures at MedAxiom, Joe helps members access the technologies and solutions they need to effectively run their organizations and prepare for the future of value-based care. He currently works with companies spanning medtech, device, pharma, imaging, cath labs/ambulatory surgery centers (ASCs) and health IT to deliver economic value propositions and strategies to accelerate commercial growth. Joe has created and led programs and workgroups centering on EMR utilization and optimization, chronic care management, physician in-office dispensing of medications, CCTA, cath lab efficiency and more.Dinesh Pubbi, MD – Dr. Pubbi is a founding member of First Coast Heart & Vascular Center. He completed his electrophysiology fellowship at St. Luke's Medical Center in Milwaukee where he trained in the latest electrophysiology procedures and techniques including atrial fibrillation ablations, device implantations and complex ablations. Dr. Pubbi completed his internal medicine residency at Sinai Samaritan Medical Center in Milwaukee and worked as an Internist and Primary Care physician for several years before completing his cardiology fellowship at Aurora Health Care at ASMC and St. Luke's Hospital also in Milwaukee.Rick Snyder MD, FACC – Dr. Snyder is a board-certified interventional cardiologist at HeartPlace, serving adults and teens in and around Dallas, Texas. He holds three board certifications: interventional cardiology, advanced heart failure and transplantation, and cardiovascular disease.Dr. Snyder joined the team at HeartPlace in 1996 and opened the satellite office at Medical City that same year. Though he's trained as an interventionist, Dr. Snyder prides himself on providing the highest quality preventive care. He believes that risk factor modification through diet and exercise can significantly reduce the risk of potentially serious issues like a heart attack or a stroke.As a cardiologist, Dr. Snyder serves as an advocate for his patients. That advocacy extends to his work with legislative leaders at both the state and national levels. His work as a physician advocate allows Dr. Snyder to help a larger number of people.Currently, Dr. Snyder serves as the president of HeartPlace. He enjoys leading the organization and has plenty of past experience — he's served as staff president at Medical City Dallas Hospital as well as president of the Dallas County Medical Society.

The PACE Radio ShowGuest: Jeremy Smith Hosts: Tamara & Al Tonight we are joined by cannabis patient advocate Jeremy Smith who is a Finalist in the Trailblazer Category at this years CannExpo in Toronto. But Jeremy isn't the only one in his family who has found the medical benefits of cannabis. Read on to learn more…. Jeremy Smith's patient story…..“I started advocating in the cannabis industry after I almost died from prescription medications for my Crohn's and eosinophilic esophagitis. I then had side effects to opioids and started using cannabis for its unbelievable medicinal properties. My advocacy strengthened after my son went into a coma after starting medication for his Autism. This was only due to the doctors ignorance about cannabis, which she stated that she was not taught about cannabis. I'd travelled throughout Southern Ontario for months with a petition for a cannabis hospitality industry. I collected over 4,000 signatures but only with the help of over 100 cannabis stories and First Nation communities. The stories I heard and the journey I went through made me realize THIS is what my true purpose of life is. I am truly passionate about advocating for a cannabis hospitality and tourism industry throughout Canada. I am now a Board Member and director of Government Relation. Working with the most amazing people that are truly passionate and knowledgeable within all areas of the cannabis industry. Thank you to everyone at CCTA for your hard work!”A note to our viewers …The PACE Radio Network as been nominated for the “Best Cannabis Related Podcast” award at this years CannExpo. If you'd like to help us out by voting please go to https://cannexpo.ca/the-cannabis-community-influencer.../ and you'll find “PACE Radio” in the “Podcast” category. Thank you.Tune In every Wednesday night at 8pm ET / 5pm PST to catch our LIVE show, only on the PACE Radio Network's Facebook pages and our YouTube channel plus at CBGTV.com. Both audio and video broadcasts are available at http://PACEradio.netThank you to our sponsors.... Legacy 420 located on the Tyendinaga Mohawk Territory in Ontario https://legacy420.com/ampbellford Lifestyle Shop in Campbellford Ontario#thepaceradioshow #paceradionetwork #patientstory #cannabis #medicalmarijuana #cannaexpo #cbgtv

When navigating ambulatory surgery centers (ASCs) in today's cardiovascular healthcare landscape, change is at the forefront, evolving the way we provide care. On MedAxiom HeartTalk, host Melanie Lawson talks with Joe Sasson, PhD, executive vice president of Ventures and chief commercial officer at MedAxiom and Marc Toth, market president, Cardiovascular Services at Atlas Healthcare Partners. They discuss both the complexities and benefits of ASCs, as well as what steps your organization can take if considering starting one of your own. Guest Bios: Joe Sasson, PhD, Executive Vice President of Ventures and Chief Commercial Officer – Joe is a tenured member of the MedAxiom team and brings with him a wide variety of perspectives on healthcare operations and market access strategies. As chief commercial officer and executive vice president of Ventures at MedAxiom, Joe helps members access the technologies and solutions they need to effectively run their organizations and prepare for the future of value-based care. He currently works with companies spanning medtech, device, pharma, imaging, cath labs/ambulatory surgery centers (ASCs) and health IT to deliver economic value propositions and strategies to accelerate commercial growth. Joe has created and led programs and workgroups centering on EMR utilization and optimization, chronic care management, physician in-office dispensing of medications, CCTA, cath lab efficiency and more.As the leader of MedAxiom Ventures, Joe spearheaded the development of the HeartX Accelerator, which invests into and helps accelerate five growth stage companies per year. He was also responsible for the creation and execution of MedAxiom's joint venture with Atlas Healthcare Partners, to position MedAxiom as a leader in the in the ASC space for both clinical quality and operational efficiency. Joe has also led MedAxiom's initiatives in the direct contracting space, aiming to link self-funded insurers with high quality cardiovascular providers across the nation to create steerage that improves patient experience and outcomes, while lowering costs for payers. In his role, Joe works to commercialize MedAxiom's product portfolio and continues to focus on innovation, commercial acceleration and operational execution for 40+ companies in the cardiovascular arena.Throughout his career, Joe has advised over 75 companies – from small startups to the largest names in cardiovascular care – on commercial strategy, sales execution, risk model development, market segmentation and care pathway development with a focus on commercialization. His experience has provided him with valuable relationships and expertise spanning numerous aspects of the healthcare industry, which has provided him a unique skill set that enables him to author the development and delivery of successful responses to the new challenges in this rapidly changing environment.Joe holds a PhD in Behavioral Science and a master's degree in organizational improvement. Marc Toth, Market President, Cardiovascular Services at Atlas Healthcare Partners – As the President of Cardiovascular Services, and Chairman of the MedAtlas CV Board of Directors, Marc leads the team working to transform cardiovascular care delivery and expand patient access to high-quality cardiovascular ambulatory surgery centers (ASCs). He oversees the development and management of both the day-to-day business and clinical operations of cardiovascular ASCs for Banner Health, Corewell Health, as well as expansion efforts with Atlas' newest JV partner MedAxiom.Marc has 25+ years of leadership experience in the cardiovascular/cardiology marketplace, including product commercialization, physician-practice and outpatient-vascular-lab valuations, capital acquisition, and exit strategies. He also has been an M&A Advisor representing physicians seeking capital and strategic partners for outpatient centers.Prior to Atlas, Marc founded ACA Cardiovascular, a development and management company focused solely on turnkey development and management of hybrid cardiovascular centers (ASCs and office-based labs). Before ACA Cardiovascular, he worked as a consultant with VERTESS, a healthcare-focused M+A advisory firm, where he advised physician-owned endovascular labs looking for economic and strategic partnerships. His work also included valuations, capital acquisition, and exit strategies.Marc is also a frequent contributor to Cath Lab Digest, Cardiovascular Interventions Today, and Becker's ASC Review, and he routinely speaks at national cardiovascular meetings on outmigration trends. He also is an active member of Ambulatory Surgery Center Association (ASCA)'s government affairs board bringing his expertise to lobbying efforts that raise awareness of issue relating to cardiovascular ASCs. Marc received his Bachelor of Business Administration at the University of Michigan's Ross School of Business and is a Certified Mergers and Acquisitions Advisor.

For the millions of US patients who go to an ER or medical office with chest pain every year, doctors have several options for screening. New national guidelines recommend a quick and non-invasive heart scan known as CCTA for stable chest pain. Our guests today are leading experts in the field of advanced cardiac imaging and discuss the history and many applications of this technology, which produces a 3D image of the heart and can be used to rule out several potentially deadly conditions. The updated guidelines come from the American College of Cardiology (ACC), American Heart Association (AHA), and other groups. Meet the experts Amar Shah, MD, is Northwell's chief of cardiac imaging Michael Poon, MD is director of advanced cardiac imaging, for Northwell's Western Region.

Enduring CME will expire on 2/2/2024 Objectives: 1. Inflammation is associated with development of atherosclerosis. 2. Psoriasis is a chronic inflammatory disease associated with increased risk of myocardial infarction. 3. A reduction in systemic inflammation is associated with improvement in coronary non-calcified burden. Disclosures: - There is no commercial support for this activity - The speaker's financial disclosures are announced during his introduction. Accreditation and Designation: The Northeast Georgia Medical Center & Health System, Inc. is accredited by the Medical Association of Georgia to provide continuing medical education for physicians. The Northeast Georgia Medical Center & Health System, Inc. designates this live activity for a maximum of 1 AMA PRA Category 1 Credit(s) TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Please join author Jonathan Newman and Associate Editor Sandeep Das as they discuss the article "Outcomes of Participants With Diabetes in the ISCHEMIA Trials." Dr. Carolyn Lam: Welcome to circulation on the run, your weekly podcast, summary, and backstage pass to the journal and its editors. We're your co-hosts; I'm Dr. Carolyn Lam, Associate Editor from the National Heart Center and Duke National University of Singapore. Dr. Greg Hundley: And I'm Dr. Greg Hundley, Associate Editor, Director of the Pauley Heart Center at VCU health in Richmond, Virginia. Well, Carolyn, this week's feature, a couple of weeks ago, we had that feature forum on the ischemia trial. Now we're going to explore some of the outcomes in patients with diabetes, from the ischemia trial in the feature discussion today. But, before we get to that, let's grab a cup of coffee and start in on some of the other articles in this issue. So, how about if I go first, this time? This particular paper, Carolyn, we're going to start on one of your topics. I know you're a fan of diet related interventions. So high intake of added sugar is linked to weight gain and cardio-metabolic risk. And in 2018, the U S National Salt and Sugar Reduction Initiative proposed government supported voluntary national sugar reduction targets. Dr. Greg Hundley: This intervention's potential health and equity impacts and cost effectiveness are unclear. And so Carolyn, these authors, led by Dr. Renata Micha from Tufts University, incorporated a validated micro-simulation model - CVD Predict coded in C++, and used it to estimate incremental changes in type two diabetes, cardiovascular disease, quality adjusted life years, cost and cost effectiveness of this national policy. The model was run at the individual level and the model incorporated national demographic and dietary data from the National Health and Nutrition Examination Survey across three cycles spanning from 2011 to 2016, added sugar related diseases from meta-analysis and policy costs and health-related costs from established sources and a simulated nationally representative us population was created and followed until age 100 years or death with 2019 as the year of intervention start and findings were evaluated over 10 years and a lifetime from healthcare and societal perspectives. Dr. Carolyn Lam: Ooooh, You so got my attention, Greg, a very important topic and so, what did they find? Dr. Greg Hundley: Right, Carolyn. So achieving the NSRI sugar reduction targets could prevent 2.48 million cardiovascular death related events, 0.5 million cardiovascular disease deaths, and three quarters of a million diabetes cases, gain 6.7 million quality adjusted life years, and save $160.8 billion in net cost from a societal perspective over a lifetime. The policy became cost-effective, defined as less than $150,000 for quality adjusted life years at six years and highly cost-effective at seven years with a cost savings noted at nine years. And therefore, Carolyn, implementing and achieving the NSSRI sugar reformation targets could generate substantial health gains, equity gains, and cost savings. Dr. Carolyn Lam: Wow, thanks Greg. So, moving from a very publicly health focused paper to this paper that really focuses on hypoplastic left heart syndrome with very, very scientifically significant findings. Now, first, we know hypoplastic left heart syndrome is the most common and severe manifestation within the spectrum of left ventricular outflow tract obstruction defects occurring in association with ventricular hypoplasia. The pathogenesis is unknown, but hemodynamic disturbances are assumed to play a prominent role. Authors led by Doctors Moretti and Laugwitz from Technical University of Munich in Germany, as well as Dr. Gruber from Yale University School of Medicine, and their colleagues combined whole exome sequencing of parent offspring, trios, transcriptome profiling of cardiomyocytes from ventricular biopsies and immuno-pluripotent stem cell derived cardiac progenator or cardiomyocyte models of 2D and 3D cardiogenesis, as well as single cell gene expression analysis to decode the cellular and molecular principles of hypoplastic left heart syndrome phenotypes. Dr. Greg Hundley: Wow, Carolyn, there is a lot of data, very complex preclinical science here. So what did they find? Dr. Carolyn Lam: Indeed, Greg. As I said, scientifically incredible and rigorous, and they found that initial aberrations in the cell cycle unfolded protein response, autophagy hub led to disrupted cardiac progenator lineage commitment, consequently, impaired maturation of ventricular cardiomyocytes limited their ability to respond to growth cues. Resulting in premature cell cycle exit and increase apoptosis under biomechanical stress in 3D heart structures. Together, these studies provide evidence that the hypoplastic left heart syndrome pathogenesis is not exclusively of hemodynamic origin, and they revealed novel potential nodes for rational design of therapeutic intervention. Dr. Greg Hundley: Wow, Carolyn, we really need research in this topic and this is great preclinical science that we're getting here in our journal. Congratulations to the authors and what a great presentation of that by you. Well, Carolyn and my next paper there remain major uncertainties regarding disease activity within the Retain Native Aortic Valve, as well as bioprosthetic valve durability, following transcatheter aortic valve implantation. And these authors led by Doctor Jacek Kwiecinski, from the Institute of Cardiology, aimed in a multi-center cross-sectional observational cohort study to assess native aortic valve disease activity and bioprosthetic valve durability in patients with TAVI in comparison to subjects with bioprosthetic surgical aortic valve replacement or SAVR. Dr. Carolyn Lam: Oh, very interesting. And what were the results? Dr. Greg Hundley: An interesting comparison, Carolyn. So in patients with TAVI, native aortic valves demonstrated 18 F sodium fluoride uptake around the outside of the bioprosthesis that showed a modest correlation with the time from TAVI. Next, 18 sodium fluoride uptake in the bias prosthetic leaflets was comparable between SAVR and TAVI groups. Next, the frequencies of imaging evidence of bioprosthetic valve degeneration at baseline were similar on echo cardiography 6 and 8% respectively, CT, 15 and 14% respectively, and with PET scanning. Next, baseline 18 F sodium fluoride uptake was associated with subsequent change in peak aortic velocity for both TAVI and SAVR. And on multi-variable analysis, the 18 F sodium fluoride uptake was the only predictor of peak velocity progression. And so Carolyn, therefore, in patients with TAVI, native aortic valves demonstrate evidence of ongoing active disease and across imaging modalities, TAVI degeneration is of similar magnitude to bioprosthetic SAVR suggesting comparable midterm durability. Dr. Carolyn Lam: Very nice, important stuff. Dr. Carolyn Lam: Well, thanks, Greg. Let's tell everyone about the other papers in today's issue. There's an exchange of letters between Doctors Baillon and Blaha regarding the article very high coronary artery, calcium and association with cardiovascular disease events, non-cardiovascular outcomes and mortality from MESA. There's an ECG challenge from Dr. Bell Belhassen on a left bundle branch block, tachycardia following transcatheter aortic valve replacement. And On My Mind paper by Dr. Neeland on cardiovascular outcomes trials for weight loss interventions, another tool for cardiovascular prevention, another Research Letter by Dr. Nakamura on clinical outcomes of Rivaroxaban Mono therapy in heart failure, patients with atrial fibrillation and stable coronary artery disease. So insights from the AFIRE trial, and finally, a Research Letter from Dr. Kumoro three-dimensional visualization of hypoxia induced, pulmonary vascular remodeling in mice. Dr. Greg Hundley: Great, Carolyn, and I've got an in-depth piece from Professor Jia Sani entitled breadth of life, heart disease, linked to developmental hypoxia. Dr. Greg Hundley: Well, Carolyn, how about we get onto that feature discussion and learn more about results from the ischemia trial? Dr. Carolyn Lam: Let's go Greg. Dr. Carolyn Lam: Well, we all know how important diabetes is as a risk factor for atherosclerotic coronary disease. And we know it's a very common comorbidity among patients with chronic coronary disease, but the question is do patients with diabetes and chronic coronary disease on top of guideline directed medical therapy and lifestyle interventions, of course, do they derive incremental benefit from an invasive management strategy of their coronary disease? Well, we are going to try to answer that question today in our feature discussion. Thank you so much for joining us today. The first author and corresponding author of today's feature paper, which tells us about results from the ischemia trials. And that's Dr. Jonathan Newman from New York university Grossman School of Medicine. We also have associate editor Sandeep Das from UT Southwestern. So welcome both of you. And if I could please start with Jonathan reminding us, perhaps, what were the ischemia trials and then what you tried to answer and do in today's paper, Dr. Jonathan Newman: Of course, Carolyn, and thank you so much for having me and for the discussion with Sandeep. It's a pleasure to be here. So sure has a little bit of background, as you indicated, the ischemia trials basically enrolled and for the purposes of this discussion and this analysis, I'm referring to both the main ischemia trial and the ischemia chronic kidney disease trials. So ischemia CKD under the umbrella of the ischemia trials. Ischemia stands for the international study of comparative health effectiveness with medical and invasive approaches. And the purpose of the trial was to test to see whether a routine invasive approach on a background of intensive guideline directed medical therapy for high risk patients with chronic coronary disease and at least moderate ischemia and obstructive coronary disease documented on a blinded CCTA or computed coronary tomography angiography prior to randomization was associated with benefits for a cardiovascular composite. And we looked in this analysis at whether or not there was appreciable heterogeneity of treatment effect or a difference in treatment effect for patients compared without diabetes in the ischemia trials, in ischemia and ischemia CKD. Dr. Carolyn Lam: Great, thanks for lining that up so nicely. So what, Dr. Jonathan Newman: So the results of our analysis really highlighted a couple of things that I think you touched upon initially, the first thing that I would highlight is that diabetes was very common in this high risk cohort with chronic coronary disease, over 40% of participants in the ischemia trials, 43% with obstructive coronary disease and moderate to severe, you may have had diabetes. Perhaps not surprisingly patients with diabetes had higher rates of death or MI than those without diabetes. And the rates were highest among those patients that required insulin, had insulin treated diabetes, but using really robust methods to assess for heterogeneity using a Bassen assessment of heterogeneity of treatment effect accounting for violation of proportional hazards. The fact that there was an upfront hazard and a late benefit, we really saw no difference in death or MI, between the invasive or conservative strategies for patients with, or without diabetes over about three years of follow-up. Dr. Jonathan Newman: And the results importantly were consistent for ischemia and ischemia CKD and provided the rationale for us when we started by looking to see if the distribution of risk and characteristics allowed the trials to be combined. The study really confirms this higher risk of death or a MI for chronic coronary disease patients who have diabetes extends these findings for those patients with moderate or severe ischemia. And I think really notably also adds information about chronic coronary disease patients with diabetes and CKD. That's sort of the overall findings. And I'm happy to talk in more detail about that. Dr. Carolyn Lam: I love the way you explain that Jonathan and especially, going into detail on what was so different about the paper and the really important statistical methods that made these findings robust, very important and impactful findings. If I could ask Sandeep to share your thoughts. Dr. Sandeep Das: Thanks, Carolyn. You know, I am just a big fan of everything that's come out of the ischemia group. One of the things that I really most enjoy as a consumer of the literature is when well done studies give me results that are unexpected. And I know it's become fashionable now to say that everybody knew that all along that this is what going to be the result. But honestly, I think we all sort of are many of us thought that there's going to be a subgroup somewhere that's really going to benefit from an invasive approach in terms of preventing heart outcomes. I think the key here that really jumped out at me was that this is identifying what we typically think of is a very high risk subgroup. You know, patients with diabetes patients with multi-vessel coronary disease patients with insulin dependent diabetes. Dr. Sandeep Das: And we did see the association with mortality across the increased disease severity and the increased severity of diabetes as expected. But really we didn't see a signal that revascularization, routinely revascularizing patients, even the higher risk patients led to clinically relevant heart outcome benefits. So I thought that that was a really interesting top line finding and really that's kind of. I mean, it would have been interesting if it was the other way too, but it was, it really was kind of the hook that got me into the paper. Dr. Sandeep Das: I actually have a question for Jonathan, one of the things that I think we spend a lot of time as an editorial group thinking about and talking about, and we bounce back and forth with the authors a few times was the idea that relatively few of these patients with multi-vessel CAD ended up having CABG. So, you would typically think of diabetes multi-vessel CAD as being a pretty strong signal for patients that may benefit in terms of mortality from having bypass surgery. And here it was a relatively small group about a third, or maybe even less than a third. And I realized up front, they excluded the left main and the patients that had angina had a CTA, et cetera. But what I'd be curious as to your thoughts about, the benefits of bypass surgery and diabetes, which have been established in other trials. Dr. Jonathan Newman: It's a great question. And I think we really appreciated the questions from you and from the editors to try and get at some of the nuance with this issue. As you indicated in the ischemia and ischemia CKD trials overall, and the patients in the invasive treatment arm, it was about 25% or so 26% and 15% were revascularized with CABG. Part of the issue here is that it gets a little tricky with the use of CCTA of pre randomization CTA to define coronary artery severity, which was not required in the CKD population due to impaired renal function. But what we can say is among the patients with diabetes and multi-vessel coronary disease, 29% were revascularized surgically in their combined analysis, which is comparable to the 30% in Bery 2d that were revascularized via bypass surgery, as we've discussed. And as you know, the decision for surgical versus percutaneous revascularization in ischemia, as in Barry 2d was non-randomized though we might want to, we really tried to be very, very cautious in terms of comparing revascularization strategies on outcomes for patients with diabetes and multi-vessel CAD, which has you suggested. Dr. Jonathan Newman: And as we pointed out, the proportion with multi-vessel CAD was more common amongst in patients with diabetes compared with those patients without diabetes. The other thing I would sort of say in the framework of, the revascularization and strategies for revascularization, comparing, let's say ischemia to Barry 2d or to freedom. Basically we have very little data about revascularization approaches for those patients with creatinine with impaired renal function and, patients with the crediting greater than two were excluded from Barry 2d. So while we had about 15% or so that had severe CKD. So in the GFR, less than 30 are on dialysis. And we know that's an extremely high risk group of patients with diabetes and chronic coronary disease. And we don't have great evidence on which strategy for revascularization if at all provides additional benefit. So I think it's a really a tough question to answer, and we tried to be as judicious as possible in our comments about revascularization approaches, given the nature of the trial design. Dr. Carolyn Lam: Gee, thanks so much, Jonathan, for explaining that. So, well, I actually have a related question now, referring to the medical therapy. Can I, sort of ask you about the fact that, these days that the rage is all about GLP one receptor agonist, for example, that are known to reduce the risk of atherosclerotic cardiovascular disease and diabetes. So these ischemic trials, I assume, did not have a high usage of these medications. And what do you think would be the impact, if anything, I suppose even more for guideline directed medical therapy. Huh? Dr. Jonathan Newman: Yeah. So it's a great question, Carolyn. As you know, in strategy trials and clinical trials in general, that take a while it's always a real challenge to keep the trial contemporary with current clinical practice, whether it's revascularization strategies or changes in medical therapy. And as you indicated, the real revolution and glucose lowering therapies with profound cardiovascular benefit for patients with diabetes, we worked hard to try and stay up to date and encourage sites around the world with the use of best SGLT2 inhibitors and GLP ones. The rates were very, very low and we don't actually given the fact that the ischemia trials were conducted a real multinational and is really an international trial is over 330 sites worldwide. So we really had to balance the data that we could get from sites with the reality of collecting and running this trial across the whole world. Dr. Jonathan Newman: So we don't actually know. We know insulin use or non-use or oral medication use or non-use or no medication use or non-use, but not much more than that. From what, as, you know, unfortunately, even after now, six going on seven years of impressive data for the benefit of these agents, uptake remains low for patients with diabetes, whether it's with coronary disease or heart failure. And there was certainly the case with the trial, which started back in 2015, or sorry, before 2015, even before the results of EMPA-REG. So the rates of those agents were low. I would expect as you indicated that if we did have greater use of these beneficial therapies. Medical therapy may have performed even better and potentially given an added boost potentially for our high risk, even higher risk subgroups that we'd looked at that were available in these trials. Dr. Carolyn Lam: Oh, thanks again. I wish we could go on forever, but we've got just a little bit of time left. So I'd like to ask you both for your quick take home messages for the audience. Could I start with Sandeep and then Jonathan? Dr. Sandeep Das: Yeah. You know, I think a key take home from this is that, although it may be naively intuitive that a very aggressive invasive strategy would be superior, especially in high risk patients. You know, the data are very, very convincing that it's not. And so therefore I think in an absolute minimum, you have plenty of time and ability to think about these patients carefully, to select who, if anybody would be a great candidate for revascularization, more aggressive therapy and more invasive therapy, but the most patients will do well with conservative management. Dr. Sandeep Das: And I think that that's the, that's a real key take home here. And I think that the points that Jonathan raised about, you know, poor uptake of GLP one RAs and SGLT 2 inhibitors in the community as they're so far are key, right? So we have great medicines that we just under used, and that to me is the other sort of clarion call here is that if in the context of a nice trial, that you can see similar result for invasive conservative approaches, then lets, let's get our medical therapy where it needs to be to provide our patients the best outcomes we can Speaker 3: Love it, Jonathan. Dr. Jonathan Newman: Yeah. So I'm really glad that Sandeep brought up the issue of medical therapy in the trial. And maybe I can take a minute to sort of frame what San kind of build off of what Sandeep just said, you know, we, in the context of this clinical trial, you know, Dr. Judy Hawkman, the study chair and Dr. David Marin, the co-chair and I, we worked very hard with optimizing medical therapy across the trials, for all participants. So really getting patients on the maximum tolerated doses of high-intensity statins, lowering patient's LDL as aggressively as possible evolving our systolic blood pressure targets. And it was extremely challenging. And at the end of the day, we see that patients with diabetes were more likely than those without to get to our LDL goal. We used a threshold problematic concept that that still may be to some extent, but they were less likely to achieve their systolic blood pressure goals. Dr. Jonathan Newman: And I think Sandeep was exactly right. We have a way to go with implementing existing therapies, existing medical therapy. There may be a benefit for as demonstrated in Dr. S. for patients that remain highly symptomatic to derive symptom benefit with revascularization. The other context I would sort of add with the medical therapy issue is that despite really aggressive medical therapy, and we really did as much as we could, patients with diabetes still had, a 40, 50% greater risk of death or MI than those without diabetes. So there's still this idea of kind of residual risk. And these were patients with diabetes that were very well managed from a medical and glycemic control perspective. So we still have a lot of work to do. And I think understanding ways we can benefit our patients is really that challenge. Speaker 3: Thanks so much, Jonathan, and thank you Sandeep for joining us today. Speaker 3: And thank you audience for listening from Greg and I. This has been "Circulation On The Run", please tune in again. Next week. Dr. Greg Hundley: This program is copyright of the American Heart Association, 2021. The opinions expressed by speakers in this podcast are their own and not necessarily those of the editors or of the American Heart Association for more visit AHJjournals.org.

Two NEJM papers on mRNA-related myocarditis, AF and stroke, intensifying BP meds, and CCTA and high-sensitivity troponin are the topics John Mandrola, MD, covers in this week's podcast. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I -- Vaccine-Induced Myocarditis New Reports Help Nail Down Myocarditis Risk With COVID-19 Vaccine https://www.staging.medscape.com/viewarticle/960537 • Myocarditis after BNT162b2 mRNA Vaccine against Covid-19 in Israel https://www.nejm.org/doi/full/10.1056/NEJMoa2109730 • Myocarditis after Covid-19 Vaccination in a Large Health Care Organization https://www.nejm.org/doi/full/10.1056/NEJMoa2110737 II – AF and Stroke AF a Stroke Cause or Innocent Bystander? The Debate Continues https://www.medscape.com/viewarticle/960224 • Temporal Association Between Episodes of Atrial Fibrillation and Risk of Ischemic Stroke https://jamanetwork.com/journals/jamacardiology/fullarticle/2784332 • It's Time to Rethink (and Retrial) Our Framework for Stroke Prevention in Atrial Fibrillation https://jamanetwork.com/journals/jamacardiology/fullarticle/2784335 III- Intensification of BP Control Adding New Hypertensive May Be More Potent Than Upping Doses https://www.medscape.com/viewarticle/960454 • Adding a New Medication Versus Maximizing Dose to Intensify Hypertension Treatment in Older Adults https://doi.org/10.7326/M21-1456 IV- Hs-troponin and CAD Troponin Levels Tied to Increased CAD Risk, May Guide Imaging /viewarticle/960146 • Troponin-Guided Coronary Computed Tomographic Angiography After Exclusion of Myocardial Infarction https://doi.org/10.1016/j.jacc.2021.07.055 You may also like: Medscape editor-in-chief Eric Topol, MD, and master storyteller and clinician Abraham Verghese, MD, on Medicine and the Machine https://www.medscape.com/features/public/machine The Bob Harrington Show with Stanford University Chair of Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact news@medscape.net

Lauren Bone Noble, assistant professor of movement for the actor, talks about "Dreaming Green," our part in the global event Climate Change Theatre Action 2021.For more information about Climate Change Theatre Action, please visit: http://www.climatechangetheatreaction.com/To learn more about the Yoknapatawpha Arts Council's Goodnight Market, visit: https://oxfordarts.com/shop/event-tickets/product/3454-dreaming-green-at-the-goodnight-marketWe talked about a piece of devised theater called "Near/Far" that Lauren directed and created with our students last fall; if you haven't seen "Near/Far," you can watch it here: https://youtu.be/TAYcLtW8rX8Also, if you missed our previous interview with Lauren, check it out here: https://stageandscreen.simplecast.com/episodes/the-poetic-body-with-lauren-bone-noble-assistant-professor-of-movement-for-the-actor    

This week's episode features author Benjamin Levine and Guest Editor Walter Paulus as they discuss the article "One-Year Committed Exercise Training Reverses Abnormal Left Ventricular Myocardial Stiffness in Patients with Stage-B HFpEF." Dr. Greg Hundley: Well, welcome listeners. This is the September 21st podcast for Circulation on the Run. Sadly, I'm without Carolyn today, but I am your host today, Dr. Greg Hundley, associate editor and director of the Pauley Heart Center at VCU Health in Richmond, Virginia. Dr. Greg Hundley: Our feature discussion today is really interesting. It's from Dr. Ben Levine, and he's evaluating the utility of exercise training and actually trying to reverse abnormal left ventricular myocardial stiffness in individuals that have stage B, it's a very early heart failure and preserved ejection fraction. But before we get to that, let's grab a cup of coffee and we're going to work through some of the other articles in this issue. Dr. Greg Hundley: So the first one comes to us from Göran Bergström from University of Gothenburg in Sweden. He and his team used coronary computed tomography angiography or CCTA to determine the prevalence, severity and characteristics of coronary atherosclerosis and its association to coronary artery calcification scores in a general population of greater than 25,000 individuals all aged 50 to 64 years and without known coronary heart disease. It really comes to us from the Swedish CArdioPulmonary BioImage Study or SCAPIS. Well, Carolyn would ask me that is a really large study, and what did they find? Well, let's get to the results. Dr. Greg Hundley: So using CCTA to detect silent coronary atherosclerosis, the investigators showed that any coronary atherosclerosis was actually quite common, 42% of individuals and significant stenosis of greater than 50% was less common, only 5% of individuals. More severe forms were rarely found, only 1.9% in this very large, random sample of middle-aged individuals. Dr. Greg Hundley: Now disease onset was delayed by 10 years in women and a higher prevalence of coronary atherosclerosis was observed with higher age and accumulation of risk factors. Interestingly, CCTA detected atherosclerosis increased with an increasing coronary artery calcium score. All those with a high CAC score of greater than 400 had atherosclerosis and 45% had significant stenosis. 5.5% of those with no coronary artery calcification had atherosclerosis and 0.4% had significant stenosis. So although there was a strong association with high coronary artery calcium scores and significant stenosis, atherosclerosis was not excluded in those with zero coronary artery calcification especially in those with high baseline risk. Dr. Greg Hundley: Well, our second article comes to us from the world of preclinical science and it's from Dr. Nathan Palpant from the University of Queensland. So the article pertains to ischemia reperfusion injury, and it's one of the major risk factors implicated in morbidity and mortality associated with cardiovascular disease. Now during cardiac ischemia, the buildup of acidic metabolites results in decreased intracellular and extracellular pH that can reach as low as 6 to 6.5, and the resulting tissue acidosis exacerbates ischemia injury and significantly impacts cardiac function. Dr. Greg Hundley: So the authors today use genetic and pharmacologic methods to investigate the role of acid-sensing ion channel 1a or ASIC1a, we'll call it from now, in cardiac ischemia reperfusion injury at the cellular and whole organ level. Human induced pluripotent stem cell-derived cardiomyocytes as well as ex vivo and in vivo models of ischemia reperfusion injury were used to test the efficacy of ASIC1a inhibitors as pre-imposed conditioning therapeutic agents. Dr. Greg Hundley: So what did the authors find in this study? Well, they demonstrated for the first time that acid-sensing ion channel 1a or that ASIC1a mediates cardiac ischemia reperfusion injury. The authors identify that ASIC1a inhibition is a novel therapeutic strategy for preventing acute injury response to myocardial ischemia reperfusion injury. Dr. Greg Hundley: So what are the clinical implications of this research? Well, first there are currently no drugs in clinical use that prevent acute injury response to myocardial ischemia, despite many promising candidates identified over decades of research, all of which ultimately failed in subsequent clinical trials. Second, the identification of new therapeutic targets for preventing the injury response to myocardial ischemia reperfusion injury would therefore have profound implications in cardiovascular medicine. Therefore, the results of this study reveal that ASIC1a inhibiting drugs, they're safe and they have potential applications in heart transplant and myocardial infarction with potential use in other clinical scenarios where myocardial ischemia reperfusion injury is a risk such as those that undergo cardiac surgery. Dr. Greg Hundley: Well, our next article comes from Robin Choudhury from the University of Oxford. Have you ever wondered why cardiovascular risk and diabetes remains elevated despite glucose-lowering therapies? Well, these authors hypothesized that trained immunity in response to elevated glucose accounts for diabetic hyperglycemic "memory", we'll call it, in relation to atherosclerosis. So accordingly, the author sought to determine if hyperglycemia-induced disease relevant changes in monocyte and macrophage function and whether these changes persisted after restoration of normal glucose, thereby implying fundamental reprogramming. So the team combined studies of cellular function, metabolomics, transcriptomics and epigenomics to define how hyperglycemia altered metabolism to modulate long-term activation through epigenetic modifications. Dr. Greg Hundley: Well, what did they find? First, hyperglycemia induced a trained immunity in bone marrow progenitor cells by inducing persistent epigenetic modifications. Second, hyperglycemia-induced trained immunity persisted after differentiation into those macrophages. Finally, hematopoetic stem cells transplanted from mice with diabetes to euglycemic mice promoted exaggerated atherosclerosis. So therefore, the findings of this study may explain the resistance of macrovascular complications of diabetes to conventional glucose-lowering treatments. Dr. Greg Hundley: Well, in the mailbag this week, there are some other articles. Professor Huang has a Research Letter entitled, “Adrenergic-Thyroid Hormone Interactions Drive Postnatal Thermogenesis and Loss of Mammalian Heart Regenerative Capacity.” Dr. De Caterina has an In Depth article on coronary artery anomalies. Finally, Professor Merid has a Perspective piece entitled, “Digital Redlining and Cardiovascular Innovation.” Dr. Greg Hundley: Well, listeners, what a great group of articles, and now we're going to turn to that feature discussion with Dr. Ben Levine. Dr. Greg Hundley: Welcome listeners to our feature discussion today and we're very fortunate. We have with us, Dr. Ben Levine from UT Southwestern in Dallas, Texas and also Dr. Walter Paulus from Amsterdam. Welcome gentlemen. Dr. Greg Hundley: Ben, we'd like to start with you. Could you describe for us a little bit of the background related to your study and what was the hypothesis that you wanted to test? Professor Benjamin Levine: Sure. Oh, nice to talk with you, Greg. As you know, our lab has been very interested in the effects of both aging and physical activity on cardiac mechanics. To cut a very long story short, what we know is that sedentary aging leads to stiffening of the heart. We also know that HFpEF, heart failure with preserved ejection fraction, is a disorder predominantly of the aged. I don't know about you, Walter, but I've never seen any lead masters athlete HFpEF. Professor Benjamin Levine: What we've shown is that if you regularly exercise over a lifetime that the heart can preserve its youthful compliance and flexibility. But if you wait until somebody is older, meaning over 65, 70, regardless of how hard or intense we train, the heart seems to lose its plasticity. It can't actually get that much better. But if we start in late middle age, it turns out that you can actually reverse some of the adverse effects of sedentary aging. So we said, "Okay, we know what the dose is, how much exercise you need to do. We know what the sweet spot in time. Now how do we find those people who are most likely to go on to develop HFpEF in whom getting them on a regular exercise program might help forestall this very challenging syndrome." Professor Benjamin Levine: So as part of an AHA-funded strategically focused research network and prevention, we identified a group of patients who had left ventricular hypertrophy, but evidence that they were on the wrong path. Their biomarkers were elevated. They have an elevated NT-BNP or a high sensitivity troponin. We did a right heart catheterization and we looked at their cardiac stiffness using a technique that we've done now for the past 25 years or so, and showed that indeed those patients' hearts are clearly stiffer than healthy, but otherwise sedentary middle-aged individuals. Professor Benjamin Levine: So our key question was what happens if we put them on a long sustained high intensity exercise program? Can we reverse the effects of sedentary aging superimposed with hypertension, left ventricle hypertrophy and elevated biomarkers? Dr. Greg Hundley: Really interesting, Ben. So describe your study design for us. How are you going to set up? It sounds like a very elaborate experimental setup here. Then also, maybe just define for us your study population. Did you have men and women or- Professor Benjamin Levine: Yeah, we started by going to the Dallas Heart Study. We're blessed here in Dallas by having this room access to our remarkable population where we know a lot about them. So we picked people in late middle age of all races, both sexes, and we reached out to the members of the Dallas Heart Study if they had left ventricular hypertrophy by echo or MRI and were of the right age range. We enriched that database by going to an EKG database and looking at the Ecolab database, trying to find people who did not have heart disease already. That was important. They couldn't have had a heart attack. They couldn't have had heart failure. They couldn't have had infiltrative disease. They had to be generally healthy except had left ventricular hypertrophy. Professor Benjamin Levine: We screened a lot of patients to get there, I have to acknowledge that, almost 4,000 of them or so to get the small number who were interested in doing a one-year exercise training program. But as we eventually got a good solid number that because we use such high resolution techniques, we were able to define the key outcome variable, which is cardiac stiffness. Professor Benjamin Levine: Briefly in our lab, we put a right heart catheter in to measure wedge pressure. We use 3D-echo to measure volume and then we use something called lower body negative pressure to unload the heart. It's almost like standing up progressively or tilting upright and then we give them a rapid saline infusion, 200 mls a minute. So a lot of saline, 15 and 30 mls/kg. We can get the left atrial pressure from about three or four up until about 18 to 20 and define the entire physiologic range of left ventricular filling. We look not just at the wedge pressure of course, but the transmural pressure. Professor Benjamin Levine: John Tyberg and his colleagues in Canada have shown clearly that the pericardial pressure is pretty close to right atrial pressure. So transmural pressure, which is the distending pressure of the heart, is left atrial minus right atrial pressure. We use that as the input into a pressure volume relationship. Dr. Greg Hundley: Very nice, and then what did you find? Professor Benjamin Levine: Well, what we found is after demonstrating that these patients with LVH and elevated biomarkers have increased stiffness, what we found quite remarkably actually was that we were able to reverse that by a year of training. Professor Benjamin Levine: Now when I say training, I mean, we do use the optimal approach to training that we've demonstrated in our lab. We didn't just pick one thing, get on a bike, do that for 30 minutes three times a week, right? These were sedentary people so we built them up slowly over about seven months. We added frequency, we added duration, we added intensity. Professor Benjamin Levine: I am enamored by the four by four in old Norwegian ski team workout, which is four minutes at 95% of max followed by three minutes of recovery repeated four times. We added interval training and long slow distance battle lasting about an hour on the weekends and a little bit of strength training, too. Professor Benjamin Levine: So what we consider the ideal prescription for life, four to five days a week, one long session, one high intensity session, two or three moderate intensity sessions and a little bit of strength. We did it for a year. It took a lot of effort. We had dedicated trainers. We gave them all heart rate monitors. Each person had a trainer to follow them. Professor Benjamin Levine: We did have a control group. We randomly assign them to a group that did stretching and yoga and mindfulness and a little bit of strength training, which makes people feel better. But we know from experience, it doesn't make them fitter and doesn't change their cardiac compliance. Dr. Greg Hundley: What happened with the treatment group? Professor Benjamin Levine: Oh, they got much more compliant. They got as compliant as if they had been training most of their lives. It was quite remarkable, actually, frankly, better than we expected it to be. We check the data multiple times by multiple people to make sure that this was a real finding. We really reversed much of the effects of the adverse effects of sedentary aging plus LVH. We hope that if that would be sustained over more than a year, years of long training study, there are very few training studies that go that long. But it's not a lifetime and at least we've set the stage for the concept that if this were to be sustained over a lifetime that we think it could forestall HFpEF. Dr. Greg Hundley: Very nice. Well, Walter, I know serving as a guest editor for us at Circulation and we're most appreciative for you doing that task. What struck you about this particular article and really enticed you to want to help us move it toward publication? Professor Walter Paulus: Well, I felt that the article was very visionary. Of course, as it comes from Ben, I didn't expect anything else. But what struck me were two points. Professor Walter Paulus: First of all, he looks at patients which we would label type B HFpEF. Most of our efforts have always been focusing on sick people, stage C HFpEF, stage D HFpEF. Now Ben was so clever to go to an early stage, and I believe that many of the so-called neutral outcomes in therapy for HFpEF are related to the fact that we actually address patients population who is quite far out on its natural history. So I think this was the first point to me. He, Ben, was addressing a population at the early stages of HFpEF. Professor Walter Paulus: The second point that struck me was that the variable he was looking at is in my opinion the key variable in HFpEF. It's the main reason I appreciated that this is the disease of myocardial compliance of left ventricle stiffness, and then very nicely addressed the stiffness of the heart as its primary outcome. This is something what we miss in all the pharmacological trials. I have always been curious when are we going to see the pharmacological trial whereby somebody is going to evaluate a compound in terms of its effects on left ventricular stiffness on myocardial compliance. Professor Walter Paulus: So these were for me two very salient features and very visionary in terms of treatment of a HFpEF population. Also, a couple of things that need to be clarified for me and I did. The patient's entry criteria were very demanding, has been also already said. I have the feeling that if you have LVH and then you will try NT-proBNP to be elevated and all your required troponins to be elevated, it's probably be very hard to get such a patient population and that may be then the only remark that could come up toward an extent in such a patient population still reflective of everyday health. Dr. Greg Hundley: Very good. Well, Ben, coming back to you, what's your next study? Professor Benjamin Levine: Well, we have a large program project grant, Greg, funded by the NIH, looking at the mechanisms of dyspnea and HFpEF. We're now just entered our third year. We're looking at a strategy to try to lower cardiac filling pressures acutely to see if that improves exercise tolerance and reduce dyspnea. We're looking at peripheral mechanisms of oxygen uptake and utilization and vascular control. We're looking at autonomic function, sympathetic nerve recordings, regulation of the sympathetic nervous system. We have a group focused on pulmonary mechanics, particularly on the effects of obesity. Professor Benjamin Levine: Our team with Tom Sarma is our recruitment core expert and one of the Circulation editors and is really the lifeblood of our study and leads our effort. We have Paul Fidel from UT Arlington who's leading our peripheral function studies, Qi Fu from UT Southwestern leading our autonomic group, and Tony Babb also from Southwestern in the pulmonary division leading our pulmonary mechanics. Professor Benjamin Levine: So we're entering this phase where we're trying to say, "Are there other components?" We know myocardial stiffness is a key factor, but what else in patients with the already manifest HFpEF is causing them to be so short of breath and can we change that? Professor Benjamin Levine: So that's what we're doing next, Greg. I think that if you ask what is the next step from this study, I think it has to be population-based and pushing the concept that exercise is medicine. When you find patients who have hypertension in general, and most of these had hypertension or diabetes, I mean, Walter has led this field and in emphasizing these comorbidities and what they do to the heart and the vasculature and the rest of the body, we have to catch people early. We can't wait until they have full-blown manifest HFpEF. We have to get them to include exercise as part of their personal hygiene. Professor Benjamin Levine: I know that that's a major effort from the American Heart Association. But I think that for the long-term health of our population and preventing this disease that is so difficult to treat when it's firmly established, we have to as cardiologists and as a healthcare system, we have to start by including incentives for reducing healthcare costs to get people to use exercise as part of their personal hygiene and daily life. Dr. Greg Hundley: Very nice. Walter, from your perspective, what do you see are the next studies that need to be performed in this sphere of research? Professor Walter Paulus: Well, I will be very curious to see how many patients would actually go on to develop HFpEF in their life. It should be as if Ben's hypothesis holds, then the control group probably would have an access development of HFpEF compared to his exercise training group. I think that would really extend to study from above, from a mechanical observation to a clinically, epidemiologically more relevant endpoint. So I think that to me would be the first question, how many patients will evolve to clinical HFpEF. Professor Walter Paulus: Second point I would be very intrigued in is, are there SIP groups in the patients who have a positive response to exercise? For instance, what happens with the different ejection fractions? Because we are very intrigued at present in HFpEF that at high ejection fractions nothing seems to work. Sacubitril was notable at high ejection fractions. Empagliflozin was also neutral to ejection fractions. What would happen with exercise? Do the patients who present with the 70% ejection fraction at the angio study, do they still have a positive response? This would be a game change because this would then be the only intervention that is able to cure the HFpEF with high ejection fraction. These are some future projects that come into my mind. Professor Benjamin Levine: Let me just add that we have studied and put patients with HFpEF on a yearlong exercise program with not as much effect as we would like. I think that's one of the things that pushed us to getting earlier into the course of HFpEF, as Walter said earlier. Professor Benjamin Levine: Ambarish Pandey and Jarett Berry, also from UT Southwestern, of course are very interested in this effect of fitness at different points in the lifespan, our fitness test, for example, measured in mid-life and what means for heart failure later. I think it's hard to do the kind of studies that we do and follow patients for 20 years to see if they're going to develop heart failure, and that's where I think being creative and looking at the studies that incorporate an assessment of fitness and that follow people over time will be very informative. I hope with me, Walter's hope and hypothesis that these patients are less likely to develop HFpEF. We've got to get in there early. Dr. Greg Hundley: Very good. Well, listeners, we want to thank Professor Benjamin Levine from UT Southwestern in Dallas and also Dr. Walter Paulus from Amsterdam for bringing us this really interesting study, indicating that in patients with LVH and elevated cardiac biomarkers, sort of the stage B HFpEF that one year of exercise training reduces left ventricular myocardial stiffness. Dr. Greg Hundley: Well, on behalf of Carolyn and myself, I want to wish you a great week and we will catch you next week on the run. This program is copyright of the American Heart Association, 2021. The opinions expressed by speakers in this podcast are their own and not necessarily those of the editors or of the American Heart Association. For more, visit ahajournals.org.  

Chantal Bilodeau tells us about Climate Change Theatre Action (CCTA) 2021. Founded in 2015, CCTA is a worldwide series of readings and performances of short climate change plays presented biennially to coincide with the United Nations COP meetings.  CCTA was originally founded by Elaine Ávila, Chantal Bilodeau, Roberta Levitow, and Caridad Svich following a model pioneered by NoPassport Theatre Alliance. It has since evolved into a U.S.-Canada collaboration between The Arctic Cycle and the Centre for Sustainable Practice in the Arts. Chantal is a playwright and translator originally from Tiohtiá:ke/Montreal, but now based in New York City, the traditional land of the Lenape People. In her capacity as artistic director of The Arctic Cycle, she has been instrumental in getting the theatre and academic communities, as well as audiences in the U.S. and abroad, to engage in climate action through programming that includes live events, talks, publications, workshops, national and international convenings, and a worldwide distributed theatre festival. To tell us about one of the plays is Dr Zoë Svendsen, Lecturer in Drama and Performance in the Faculty of English, University of Cambridge. Dr. Svendson's play comes out of a larger project called Love Letter to a Livable Planet. Through collaboration with members of METIS Arts, Zoe created a short play called Love Out of Ruins, where we get to decide many of the details.  Think of it as a much more sophisticated version of Mad-Libs with the aim to create a vision of the future worth pursuing. The play begins in the present time and moves forward. You get to decide the details that shape the character's world. You can read Love Out of Ruins by Zoë Svendsen at one of your CCL events. In fact, having a group of friends, students, or climate advocates sit and each fill in the lines can be a mind and heart expanding activity.  Then you can share the results at a Climate Change Theatre Action event you host and read some of the plays by the 49 other playwrights from around the world.  Learn more about how you can get your hands on these plays and host your own event. Visit climatechangetheatreaction.com.  The Art House As a podcaster and radio producer, our host, Peterson Toscano listens to many climate change podcasts. Every now and then though he hears a well designed podcast that hits him in the heart and the gut. It becomes a transformative audio experience. This is exactly what happened when he first listened to Claude Schryer's Conscient podcast. As a sound designer, he is able to reach deep into a listener's mind and even our bodies. Sound has that power. Peterson chatted with Claude about his podcast and his own journey as an artist addressing climate change. From that recorded conversation, Claude wove in sound effects and personal reflection.  We encourage you to listen with headphones on.  The conscient podcast / balado conscient is a bilingual series of conversations about arts, conscience and the ecological crisis.You will find it wherever you listen to podcasts.  You can hear standalone versions of The Art House at Artists and Climate Change Good News Report Our good news story this month comes from the US State of Utah. Tom Moyer shares How 25 Republicans in Utah came to endorse carbon fee and dividend.  If you have good news to share, email us radio @ citizensclimate.org We always welcome your thoughts, questions, suggestions, and recommendations for the show. Leave a voice mail at 518.595.9414. (+1 if calling from outside the USA.) You can email your answers to radio @ citizensclimate.org   You can hear Citizens' Climate Radio on iTunes, Spotify, Stitcher Radio, SoundCloud, Podbean, Northern Spirit Radio, Google Play, PlayerFM, and TuneIn Radio. Also, feel free to connect with other listeners, suggest program ideas, and respond to programs in the Citizens' Climate Radio Facebook group or on Twitter at @CitizensCRadio.  

Chantal Bilodeau tells us about Climate Change Theatre Action (CCTA) 2021. Founded in 2015, CCTA is a worldwide series of readings and performances of short climate change plays presented biennially to coincide with the United Nations COP meetings. CCTA was originally founded by Elaine Ávila, Chantal Bilodeau, Roberta Levitow, and Caridad Svich following a model pioneered by NoPassport Theatre Alliance. It has since evolved into a U.S.-Canada collaboration between The Arctic Cycle and the Centre for Sustainable Practice in the Arts. Chantal is a playwright and translator originally from Tiohtiá:ke/Montreal, but now based in New York City, the traditional land of the Lenape People. In her capacity as artistic director of The Arctic Cycle, she has been instrumental in getting the theatre and academic communities, as well as audiences in the U.S. and abroad, to engage in climate action through programming that includes live events, talks, publications, workshops, national and international convenings, and a worldwide distributed theatre festival. To tell us about one of the plays is Dr Zoë Svendsen, Lecturer in Drama and Performance in the Faculty of English, University of Cambridge. Dr. Svendson's play comes out of a larger project called Love Letter to a Livable Planet. Through collaboration with members of METIS Arts, Zoe created a short play called Love Out of Ruins, where we get to decide many of the details. Think of it as a much more sophisticated version of Mad-Libs with the aim to create a vision of the future worth pursuing. The play begins in the present time and moves forward. You get to decide the details that shape the character's world. You can read Love Out of Ruins by Zoë Svendsen at one of your CCL events. In fact, having a group of friends, students, or climate advocates sit and each fill in the lines can be a mind and heart expanding activity. Then you can share the results at a Climate Change Theatre Action event you host and read some of the plays by the 49 other playwrights from around the world. Learn more about how you can get your hands on these plays and host your own event. Visit climatechangetheatreaction.com. As a podcaster and radio producer, our host, Peterson Toscano listens to many climate change podcasts. Every now and then though he hears a well designed podcast that hits him in the heart and the gut. It becomes a transformative audio experience. This is exactly what happened when he first listened to Claude Schryer's Conscient podcast. As a sound designer, he is able to reach deep into a listener's mind and even our bodies. Sound has that power. Peterson chatted with Claude about his podcast and his own journey as an artist addressing climate change. From that recorded conversation, Claude wove in sound effects and personal reflection. We encourage you to listen with headphones on. The conscient podcast / balado conscient is a bilingual series of conversations about arts, conscience and the ecological crisis.You will find it wherever you listen to podcasts. You can hear standalone versions of The Art House at Artists and Climate Change Good News Report Our good news story this month comes from the US State of Utah. Tom Moyer shares How 25 Republicans in Utah came to endorse carbon fee and dividend. If you have good news to share, email us radio @ citizensclimate.org

In this month's EM Quick Hits podcast: Justin Morgenstern on the evidence for NG tubes in SBO, Jesse MacLaren on recognition of hyperacute T-waves vs other causes of tall T-waves, Brit Long on malignant otitis externa clinical pearls, Salim Rezaie on the value of CCTA in NSTEMI, Justin Morgenstern on the value of CCTA in low-risk chest pain, Hans Rosenberg on how to use the Canadian Syncope Score and it's validation in Canada... The post EM Quick Hits 31 NG Tubes in SBO, Hyperacute T-Waves, Malignant Otitis Externa, CCTA in NSTEMI and Low-risk Chest Pain, Canadian Syncope Score appeared first on Emergency Medicine Cases.

Episode 22: Complex Coordinated Attack (CCA)A discussion of Complex Coordinated Attack (CCA), sometimes referred to as Complex Coordinated Terrorist Attack (CCTA).Bill Godfrey:Welcome back everybody to our next podcast. Today's subject, we are going to talk about Complex Coordinated Attack. Now, interestingly, the terminology means a little bit different depending on where you are or who you're talking to. Some people call it CCA, Complex Coordinated Attack. Sometimes it's referred to as CCTA, Complex Coordinated Terrorist Attack. For the purposes of our conversation here today, it's all the same. My name is Bill Godfrey, one of the instructors here at C3 Pathways. I've got with me, Bruce Scott, one of our other instructors. Bruce, say hello.Bruce Scott:HelloBill Godfrey:And Tom Billington.Tom Billington:Hello, how you doing?Bill Godfrey:And Don Tuten.Don Tuten:Good afternoon.Bill Godfrey:All right, so we've got four of our instructors. Actually, this team that's with you today was part of the group that just did our new CCTA for EOC a class a few weeks ago. We've got another delivery coming up in a few weeks, but we wanted to talk a little bit about some of this. So let's start off by talking about our definition of a CCA which is more of a responder's definition, the necessarily like our research definition, and some of the challenges with that.So I'll share this with you, the way we define a CCA is, it's three or more attackers, or two or more sites, or an act of terrorism that overwhelms the local jurisdiction. Now, that sounds pretty loosey goosey on the surface, and we don't disagree with that. But the point is, is that our definition is designed for use by responders. When you're listening to the radio, you're listening to the dispatch, you're listening to what's going on to be able to say, "Huh, that doesn't sound good. That sounds like that could be a CCA." So Don, why don't you talk a little bit about the importance of early recognition, and why that matters? Why we kind of steered away from the research grade definition and went to that instead?Don Tuten:Absolutely. So first and foremost is you're going to be competing for resources, that is the biggest thing, and knowing what type of incidents or incidents are out there, and who is performing these incidents, whether they're terrorists, whether there are foreign terrorists, whether they're homegrown terrorists. To us, the intel is a big piece of it, but ultimately, we have to really gather those resources to be able to manage and take care of each one of those scenes independently as well as collectively, because they may be tied together as you know, Bill. And they're working with our federal partners, working with our local jurisdictions, making sure everybody's on the same page to be prepared, training together, ensuring that we have MOUs with each other, especially, in smaller agencies and smaller jurisdictions, where we're all competing for the same resources and having some type of understanding of who we call, when we call, and how they'll get there in some of our staging areas, that's another piece that we really see is obviously, is where we're going to bring those resources into.Bill Godfrey:Tom, you've got a lot of background in emergency management as does as, well, actually, all of us do quite frankly. But what's your thoughts on the importance, especially on the fire-EMS side of recognizing pretty early on that this is not your usual call?Tom Billington:Well, first of, these events are going to happen at 1:00 in the morning during the week. They're not going to happen 9:00 a.m. on a Monday when everybody's in the office. So it's important that our line personnel, or shift commanders, battalion chiefs, lieutenants, law enforcement, supervisors have a good idea of what a CCA or CCTA is and when to declare that it is happening. So the sooner the better, because obviously, if you have three or four different incidents going on in your county, it's going to be the shift supervisor has to determine, are these things connected, or are they just three separate issues? So that's the main thing, putting the puzzle together. If I have a shooting in one area, a car blows up in another area, and suddenly, I hear about a shooting. Are these connected? Is this a complex attack, or are they just separate incidents? So it's going to be the ground supervisor, the line supervisor to find it out as soon as possible and put the puzzle together.Bill Godfrey:Bruce, what's your take?Bruce Scott:I think the key, Bill, is that early recognition, right? So the definitions that we provide kind of allow us to say, this is abnormal, this is way out of the ordinary, this is a trigger that some things need to happen. And those things may very well be that establish of that area command, that establishment of activation your EOC, the notification of your senior officials. So having those triggers already there and putting them in the back of your head and said, these are not, this is a huge abnormality, and we need to make these triggers happen. Because as Tom alluded to that it takes a long time to start putting these resources together, and so having those definitions early on and allow those triggers to make things happen.Bill Godfrey:Yeah, it's interesting all of you have kind of mentioned now the idea of area command. Let's talk about that a little bit. First of all, let's explain what area command is, and then kind of dig into the dirt a little bit about why we felt like that was such a great tool for addressing CCAs. Bruce, you want to go into the basis of area command, that concept behind it?Bruce Scott:I sure would, because I think it's one of the most misunderstood things in the incident command system and the least trained on, right? So we touch about it. I'll touch a little on it. When we teach I3 or G300 or G400, we talk a little bit about area command, but we really don't practice it. People don't understand it. And the thing is, you can't plant a higher ICS flag and incident command flag in area command. So you put that flag in the ground and say, "You know what? We're in charge. We have jurisdictional authority." And now, we're going to begin coordinating all the efforts if it is multiple sites, if it is multiple shooters, it allows us to begin the coordinating effort at a high level of an incident.Don Tuten:And I tell you, I like to expand on that too, is because you've got to think outside of what our local responses are, you're going to get federal responses, and they need to come to one place, know where to go, especially when you have multiple sites, and then how are you going to divvy those resources out to those sites, and then give them tasks to work with those specific incident commanders at those different sites.Bill Godfrey:Absolutely. Tom, Bruce mentioned planting the flag and putting that in, but when you've got multiple jurisdictions involved which is easy to have happened and accomplish coordinate attack, what does that look like at area command? How do you make that work when your incidents or your attack across a bunch of jurisdictions?Tom Billington:This is something that has to be decided beforehand. We talk about that a lot, medium counterparts, having mutually agreements, having automatic aid agreements. Because if it's a complex coordinated attack, you're right, it could be going over county lines, even state lines in some areas. These are things we need to figure out ahead of time, and there needs to be a statement of jurisdiction, which is kind of hard to get several counties online, but it can be done, deciding ahead of time if it's hits two or three counties. Are we going to work together and do a unified area command? So again, pre-planning with your partners beforehand is important.Bill Godfrey:Yeah, I think the key element there was the idea of a unified area command, which it's not any easier than a regular unified command, which can be fun. You all can't see it but all three of the other instructors are laughing with me. We've always kind of seen that before. So the unified command concept is a great one. It's hard to do if you haven't practiced it or you got a bunch of people that are having to work together that don't know each other. It doesn't mean it can't work, but boy, it's a whole lot easier if you can meet your counterparts and leadership folks from the other agencies and other jurisdictions in training and things like that, just kind of getting that.The other thing I want to touch on an area command before we kind of leave that is a concept and talking about why you want to use it, and I think this tangents into it is, one of the differences between a gathering a bunch of incidents and making them a complex under one incident in area command is that each of the incident commanders at the individual sites retains their incident command authority.That site is their responsibility, and they're making the decisions at the call where area command is setting the priorities, setting the big picture objectives, setting the resources. In other words, Bruce, if you've got an incident, and you've got 10, 12 people that are injured and down, but there's nothing active going on right now, but you're calling for help. And Tom's got an incident going on, and he's got half a dozen or a dozen with a car through the crowd and a problem. But over at Don's place, it's just bad news.There's three or four people with automatic weapons and the killing is ongoing. Well, the three incidents, you guys might not even know about each other's existence or that the incidents are going on but area command is, and they're the ones that have to make the decision to say, "Bruce, Tom, do the best you can with what you got. We'll get you some when we can. But in the meantime, I got to push resources over to Don" on this third incident, so that was one of the things I wanted you guys to talk about.Don Tuten:Well, in staging, an area staging is a big part of that also, is you have to, once again, lean forward thinking if this is going to be an area command is going to take over, managing these two, three, four different incident sites, you have to set up an area staging as soon as possible. Everybody has to be on board to push things out, and I think a good way to practice this, Bill, is on larger, special events that are taken over two or three locations. And even in some of these different communities can practice, each individual parking could be set up as a separate incident command for instance, inside a venue. And that's a smaller way to practice how this is going to work by setting up an area command.Tom Billington:And, Bill, if I can add, we just need to remember that an area command is not an EOC, an emergency operations center, totally two separate items, two separate very important items. At the emergency operation center, usually, I know most jurisdictions takes hours to get stood up. An area command handles the problems that are right now, right here, right now, let's handle it, but we do need to get that EOC set up or multiple EOC set up in various counties.Bill Godfrey:Yeah, absolutely. Bruce, you want to talk a little bit more about that?Bruce Scott:Well, first off, I'd like to say that as you alluded to, Bill, area command has to make those critical resource decisions, right? And the only way you can do that successfully is number one, have pre-established relationships and good communications with your incident commanders, right? You have to be able to explain to them what the overall situation is and understand, "Hey, you just can't. Tom, you're going to have to wait on your resources." So it has to be an understanding and trust that's been developed. And as Tom alluded to earlier, the only way you do that is plan together, train together, exercise together, and continue to do that. Emergency operation centers do take a long time to get set up, and they can help you with those critical resource decision, not necessarily where are you going to allocate those resources but the amount of resources that you can bring into the fight from both your mutual aid partners, your state partners, and your federal partners, and help coordinate that.And one of the things I think that really emergency management brings to the table, if you would, Bill, if you order a hundred police officers, or a hundred fire trucks, and a hundred ambulances, where are they going to stay? Where are they going to eat? Where are they going to go to the restroom? How are they going to get fuel? An emergency management does a lot of that planning in the foreground and probably have logistical staging areas set up and an ability to support those resources as they come in. So I think emergency management and your merchant operation center play a key role in that.Bill Godfrey:Yeah, absolutely they do. They're complementary roles. And I think, Tom put it well. The reason for area command is we don't have time to wait. This is a right now-right now problem. As our friend, Jeff used to always say, "We got to get on it", and that's the role of area command. But the role of the EOC is to almost be shoulder to shoulder with area command and partnering on those resources. Because I think the other thing that people sometimes forget is no matter how good your comm center is, no matter how good that dispatch center is, no matter how well their staff, they are going to get overwhelmed and overloaded. And once you've stripped the resources that are available to them through the CAD system, or through the radio, now they got to go old school, and start picking up phones, and calling agencies, and calling other dispatch centers, and that's slow and tedious.And when they're already overloaded, that's hard to do. But the EOC has mechanisms in place to be able to say it, Bruce, as you said, "I need a hundred cops, and I need them. I need a 500 cops. I need a hundred engines or a hundred ambulances", whatever the case may be. That's a big request order, but they can get that done. Now, as you pointed out rightfully so, there's a lot of responsibility that comes with ordering up that many folks. So that's really kind of interesting. So let's go back and talk a little bit more now that we kind of explained how those pieces fit together. Let's talk about some of the issues that area command needs to focus on versus the individual incident commander at a site.So let's take my example that I just gave you guys. We've got three active sites that are working, and area command is having to split the decisions. Give me some examples of what the incident commander at a site has to worry about versus the area command team or the unified area command that's making the bigger picture resource decisions and things like that.Bruce Scott:Well, I'll tell you. As an on-scene incident commander, I'm only concerned about my incident, right? So if I'm thinking that there's nobody more important in the world than me at that particular incident some time, and I really think that it's the understanding of what the area command mechanism is put in place, that you have that understanding of there are other incidents going on, and then there may be those critical resource of decisions that are being made, they're being made for a good reason. I think that's the understanding of that that has to happen.Don Tuten:Yeah, and I think you put it well. As the incident commander, you're over that one incident, and you may not know, like you said, what the other incidents are until that area command comes in and explains to you, "Listen, you're one piece of the pie. There's three additional horrible and terrible incidents out there. And we have manage those resources coming in because we're all competing for the same thing." We all want it as an incident commander for a specific site, but we're given a hundred percent for that site, but we may not know what Tom's working, or what you're working at another place. In area command, gels all that together, understands what the priorities are, and then ultimately utilizes the resources and the individual strengths to handle the big picture, and what's going on as well as gathering the intel, because you may only have the intelligence of your one specific location and not know how it ties into the other locations.Bruce Scott:Right, and I think that's what Bill is actually alluding to. The intelligence that we're gathering at our incident merge with the intelligence that you're gathering from your incident, be able to put those pieces, big picture together are we see some commonalities.Don Tuten:Absolutely.Bruce Scott:And again, I'm sorry, I didn't mean to interrupt you, if we can start predicting, and get out of a reactive state, and move into a proactive state, and maybe prevent that third or fourth incident from happening because we're doing a good job of gathering intelligence and sharing of information.Bill Godfrey:That's a perfect segue was where I was going to go. Tom, imagine you're the area commander, or you're part of the unified area command team. We've got three incidents. One's at a train station. One's at a plane, an airport, and one's at a bus terminal. What are you thinking is the area command? Each of the incident commanders were up to the weeds. We're in the weeds up to our necks, trying to deal with our individual incidents. What are you starting to think as the area commander? What are the thoughts running through your head? What are some of the community action steps that you might be taking that we would never even think of as incident commanders?Tom Billington:This is where the big hat comes in and being every command. You don't only have to know what's going on now, what's coming next, and do I have resources what's coming next? If I have transportation hubs that are being attacked, do I have another railroad station, another airport they have to consider? Do I want to make sure I pre-positioned resources elsewhere where attacks may happen? What is my intelligence telling me? I need a good area intelligence, as Bruce said, to give of the other three incidents that are going on, to see what commonalities are. So these are the things that Eric Mann has to think about. Yes, I need to support my three incidents that are ongoing. But what is getting ready to happen, when it happens, how am I going to respond to it?Don Tuten:And nationally, I mean, transportation is one of those things that as an area commander, you have to, once again, think about, yeah, not only is the transportation sector in my area where these three events are, but this could be an ongoing national event, and that area commanders starts pushing up to their state and federal resources. We may be one of three or three or four sites of a national attack that's coordinated that we may not know about. So important for that area commander to work well with those federal and state partners and push that information up just like an incident commander would.Bruce Scott:And I think it's also important to note that if local jurisdictions fear that they may be next, your normal way of getting those resources and that help that you thought they're going to hold onto that help. So again, that early recognition, that early cry for help, potentially, we'll get your assistance quicker, because typically, local communities will hold onto their resources and not send them to help anybody else if they think it may happen there.Bill Godfrey:Yeah, exactly. For example, you know, if we have the situation we just described as pretty clearly attack on transportation sector, as the area commander, I might be thinking, okay, what other transportation hubs do we have? Do I need to preemptively, you know, if we've got a commuter rail system, do I need to preemptively put a law enforcement assets at each rail station? Do we need to shut the rail station down? Do we need to shut the bus lines down? Assuming the airport has been closed, how many passengers have I just stranded? And boy, that's going to keep EOC busy, trying to figure out how to house 5,000 people, 2000 of which left their ID, wallets, and cell phones in their purses, and carry on’s, and drop luggage that they ran away from. So there's all of these community... I've never really figured out what the right phrase is. I want to call them like these community reaction phrases.But there's a lot of stuff that the EOC does, but at some point, as Tom said, somebody with the big hats got to make the big, hard decision that is going to involve, shutting down services, tying up a lot of resources. I mean, even if you don't shut down your rail system, let's say you've got a commuter rail system, if you've got a station that's been attacked, at the very least your rail traffic's not running through that station, so now you've got to do a bypass for your hundreds or thousands or you know.Don Tuten:You're affecting the communities where they left from where they're going to next. And everybody in ancillary all the way around, this is going to have to stop a hundred miles, 50 miles short of there, as well as those flights that may be in the air that when this happened, they're now having to be diverted that you're going to have to work with your federal partners, especially when it comes to transportation.Bill Godfrey:So just to kind of recap this, the idea and where we're kind of focused on the training is, again, from the field responders and EOC perspective of not just one incident or though, or it could be a very complex singular incident, again, if it's three or more attackers, or two or more sites, or an act of terrorism that overwhelms a local jurisdiction, we're recommending that you establish an area command. And in some cases, in fact, some of the scenarios that we run in training, we've got the one that's one of my favorite, it's the three attackers at an outdoor mall. And so it's a single site, except it's not because as soon as you start chasing the intel, you realize that there are witnesses telling you that there are potential suspects, at least persons of interest that have fled the area. They fled to the airport, the license plate reader gets a hit on that.Now, we've got to chase these, question mark, are they suspect persons of interest down? There's an airport involved, we've got the crime scene. We're going to start working the ID of these attackers. Now, we're going to have potentially multiple crime scenes. All of that has to get coordinated somewhere. An area command is a great tool. If you get a manhunt, you could have a really, what's a fairly straightforward attack. I can't believe I just said it that way, but you can have an attack that on the surface doesn't ride to a complex coordinated attack. But because you have people that fled the scene or are in the wind, and now you've got a manhunt, that's a great example of when area command can be very helpful, is you managed to coordinate that.So that's why we're kind of suggesting that now. Given that we've been talking about complex coordinated attack in this conversation, we want to wrap it up by talking a little bit about civil unrest, and how those incidents can actually be managed with this same process, the same layered approach of the incident sites. Don, how about you tee this one up for us and kind of talk us through it and we'll take it from there.Don Tuten:Obviously, if anybody's been watching the news for the past 12 months, civil unrest has been a challenge for all agencies, all communities. It's the unfortunate part of our history of America right now. But the biggest thing for law enforcement, for our emergency responders is, as soon as possible, getting that intelligence out. The sooner you get the intelligence on the amount of people, the locations fostered with your pre-planning, that hopefully every community is doing now on what resources they have to combat this along with training, that's the biggest piece of it. I mean, there's so many different facets to civil unrest versus working in the community with the different community groups and trying to tort this versus the radicals that come in that just want to cause havoc in your community. But I think civil unrest unfolds the same as it does for CCA or CCTA.You have to have those established relationships ahead of time. You have to have plans. You have to know who is going to be, who is going to run that area command position. What the communications are? Which liaisons, with all the different agencies that are going to work together? And then obviously, have the common goal of sorting this no matter where it goes. Because as you know, civil unrest, when some of these groups, they're doing the same thing. they're going to two or three different places and locations at one time trying to overrun our emergency services.Bill Godfrey:Yeah, and the scary part is, is that you may think you know what the plan is but sometimes you don't.Don Tuten:Absolutely.Bill Godfrey:Sometimes you don't know where they're headed. You get a protest, you get a fixed protest that isn't supposed to move and then does, or you get a second one that pops up, or you move in to disband the first protest, cleared an un...Don Tuten:Unlawful assembly.Bill Godfrey:... unlawful assembly. Thank you. You declared an unlawful assembly and you break that one up, but in the process, they all just moved to a new location.Don Tuten:Yeah, it so hard for law enforcement because while we want to protect their civil rights, at the same time, these same people unfortunately want to cause havoc for everybody else. So it's such a hard subject for law enforcement. And I know my brothers and sisters in firefighting and emergency management go through the same thing because they're all being taxed. They're all going through the same pains that we all are so.Bruce Scott:Yeah, just real quick, we talk about, if you know these things, don't plan on what you think is going to happen. You need to be planning and thinking what might happen, right? And it allows us to hopefully, put those resources in place. At least the ability to mobilize those resources earlier and faster. A question for you, Bill, if you don't mind me throwing one to you, why do you think that... What's your opinion on the resistance to this whole area command concept? And again, I kind of like you to speak to it from a political or appointed leadership position. Why do you think some, as a first responder be say, "I want to set up area command, and I want to order 500 resources", in anticipation of something that might happen.Bill Godfrey:You know, I think it's a couple things. I think it's two fold. One is the question mark in your mind as the leader as the area commander, who says, "Man, 500 law enforcement officers, can I actually make that decision? Do I have the authority? Am I putting my city or county or region on the hook for half a million dollars? How does this get paid for?" Those can be pretty scary and intimidating things. And so if you don't really know where you stand or you can't just say, "Okay, I'm not necessarily sure what the downstream consequences are going to be, but this is what needs to be done right now, and I'm going to make the best decision I can, and if there's hell to pay afterwards, then there's hell to pay afterwards."So I think part of it is that, it's a little scary for leaders to pull the trigger on some of that, and to say, "We need this much help", or "I think we might need this much help." Because in the mind of a leader, "Okay, I need 500 officers." And they end up in staging, and don't do anything, and we never deploy them because we didn't need them.Don Tuten:It's expensive insurance policy.Bill Godfrey:It sure is. And you know what? You really can be criticized, but I would also say, Don, you mentioned it, if you've been listening to news the last 12 months, you might've heard of these things called field hospitals that have been set up and torn down and set up and torn down all across the country over this last year as we've battled COVID. Not very many of these field hospitals ever saw patient one, and the ones that did see him didn't see very many, and those were very expensive insurance policies.But at the time there were leaders in place that said, "I think this is what we need to do, and we need to move forward and make it happen." So I think part of it is that reluctance to just put it on the line and say, "We're going to do this." The second part, which I don't really think is directly related, but maybe tangentially related is the political implications of it. And I got to admit when I was active duty in the fire service, I was just as bad. I was the poster child of territorialism and this is our district in our zone, in our area, and it was terrible. I cringe when I think back to the way I handled some of those things. And then you get a perspective, of course, after you've retired, left active duty that goes. Well, maybe it wasn't such a good idea to act like jackass, but I think that's a piece of it too.We in the industry, in the first response industry, police, fire, EMS, all of them, there's a competitive spirit, and to a degree, that competitive spirit is healthy and good. But at some point, you got to get over that. You've got to be able to work together. And sometimes the problem is in the field, but my experience has been, that's pretty rare. Most of the time, the problem is in leadership. It's higher up, and sometimes it's not even in the fire department or the police department, it's at the city government level or the county government level. They just don't like each other or can't get along. The best way I've seen to fix that is just training. You do joint training and bring everybody together.Bruce Scott:And relationship building.Bill Godfrey:Absolutely.Don Tuten:That's number one, relationships.Bill Godfrey:Absolutely. So yeah, thanks for putting me on the hot seat, Bruce. I appreciate that. Tom, you got anything you want to throw in here?Tom Billington:I just realize that leadership positions, you're not always going to get the pat on the back. There's going to be times when you go for it on fourth down and you don't make it and you're not going to be very popular. So you have to realize there's going to be good times, bad times. That's why you have to know who you're reporting to, that will they trust your decision tomorrow? What would the Monday morning quarterback issues be? So it's not easy, but you have to do it. Somebody has to step up and lead.Bill Godfrey:You know, I think Tom, you just made me think of something that I didn't say that I think probably needs to be said. As a leader, as a fire chief, or a police chief, or an EMS chief, or even the emergency manager, I think the most important thing that you can do is have a joint sit down with your city manager, county manager, whoever the top bosses you report to, especially if it's a civilian, and sit them down and say, "Look, these are our procedures. These are our processes. This is how this works. This is how this unfolds. These are the things that we're going to do, and this is why."Because if you tell them ahead of time, it's a lot easier. They know what you're doing. They know what to expect. When a reporter shoves a microphone in their face, they know how to answer the question, and give you a little bit of breathing room, and give you the benefit of the doubt. All right. I wonder what comments we're going to get from this podcast.Bruce Scott:That'll be interesting.Bill Godfrey:Yeah, yeah, to say the least. Well gentlemen, any parting words before we wrap up?Tom Billington:No, not at all.Don Tuten:No. Thanks for bringing the, you know, to the forefront that obviously, area command is a big part of all of these things that we talked about and I hope people take it to word, and train for it, and do their best to try to implement it whenever possible.Bruce Scott:And practice it.Tom Billington:And build your relationships with your partners, and your superiors, and make sure everybody knows what you're going to do, so it's not a surprise.Bill Godfrey:Absolutely, and Bruce, I'll echo on to the practice. If somebody tells you that you can't practice this anyways, other than a tabletop bologna, pick up the phone and give us a call, We'll tell you how we do it. It's not a big secret. We're happy to share, and we're happy to help you. If you need help doing it. You can practice live, functional, and even full-scale scenarios for the command and control element of a CCA. We do it every week in the training classes that we provide. Well, ladies and gentlemen, thank you for taking the time with us today. We hope you enjoyed it. If you have any questions or comments, please feel free to email them to us. If you haven't already subscribed to the podcast, please do that until next time stay safe.

CardioNerd Amit Goyal is joined by Dr. Erika Hutt (Cleveland Clinic general cardiology fellow), Dr. Aldo Schenone (Brigham and Women’s advanced cardiovascular imaging fellow), and Dr. Wael Jaber (Cleveland Clinic cardiovascular imaging staff and co-founder of Cardiac Imaging Agora) to discuss nuclear and complimentary multimodality cardiovascular imaging for the evaluation of abnormal coronary anatomy including anomalous coronary arteries and myocardial bridges. Show notes were created by Dr. Hussain Khalid (University of Florida general cardiology fellow and CardioNerds Academy fellow in House Thomas). To learn more about multimodality cardiovascular imaging, check out Cardiac Imaging Agora! Collect free CME/MOC credit just for enjoying this episode!  CardioNerds Multimodality Cardiovascular Imaging PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll Subscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Show Notes & Take Home Pearls Five Take Home Pearls Anomalous coronaries are present in 1-6% of the general population and predominantly involve origins of the right coronary artery (RCA). Anomalous origination of the left coronary artery from the right sinus, although less common, is consistently associated with sudden cardiac death, especially if there is an intramural course. Sudden cardiac death can occur due to several proposed mechanisms: (1) intramural segments pass between the aorta and pulmonary artery making them susceptible to compression as the great vessels dilate during strenuous exercise; (2) an acute angle takeoff of the anomalous coronary can create a “slit-like” ostium making it vulnerable to closure. Anomalous left circumflex arteries are virtually always benign because the path taken behind the great vessels to reach the lateral wall prevents vessel compression.Myocardial bridging (MB) is a congenital anomaly in which a segment of the coronary artery (most commonly, the mid-left anterior descending artery [LAD]) takes an intramuscular course and is “tunneled” under a “bridge” of overlying myocardium. In the vast majority of cases, these are benign. However, a MB >2 mm in depth, >20 mm in length, and a vessel that is totally encased under the myocardium are more likely to be of clinical significance, especially if there is myocardial oxygen supply-demand mismatch such as with tachycardia (reduced diastolic filling time), decreased transmural perfusion gradient (e.g. in myocardial hypertrophy and/or diastolic dysfunction), and endothelial dysfunction resulting in vasospasm.PET offers many benefits over SPECT in functional assessment of MB including the ability to acquire images at peak stress when using dobutamine stress-PET, enhanced spatial resolution, and quantification of absolute myocardial blood flow. For pharmacologic stress in evaluation of MB, we should preferentially use dobutamine over vasodilator stress. Its inotropic and chronotropic effects enhance systolic compression of the vessel, better targeting the pathological mechanisms in pearl 2 above that predispose a MB to being clinically significant.CCTA can help better define the anatomy of MB as well as anomalous origination of the coronary artery from the opposite sinus (ACAOS), help with risk stratification, and assist with surgical planning.Instantaneous wave-free ratio (iFR) measures intracoronary pressure of MB during the diastolic “wave-free” period – the period in the cardiac cycle when microvascular resistance is stable and minimized allowing the highest blood flow. This allows a more accurate assessment of a functionally significant dynamic stenosis than fractional flow reserve (FFR) – which can be falsely normal due to systolic overshooting. Read more hidden text Detailed Show Notes What are some examples of abnormal coronary anatomies and how often do they lead to clinical events?

Episode 19 Back To Training: What's New and What You Can Do NowWe're back with updates, what's new, and how you can get great training now!All:We're back!Bill Godfrey:Hi and welcome back to our next podcast installment. We have been silent for a little while. It's been a while since we've done our last podcast, but that's not because we haven't been ... We've been quite busy. We're not sitting around on our hands. And that's what we're going to talk about today, is just kind of catch you up on everything that's been going on here, and talk about some of the new stuff that's happened and where we're heading with it.Bill Godfrey:Today I have with me three of the other instructors from C3 Pathways; Billy Perry, we have Don Tuten, and Mark Rhame. My name is Bill Godfrey, your host, and today we are going to kind of catch you up on what we're doing. Guys, thanks for taking the time to join us. I appreciate you all being here.Billy Perry:Thanks for having me here.Mark Rhame:Awesome. Thanks for the opportunity.Bill Godfrey:Absolutely. So, been an odd time with COVID.Billy Perry:Definitely been challenging.Bill Godfrey:Yeah. Yeah. No kidding. A little bit for all of us. And I kind of, for us, the way I always describe it ... and you guys have heard me say this ... is I break it into this idea of phase one and phase two. Phase one of COVID, "Eh, we'll hunker down for a month or two. This'll blow over and we'll go back to being normal," and phase two was, "Yeah, that's not going to happen. We need to shift gears and do something different." So let's talk about that.Bill Godfrey:So, since we kind of had our face-to-face training shut down, we've actually got a number of new courses that we've put out, and a whole new training platform. So the first one I'd like to talk about is SSAVEIM. SSAVEIM is our School Safety And Violent Event Incident Management course. And Mark, you were there for the pilot delivery that we did up in the Jacksonville area. Can you talk a little bit about the class and what your experience was?Mark Rhame:Well, I think the amazing thing to me was that it was a class that had a lot of teachers, school administrators, along with a cadre of law enforcement officials and fire and EMS. So what it gave the school principals and teachers the opportunity to see is why we do this. I think that was one of the biggest things I took away from that class, is that they didn't get why we did so much and why we did that particular activity at an event at their school, and when we got done with the class, it pretty much opened their eyes. They said, "Now we understand it. We understand how we're part of this procedure, this policy that you're going to enact if there's unfortunately an active shooter event at our school."Mark Rhame:And it's something that opened my eyes too, because I figured that they had been training on this, they had been talking about the threats and the active events that might happen at their school, the possibility, but I think this class really gave an opportunity for those teachers, those administrators to actually see it in practice, and how they are really an important cog in that whole wheel, if you will. Because without them, we're not going to be successful. We need them to be part of the response, if you will, and making sure that we get these people in a safe environment so we can do our jobs.Bill Godfrey:Yeah, I saw a lot of the same things. There was a lot of the eyes wide open when we got to the ... It wasn't really so much about the process of getting the bad guy ... I think they kind of generally got that that's the priority ... but I think they were a little bit surprised by how much it took to get the injured off of the scene, and I saw a lot of eyes really wide open once we got the bad guys taken care of, the injured are off the scene; now we've got to figure out how to move the kids from the classrooms, doing an offsite reunification. A lot of them thought, "No, we're going to use our own school." Why does that now work out too well, Billy?Billy Perry:Right. It's a crime scene, and there's a lot of things going on there, a lot of moving parts, and yeah, it's just not practical.Don Tuten:And you have an influx of parents trying to get there, you have a lot of traffic issues obviously, you have emergency personnel coming and going nonstop, and it's just ... It's not the way we do business to make things flow and to make it [inaudible 00:04:17] There's a lot of challenges with that that I think, you're correct, it opened their eyes on a lot of things and it had them reevaluate their plans, as well as taking this training and understanding that this is opportunity for them to not only learn something from this class, and how police and fire work, but also how they can tailor their plans to help them better prepare around our tactics and around our procedures and how we make these things go away.Mark Rhame:Yeah, and Bill, I think there was a lot of misconception that they had, as you stated earlier, about ... as Billy said, this is a crime scene. They can't use that school for their reunification purposes, and when we talk about reunification, we can't use them either, because they were involved. They are witnesses. Or maybe we want them to be the ones that stay with their kids so that we can have accountability. So that portion of it, on the reunification side, they just didn't get it. They thought, "Oh, well we're going to be part of the process." Well no, actually you're not. You're part of the initial assault. You're going to be involved in being either the witness, or you're going to be making sure those kids get into a safe environment, because we've got to have accountability. And I don't think they understood it, but I think they did when we walked out of there.Bill Godfrey:Yeah, I thought so too, and of course I don't want us to spend too much time talking about SSAVEIM today, because our next couple of podcasts ... we've got a two-part series coming up with John-Michael Keyes from the I Love U Guys Foundation talking about the SSAVEIM course, which was a partnership with I Love U Guys ... and talking about reunification as well, but ... So I know here in Florida we've been back to school for a while, but across the country, it's kind of all over the place; some are back, some are going back, some are in between, some aren't going back. Do you think we've been pretty lucky, given the tenor and tone of what's going on in the country, that we haven't had any events at schools in this year?Billy Perry:Absolutely.Don Tuten:Yeah. I think that with anything that challenges school or business and everything going on right now, we've lost focus on ... I won't say lost focus; maybe we're not as clear focused because these kids are out of school, for the most part, and I think now is the time for people really to start thinking, "Okay, this is why we train. This is why we do this." And just because the majority of kids may not be in school right now, and as they're coming in, we really need to stay focused on that continuous threat that's out there wanting to harm our kids.Mark Rhame:And I also think there's an enhanced level of stress and depression going on right now.Billy Perry:That's what I was going to say, Mark. I agree.Mark Rhame:You know, from school kids to teachers. I mean, I've got friends who are teachers who say it's not unusual to lose a teacher who just can't take it anymore. They're leaving the profession. And the kids are stressed out. So we've got a new faction of stress and depression and anxiety coming from the COVID environment from this last year that we've been through.Billy Perry:And I will say we've lost focus, but I mean, I think we have. I think we're all on a powder keg. We're sitting on a powder keg with all the things that we were talking about; with the depression, with the cabin fever, with the being isolated, with the can't go to movies, you can't go to bars in certain areas. I mean, I think everybody's really frustrated.Don Tuten:Well, COVID's become the headline unfortunately—Billy Perry:Absolutely!Don Tuten:And not safety of and response of [crosstalk 00:07:34]—Billy Perry:Right. And everything we're doing here, they're perishable skills. They're no different than shooting—Don Tuten:Absolutely.Billy Perry:They're no different than driving, they're no different than life safety. They're perishable skills, and the longer we stay away from them, the more they degrade and erode.Bill Godfrey:Yeah, absolutely.Mark Rhame:And I think it's been put on the back shelf. I mean, frankly this isn't the issue people are talking about right now until it happens again. When it happens again, it'll go to the front of the line.Bill Godfrey:Yeah, and you know, to a degree I kind of understand the put it on the back shelf for a little while, but I think that's why it's important to start talking about it again. Let's not wait to get back to that until a tragedy happens. Let's ... All right, we had to take a pause, we had other things to do. COVID was a really big deal, and it was hard on responders, but let's not forget we've got to ... even if life hasn't gone back to normal, we've got to re-normalize getting back to training and doing that.Billy Perry:I'm a fighter, and I equate it as fighting multiple attackers. You address the immediate danger first, but that doesn't negate the danger that's [crosstalk 00:08:41] address the immediate danger ... COVID ... now let's address the other danger, which is the normal stuff that we have. That hasn't gone away.Bill Godfrey:Yeah. Absolutely. So, let's tangent away. For those of you that are interested in learning more about SSAVEIM, School Safety And Violent Event Incident Management, tune into the next couple of podcast. I think you'll find it a fascinating conversation with John-Michael Keyes, which ironically we actually recorded before COVID really took hold, but they're still very appropriate to take a listen to.Bill Godfrey:So let's talk about our latest training platform that we created for being able to do hands-on training remotely. That was the big topic we were all talking about as instructors. Everything we do involves hands-on training. How in the hell are we going to do that remotely? And the answer was we needed to build our own platform to do it, you just couldn't ... What we need to do, we couldn't do in Zoom or Microsoft Teams, and so we did that as part of this campus project with the National Center for Integrated Emergency Response ... NCIER ... so we've got a NCIER campus now as this tool to be able to put everybody into a training environment.Bill Godfrey:So when you sign in, you literally join into this grand lobby ... which I've got to tell you guys, I'm a little spoiled, but I love those floor-to-ceiling windows that overlook Biscayne Bay and Miami. It's just ... Every time I sign in, it's just so calming.Don Tuten:It's a perfect training environment. It's a perfect training environment that I'll tell you is unreal, and I would encourage everybody to go to YouTube and look at some of the information on NCIER through C3 Pathways. It's a great place to work. It's phenomenal, and the technology is second to none right now.Bill Godfrey:And Billy, I'm going to actually throw this one over to you, because you were one of the very first instructors who I called up and said ... because you lean so heavily into the hands-on training component. And I called up and I kind of pitched this idea to you that was bouncing around in my head before we had started on anything, because I figured your reaction would tell me what I needed to know. Do you want to tell people what you were thinking?Billy Perry:I'm like, "This is beyond challenging." Yeah, I had a more skeptical view. I was the skeptic. Yeah.Bill Godfrey:Well, absolutely. Absolutely.Billy Perry:100%. Because I was afraid that ... because I've seen the Zoom meetings and I've seen that from other agencies and things, and where people log on and leave and go do other stuff and come back and say, "Yeah, that sounds great," and then gone again. Go for a run, whatever. Literally. That's not hyperbole, that literally happens. But you've built things into that. Because I was the skeptic of this.Don Tuten:And this program is so interactive—Billy Perry:It is.Don Tuten:You can't do that.Billy Perry:Right. Right.Don Tuten:This is a video game ... and I hate to use that analogy—Billy Perry:I do too.Don Tuten:Because it's not ... but it's the highest quality that you can have, minus a video game, based around training.Billy Perry:Well, Bill did what I didn't think could be done.Don Tuten:That's amazing.Billy Perry:No, he removed anonymity.Don Tuten:Yeah.Billy Perry:Because in all the other, in the Zooms and everything else, you have anonymity.Don Tuten:Right.Billy Perry:This one you don't have anonymity.Don Tuten:No.Billy Perry:I mean, because when we walk up to you with proximal mics, when we walk up to you and go, "Hey. What are you doing?" and you don't answer, we turn you off. And you come back and you're like, "Oh my gosh, I've been turned off!" Yeah.Mark Rhame:Well, how many of us are going through our careers and we have to get re-certified every single year, every two years, and it's the same old course?Billy Perry:Right.Mark Rhame:You take something on a video. As you said before Billy, you bring it up and then you walk away. Do you really pay attention to it? Maybe you do so you can take the test at the end. But this has everybody involved. Everybody is involved in the scenarios. It's not just a lecture, it's not just a PowerPoint, it literally is involvement in multiple scenarios that reinforces what we just talked about.Don Tuten:It's some of the most realistic training I've seen, without being face-to-face, in anything. And there again, I'm not a gamer, I'm not a videographer on stuff, but I was amazed when I sat down and thought, "Man, I am in this room. I am interacting with this instructor and I'm a thousand miles away."Mark Rhame:And especially for those people who have taken the Asim Advanced. This is a great complement to the Asim Advanced. Because you could actually still get your incident management training in a remote platform. We don't have to band to that. We can keep going [crosstalk 00:13:14]Billy Perry:Plus, these are perishable, and it gives you reps.Don Tuten:Well, and everybody's on the same playing field too, whether you're an emergency manager or a police officer or you're a firefighter. Personally I think this allows people to communicate a little bit better than wearing their stars, bars, and egos on their shoulders. When we're face-to-face and we go through that, now everybody's on the same playing field. You know your job. And I think, Bill, you've built a program here to where we haven't lost the value of that training. Personally I think the communication's a little bit better on this, because everybody's within the close proximity of the rooms that you built.Billy Perry:I think ... and openly and admittedly and laughingly we say I was the biggest skeptic. I don't think it's going to replace face-to-face, but I do think that it is an absolute ... I don't think it's going away, though, after COVID. I think this opens up venues to people that couldn't do the other, and I think this is huge. I think this is an opportunity for training.Billy Perry:All training is not good training. Good training is good training. And this is amazing training.Bill Godfrey:And I certainly appreciate the compliments, but remember, this was a huge team effort. I mean, we—Billy Perry:It was a heavy lift.Bill Godfrey:It was a heavy lift. We did the programming and the coding. For those of you that don't know, C3 has a bunch of programmers and developers that we use because we've been into simulation technology pretty heavy for years. We did the bulk of the programming in 60 days, and then spent another 30 days kind of debugging and fixing things. So a total of 90 days to develop this thing, which was an insane schedule. We kind of all knew that, but everybody knew what we needed to get done. We brought six of the instructors on board to be kind of our anchor instructors and give us feedback. Billy, you saw some of the early versions that were really rough.Billy Perry:We've come a long way.Bill Godfrey:Coming a long way, but I've also got to give a big shout out to [Jay Darren 00:15:03] up in Wisconsin, and [Terry Nichols 00:15:05] out in Texas, who agreed to be the first couple of pilot deliveries on this platform and kind of be the guinea pigs. There were still a lot of bugs in those first couple of classes, but it was amazing because there was still training going on. Even with the challenges, just the attitude of the participants was fantastic, and it allowed us to learn what we needed to learn to get to where we are now, which is a much more stable platform and much more ... So it was a team effort, and shout out to those guys.Bill Godfrey:I think the other piece that bears mentioning is that we're not done building this platform yet. We just added, in the last few weeks, the computer-aided dispatch system for our dispatchers. Many of you know that we've had that capability in the advanced class for the dispatchers, to be used in a CAD system and be dispatching and talking to the units on radio, but we've added that into this capability as well. So in the NCIER campus, we've got not only the breakout rooms where we're actually running the scenarios and doing the downrange tactics and the command post, but we've got a dispatch center and an EOC setup that has the computers that lets them log into CAD.Bill Godfrey:So there's a lot of adventures to come ahead, but let's talk a little bit about the two-day active shooter incident management class. This is our Asim Intermediate class. The certified version is PER352. Many of our listeners are probably aware of the advanced class, the three-day class, which is PER353.Bill Godfrey:So what's your takeaways about what we've had to change? What's the good and the bad with the two-day version versus the three-day? I mean, obviously there's the obvious one ... the three-day advanced class is taught face-to-face and we're not doing that now. In fact, we don't really know when DHS is going to let us start doing face-to-face classes again, but it's going to be a while. So we're doing the intermediate now. But what are your thoughts on it?Don Tuten:I can tell you on my behalf, I think that there's a lot less time learning the system in the two-day class, and how we're delivering it right now. I think the information is there, I think it's ... The information hasn't changed whatsoever, but I think it's less learning on the student on how to manipulate some of the simulations. I think it's easier ... for lack of better terms ... on this platform, it's easier to teach somebody, and the main reason is is because the way that this has been created, it's so user friendly, personally you get a lot better learning objective out of it. I mean, you can still write on the boards, you can still put vests on, you can still ... the proximity talking when you talk and move around.Billy Perry:[crosstalk 00:17:53] talk to each other.Don Tuten:Exactly, talk to each other. You have a radio still, with seven channels, that you can go to different channels. You got staging, you ... For me, it's less moving parts from the face-to-face, which there's pros and cons to that; because we like having, when we do the longer class, people actually being able to move around, but I think under these conditions, this is one of the best ... personally, I just think it's the best of two worlds, of not having anything versus face-to-face and having three days and how do we put that information into two days? I don't know, I encourage everybody to go, once again, on YouTube and look at some of the different trailers for this, and you judge for yourself. You judge for yourself.Billy Perry:My biggest positive for me is accessibility. I think that more people can get to it because you don't have to travel, you don't have to fly to somewhere, you don't have to be boarded, you don't have to pay for a per diem, you don't have to do all that. You can do it right there. And I think it's more accessible for somebody from, especially a small financially strapped department, especially these ... That's just me.Mark Rhame:I'm going to step away from the technology side and say that it's a great introduction and usage of the check list. That's one of the things, a stumble block when we get into the Asim Advanced. We go through that first day generally, and you're looking at people and they're still kind of lost. They're going, "How does this system work?" Day two, they get it, they're starting to run with it, and by day three you can almost not even coach them. You can let them go because they get it.Mark Rhame:And this platform does the same thing in a two-day process. We introduce that checklist, the validated checklist that they can utilize in their own department if they choose to do so, and it does it in a two-day period, allowing us to step up scenarios in a two-day period from the very basic in the very beginning all the way down to a complex coordinated attack at the very end. And again, in a two-day period in a remote training platform. So it works.Bill Godfrey:Yeah. Interesting. You know, one of the most telling things to me was the breaks. And I don't know about you guys, but my ability on Zoom and the other platforms is about, honestly, 15 to 20 minutes and then I'm drifting. It's hard to focus past that.Billy Perry:That's on a good day.Bill Godfrey:Yeah, that's very true. And we thought that was going to be the same here. In fact, the very first delivery we did, we scheduled in very, very frequent breaks and some of the feedback we got almost immediately is like, "Hey, can we skip that? We don't need a break. We're good to go. Let's just keep pushing." And we've seen, with comfort, with student comfort and positive student feedback, 45, 50, 60-minute sessions. We had one the other day we did for the City of Baltimore on their final kind of mack daddy scenario. The scenario ran a solid hour, the debrief ran probably 30 minutes, and everybody just wanted to go right through it. They were like, "No, we get it. We want to talk about it. Let's just move through it."Mark Rhame:Well, I can see it also in the PowerPoint presentation. When you're talking to this group of ... and it's avatars, it's their avatars out there in the audience. When you ask them a question and say, "Hey, does anyone experience this? Jump up and down if you do," and you're seeing the whole room of people jumping up and down, and you can walk up close to them and said, "Lieutenant Jones, tell us about how your department does this." And that person has the ability in a remote training platform to tell an experience of their own department and what they've been through, how it applies to what we're talking about at that point in time. And you're not going to get that in another remote training platform. This one is totally different.Don Tuten:No, and I think this sets people up for that advanced training also once they go through this, because in the advanced, they've had the opportunity to go through how some of this stuff works and then how we communicate, and it's a little bit easier communicating over the computer versus some of the communication challenges that we have in person.Don Tuten:But by that three-day course, building in the PIO piece that's a little bit more robust, and having to write the information for the PIO, having to get the emergency manager to actually go get the information or have a liaison give them the information, and doing that on scene. So it's not a negative, it's the positive negative, for lack of better terms. When you go to that three-day course is ... Now you have the baseline of the two-day course. Move into the three-day course. Now you're getting a little bit more of the complexity of actually having to communicate back and forth.Don Tuten:I don't know, I think this is an easier way to communicate. I think maybe that some of the time restraints that maybe the three-day takes is people getting used to the communication piece. But I think that's good training as well, because that's realistic.Bill Godfrey:It is real world.Don Tuten:Absolutely.Bill Godfrey:There are communication problems on real-world events.Don Tuten:On everything, right.Mark Rhame:In fact, I would say even more so. This sort of mirrors that.Bill Godfrey:Yep. Absolutely. So, the other thing I want to talk about before we wrap up today is the other new class that we've come out with during this period that we've put onto the NCIER platform, is our CCTA class for EOC. So this is a complex coordinated terrorist attack class for EOC. Who wants to describe it? I mean, I know you were all there teaching that first delivery he did.Mark Rhame:Well, it's applying what we do in our Asim class, and we bring in the emergency managers in the community, the people who work in those ... And it sounds insulting when I say support roles, because it frankly is not. They're in leadership roles and they're in their own communities. But bringing in that next phase of our response and our emergency management response.Mark Rhame:Now, I have to tell you that not every community is the same. We've taught in some classes where the emergency management, when they stand up their EOC, they frankly become a level of in charge, if you will; part of that incident command structure. And then you have some other communities that when they stand at their emergency operation center, they become more of a support role; assisting the incident commander, the law enforcement officers, and the fire and EMS personnel responding to this environment.Mark Rhame:So we have to adapt to those classes of those people we're talking to, but it really does allow the emergency managers to show what they have to offer in their community. Because a lot of times we talk about it ... You know, you talk about to an incident commander ... whether it's law enforcement or a firefighter or an EMS personnel ... about what they do when they stand up their incident command structure, but do they really get engaged about that support roles; the other pieces and parts in their community that are going to make them successful? And that's what emergency management's going to do for you.Don Tuten:I think the biggest thing for the first responders is they get to interact with the emergency managers where a lot of times they're not face-to-face, they're passing up information and the education that those first responders are getting on exactly what these emergency managers do. And then conversely, the information that the emergency managers get on the challenges that law enforcement and firefighters go through in, one, handling the challenge that is out there for them to do; two, passing up the information; and then three, closing that loop between all of them. And I think, I don't know, personally I wish I would've had this class 20 years ago just to know that this is what emergency managers do, this is what they can bring to the table, and this is where my information is going to ultimately in a complex coordinated attack.Billy Perry:Right. It illuminates the fact that there are challenges, A, and B, here are the solutions to the challenges. I think that's the big thing. And that's one of the things about all of this that we've been talking about. These aren't procedures, they're not plans, they're not tactics, they are solutions.Don Tuten:Yeah. And I'll tell you, you bring up a good point, because there's a lot of things that first responders ... We will do the job that we're asked to do, but we forget about the fact that, listen, these emergency managers are worried about, "Where am I going to put these people, and what resources do I have to call?" And it's good for the first responders to see some of those challenges so they can be forward-thinking and forward-leaning after taking this class and knowing some of those challenges that are going to be coming up, whether it be—Billy Perry:It's the same thing as the educators in SSAVEIM.Don Tuten:Absolutely.Mark Rhame:And the emergency managers also see the value of crossing jurisdictional lines and asking for additional assets and resources, whereas a line firefighter, EMS personnel, or law enforcement officer probably doesn't see that. They don't see the big picture of where does this stuff come from, and who asked for it. Who's paying for it, frankly, because there's a lot of things that are happening in the background that they don't see, and this class allows them to see that, "Oh, that's how that happens. That's how we get those assets from the local community next to me," or maybe the state assets or the federal assets. And that's what your emergency managers have the capability of doing for you.Don Tuten:And the contacts. And the contacts they have prior to an incident happening on—Billy Perry:All the contracts they have.Don Tuten:Exactly. Buses and, I mean just, it's amazing.Bill Godfrey:Well, and I'll be the first to say it; we learned a lot of lessons on that very first delivery for some things that we needed to adjust to hit the bullseye a little bit better. We needed some additional facilities within the NCIER campus, we just didn't have some of the tools that we needed and some of the support material that I wanted to have to keep the scenarios flowing and involve the emergency managers a little bit better. And so those adjustments, we've already made some of them. We've got some pretty massive expansion that's planned for the campus; a whole new EOC add-on that's going to be coming in the very near future that I think is going to be pretty exciting.Bill Godfrey:So, this about wraps up our time. Gentlemen, thank you very much for taking the time to be with us today. I hope you enjoyed it. Please don't forget to tune in to the next couple of podcasts with myself and John-Michael Keyes from the I Love U Guys Foundation, talking about our partnership and reunification and the SSAVEIM course. And also don't forget to subscribe. We are back on our stride. We're going to be pushing out the podcasts regularly. Our goal is to get up to a one-a-week schedule. If you're interested in getting into the Asim Intermediate class, those classes are funded by DHS, so they're no cost to the participants. So if you're an emergency responder out there in the US, it is no cost to you to be in this class.Bill Godfrey:There is a little bit of a process to go through, but you can certainly reach out and contact us. We have classes that are ... I cannot believe how much the schedule has filled up. We've got classes going on every week. In a couple cases, we've got two or three classes happening a week, so there is a lot of activity going on. But please, by all means, feel free to reach out to us. Either give us a call at the office or send us an email through the website.Bill Godfrey:And special thanks to our partners, our training partners, both at [Alert Antiques 00:29:03] and the NDPC at FEMA DHA for providing that support and that funding, and encouraging us to build this platform. I think there were a lot of people upstream of me, Billy, when we've hatched some plans that had the very very similar reaction to you and they weren't really sure we could pull it off, but I'm excited to be where we are.Bill Godfrey:So come along with us for the ride, and if you haven't subscribed to the podcast series, please do that. In the meantime, stay safe and we'll talk to you next time.

Merhabalar, Bugünkü yazımızda ESC’nin (Avrupa Kardiyoloji Cemiyeti) acil hekimlerini yakından ilgilendiren NSTEMI (ST segment yükselmesi olmayan miyokardiyal infarktüs) kılavuzundaki yenilikleri sizlerle paylaşacağız. Akut yönetim sonrası idame tedavi, yaşam tarzı önerileri ve geç komplikasyon yönetimi gibi konular yazıya dahil edilmemiştir. iyi okumalar dilerim NSTEMI ESC 2020 kılavuzunun tamamına buradan ulaşabilirsiniz. GENİŞ ÖZET NSE-AKS hastalarında miyokard düzeyindeki patoloji, troponin salınması ile ölçülebilen kardiyomiyosit nekrozu, veya daha seyrek olarak hücre hasarı olmaksızın miyokardiyal iskemidir (anstabil anjina). Genel olarak, anstabil anjinalı kişilerde ölüm riski belirgin olarak daha düşüktür ve agresif farmakolojik ve girişimsel yaklaşımdan daha az fayda görürler.Benzer maliyetle daha yüksek tanısal doğruluk sağladıklarından, daha düşük duyarlılıklı kitlere nazaran, yüksek duyarlılıklı troponin (hs-Tn) kitleri ile ölçüm önerilir. Miyokard infarktı dışında birçok kardiyak patoloji de kardiyomiyozit hasarına neden olarak kardiyak troponin (cTn) artışıyla sonuçlanır.Diğer biyomarkerlar, bazı klinik durumlarda yüksek duyarlılıklı olmayan kardiyak troponin T ve I (non-hs-cTn T/I) ile kombine olarak kullanılarak klinik uygunluk yakalanabilir. MI sonrası CK-MB daha hızlı bir düşüş gösterir ve erken re-infarktın saptanmasında ek fayda sağlayabilir. MI’ın erken dışlanmasında ek biyomarker olarak copeptinlerin rutin kullanımları, hs-cTn kitlerinin mevcut olmadığı, çok nadir durumlarda önerilir.Başvuru anında MI tespitinde daha yüksek duyarlılık ve tanısal doğruluğa sahip olmalarından ötürü, hs-cTn kitlerinin kullanımı ile ikinci cTn çalışılma süre aralığı kısaltılabilir. 0 saat/1 saat (en iyi seçenek) veya 0 saat/2 saat (en iyi ikinci seçenek) algoritmalarının kullanılması önerilir. Klinik ve EKG buluguları ile birlikte değerlendirildiğinde, 0 saat/1 saat ve 0 saat/2 saat algoritmaları erken taburculuk ve ayaktan tedavi hastalarının saptanmasına olanak verir.Hs-cTn konsantrasyonun belirgin olarak etkileyen 4 değişken yaş (sağlıklı genç ve sağlıklı yaşlılarda %300’e varan değişkenlik), böbrek yetmezliği (çok yüksek ve çok düşük GFR’li hastalarda %300’e varan değişkenlik), göğüs ağrısı başlangıcı (>%300) ve cinsiyetir (yaklaşık %40).İlk cTn düzeyleri kısa ve uzun dönem mortalite için prognostik bilgi verir. Hs-cTn düzeyleri ne kadar yüksekse ölüm riski de o kadar fazladır. NSTE-AKS’li hastalarda, prognozu etkileyeceğinden ve GRACE risk skorunun bileşenlerinden olduğundan dolayı serum kreatinin ve eGFR düzeyleri de bakılmalıdır. Ek olarak, natriüretik peptidler de değişen düzeyde prognostik bilgi sağlayabilir.Yüksek Kanama Riski için Akademik Araştırma Birliği (ARC-HBR) yaklaşımı, ikili antiplatelet tedavi (DAPT) süresi ve yoğunluğu ile ilgili klinik çalışmalardan çıkartılmış olan yüksek kanama riskli hastalar üzerinde yapılmış en yakın zamanlı çalışmaları kapsayarak kanama riski değerlendirmesi için pragmatik bir yaklaşım sunar. DAPT süresi ile ilgili kılavuz olarak PRECISE-DAPT skoru kullanılabilir. Major kanama için prediktif değeri yüksek olmakla birlikte, hasta sonlanımlarını iyileştirmedeki değeri belirsizdir.MI tanısı dışlandıktan sonra dahi klinik değerlendirmede elektif noninvaziv ve invaziv görüntüleme gerekebilir. Düşük ve orta klinik olasılıklı anstabil anjinalarda normal tarama koroner arter hastalığını dışlayacağından, kardiyak bilgisayarlı tomografi anjiografi (CCTA) bir seçenek olabilir. CCTA’nın AKS’yi dışlamada prediktif değeri yüksektir ve AKS için düşük-orta pretest olasılığı olan ve CCTA’sı normal olan hastalarda sonlanımı çok başarılı bir şekilde öngörebilir. Stres kardiyak manyetik rezonans görüntüleme (CMR), stres ekokardiyografi ve nükleer görüntüleme de risk değerlendirmesine bağlı olarak birer seçenek olabilir.Hs-cTn düzeyleri, GRACE risk skorunun >140 olması, yeni veya yeni olduğu düşünülen dinamik ST segment değişikliklerinin olduğu NSTEMI’de başvurunun ilk 24 saatinde er...

Merhabalar, Bugünkü yazımızda ESC’nin (Avrupa Kardiyoloji Cemiyeti) acil hekimlerini yakından ilgilendiren NSTEMI (ST segment yükselmesi olmayan miyokardiyal infarktüs) kılavuzundaki yenilikleri sizlerle paylaşacağız. Akut yönetim sonrası idame tedavi, yaşam tarzı önerileri ve geç komplikasyon yönetimi gibi konular yazıya dahil edilmemiştir. iyi okumalar dilerim NSTEMI ESC 2020 kılavuzunun tamamına buradan ulaşabilirsiniz. GENİŞ ÖZET NSE-AKS hastalarında miyokard düzeyindeki patoloji, troponin salınması ile ölçülebilen kardiyomiyosit nekrozu, veya daha seyrek olarak hücre hasarı olmaksızın miyokardiyal iskemidir (anstabil anjina). Genel olarak, anstabil anjinalı kişilerde ölüm riski belirgin olarak daha düşüktür ve agresif farmakolojik ve girişimsel yaklaşımdan daha az fayda görürler.Benzer maliyetle daha yüksek tanısal doğruluk sağladıklarından, daha düşük duyarlılıklı kitlere nazaran, yüksek duyarlılıklı troponin (hs-Tn) kitleri ile ölçüm önerilir. Miyokard infarktı dışında birçok kardiyak patoloji de kardiyomiyozit hasarına neden olarak kardiyak troponin (cTn) artışıyla sonuçlanır.Diğer biyomarkerlar, bazı klinik durumlarda yüksek duyarlılıklı olmayan kardiyak troponin T ve I (non-hs-cTn T/I) ile kombine olarak kullanılarak klinik uygunluk yakalanabilir. MI sonrası CK-MB daha hızlı bir düşüş gösterir ve erken re-infarktın saptanmasında ek fayda sağlayabilir. MI’ın erken dışlanmasında ek biyomarker olarak copeptinlerin rutin kullanımları, hs-cTn kitlerinin mevcut olmadığı, çok nadir durumlarda önerilir.Başvuru anında MI tespitinde daha yüksek duyarlılık ve tanısal doğruluğa sahip olmalarından ötürü, hs-cTn kitlerinin kullanımı ile ikinci cTn çalışılma süre aralığı kısaltılabilir. 0 saat/1 saat (en iyi seçenek) veya 0 saat/2 saat (en iyi ikinci seçenek) algoritmalarının kullanılması önerilir. Klinik ve EKG buluguları ile birlikte değerlendirildiğinde, 0 saat/1 saat ve 0 saat/2 saat algoritmaları erken taburculuk ve ayaktan tedavi hastalarının saptanmasına olanak verir.Hs-cTn konsantrasyonun belirgin olarak etkileyen 4 değişken yaş (sağlıklı genç ve sağlıklı yaşlılarda %300’e varan değişkenlik), böbrek yetmezliği (çok yüksek ve çok düşük GFR’li hastalarda %300’e varan değişkenlik), göğüs ağrısı başlangıcı (>%300) ve cinsiyetir (yaklaşık %40).İlk cTn düzeyleri kısa ve uzun dönem mortalite için prognostik bilgi verir. Hs-cTn düzeyleri ne kadar yüksekse ölüm riski de o kadar fazladır. NSTE-AKS’li hastalarda, prognozu etkileyeceğinden ve GRACE risk skorunun bileşenlerinden olduğundan dolayı serum kreatinin ve eGFR düzeyleri de bakılmalıdır. Ek olarak, natriüretik peptidler de değişen düzeyde prognostik bilgi sağlayabilir.Yüksek Kanama Riski için Akademik Araştırma Birliği (ARC-HBR) yaklaşımı, ikili antiplatelet tedavi (DAPT) süresi ve yoğunluğu ile ilgili klinik çalışmalardan çıkartılmış olan yüksek kanama riskli hastalar üzerinde yapılmış en yakın zamanlı çalışmaları kapsayarak kanama riski değerlendirmesi için pragmatik bir yaklaşım sunar. DAPT süresi ile ilgili kılavuz olarak PRECISE-DAPT skoru kullanılabilir. Major kanama için prediktif değeri yüksek olmakla birlikte, hasta sonlanımlarını iyileştirmedeki değeri belirsizdir.MI tanısı dışlandıktan sonra dahi klinik değerlendirmede elektif noninvaziv ve invaziv görüntüleme gerekebilir. Düşük ve orta klinik olasılıklı anstabil anjinalarda normal tarama koroner arter hastalığını dışlayacağından, kardiyak bilgisayarlı tomografi anjiografi (CCTA) bir seçenek olabilir. CCTA’nın AKS’yi dışlamada prediktif değeri yüksektir ve AKS için düşük-orta pretest olasılığı olan ve CCTA’sı normal olan hastalarda sonlanımı çok başarılı bir şekilde öngörebilir. Stres kardiyak manyetik rezonans görüntüleme (CMR), stres ekokardiyografi ve nükleer görüntüleme de risk değerlendirmesine bağlı olarak birer seçenek olabilir.Hs-cTn düzeyleri, GRACE risk skorunun >140 olması, yeni veya yeni olduğu düşünülen dinamik ST segment değişikliklerinin olduğu NSTEMI’de başvurunun ilk 24 saatinde er...

Lucky Number 7! This episode is amazing and features some fabulous theatrical arts teachers who are not just doing fabulous performing, they're sharing their talents with so many young people! I know that you want to find out what Alex and Lisa discovered: - Gerald, as Education and Programs Director for Columbia Center for Theatrical Arts, does amazing performing arts programs for youth that transform and inspire - Brynn is a fabulous Broadway performer with a Pittsburgh connection that you won't believe (there's a hint in the picture) - Both of them are wonderful with youth in the virtual Theatrical Arts Summer Camp! Gerald Jordan Education & Programs Director Gerald is a Maryland native who attended both Hofstra University and the University of Maryland, Baltimore County. He has been an integral part of CCTA since 2013. Originally, he came to us as an instructor and now works as our Programs and Education Director. He works especially hard to build our Baltimore Outreach Program, and even performs as the lead in our Baltimore Residency Program as Jackie Robinson in Most Valuable Player: The Jackie Robinson Story. From his own personal experience, he knows how much of a difference the arts can make in someone’s life, and he works diligently to provide the best experience for everyone within our programs. Brynn Williams Professional Actor Brynn Williams is a Maryland-raised, self-proclaimed theatre geek with a passion for storytelling. An entertainer from birth, Brynn started performing professionally at 6-years-old, and by twelve made her Broadway debut. She currently has of a total of 6 Broadway shows and a first national tour under her belt. Her favorite credits include—but are not limited to— SpongeBob SquarePants (Sandy/Pearl understudy), Bye Bye Birdie (Ursula Merkle), and 13 The Musical (Cassie) where she can be heard throughout the cast album and featured in the song “Brand New You.” In addition to an impressive performance resume Brynn also boasts over 10 years of experience in the educational field teaching, coaching, and directing performers of all ages. When not onstage, Brynn is passionate about taking her first-hand experience in this ever-evolving industry and passing it along to the next generation of rising storytellers. https://cctarts.org/ https://mdtheatreguide.com/.../theatre-news-brynn.../ --- Send in a voice message: https://anchor.fm/applausethepodcast/message

Commentary by Dr. Valentin Fuster

Join Kavitha Chinnaiyan, MD, FSCCT as she takes a deep dive into three featured articles in the May – June 2020 issue of the Journal of Cardiovascular Computed Tomography (JCCT). Dr. Chinnaiyan will chat with JCCT Editor in Chief, Todd Villines, MD, MSCCT, Joao Cavalcante, MD, FSCCT, Jeroen Bax, MD and Vincenzo Vingiani, MD, FSCCT.This episode will explore:Baseline global longitudinal strain by computed tomography is associated with post transcatheter aortic valve replacement outcomes Coronary atherosclerosis scoring with semiquantitative CCTA risk scores for prediction of major adverse cardiac events: Propensity score-based analysis of diabetic and non-diabetic patients Low-kV coronary artery calcium scoring with tin filtration using a kV-independent reconstruction algorithm Support the show (https://scct.org/donations/donate.asp?id=18823)Support the show (https://scct.org/donations/donate.asp?id=18823)

Show Notes   Please click here and take our listener survey Emergency Department management of Non-St Segment Elevation Myocardial Infarction, by Drs Julianna Jung and Sharon Bord. Chest pain is the second most common complaint Over 6.4 million visits to US EDs annually include chest pain. 25% will be diagnosed with ACS 1/3 will have STEMI, 2/3 NSTEMI. Guidelines reviewed include those from: AHA/ACC ACEP European Society of Cardiology In addition to reviewing the primary literature each of them used as a basis for their recommendations.   Show More v Please click here and take our listener survey Part 1: Definitions Myocardial Infarction: elevated cardiac biomarkers (aka troponin) with clinical evidence of acute myocardial ischemia (aka signs and symptoms, ECG changes, abnormal imaging, or coronary thrombosis at cath or autopsy). Myocardial injury, unfortunately also can be abbreviated as MI, but not in our discussion. This term refers solely to cases where biomarker elevation is present without any other clinical evidence for ischemia. STEMI definition from the European Society of cardiology: ST elevation >1mm in two or more contiguous leads other than V2-V3 ST elevation in V2-V3 > 2.5mm in med < 40 yrs old >2 mm in men > 40 yrs old >1.5mm in woman, regardless of age. MACE= Major Adverse Cardiovascular Event: including re-infarction, stroke, dysrhythmia, heart failure, cardiogenic shock, and death. Part 2 : Why do we care? In-hospital mortality rates are about the same for STEMI and NSTEMI, about 10%. 1-year fatality rate in NSTEMI is more than double that of STEMI, at about 25% Part 3: Pathophysiology Type 1 MI (Infarction) is caused by atherosclerotic plaque rupture. Type 2 MI is the "mismatch" due to an imbalance in myocardial oxygen supply and demand. This can be the result of hypotension, tachycardia, sepsis, PE, etc. Part 4: Pre-hospital care Prehospital ECGs decrease time to intervention. (PCI) in STEMI Early administration of aspirin decreases mortality and complications of MI (all types). (19), and is safe in the pre-hospital setting (20) - only 45% of get it during EMS transport, so room for improvement here (21) Part 5: ED evaluation: Some of the interesting highlights History Diaphoresis Vomiting Radiation of pain to both arms or shoulders Radiation of pain to right shoulder Although teaching has been that women have atypical presentations, a 2016 study did not support it. However, it did find that elderly patients and those with diabetes may present atypically. (dyspnea, fatigue, nausea, or epigastric pain) Past Medical History Family and personal history of CAD Other medical diagnoses Tobacco use Illicit substance abuse Age (CAD prevalence in age80 is 25%) ** HIV - find citing 8. Grunfeld C, Delaney JA, Wanke C, et al. Preclinical atherosclerosis due to HIV infection: carotid intima-medial thickness measurements from the FRAM study. AIDS (London, England). 2009;23(14):1841–9. [PMC free article] [PubMed] [Google Scholar] 9. Holloway CJ, Ntusi N, Suttie J, et al. Comprehensive cardiac magnetic resonance imaging and spectroscopy reveal a high burden of myocardial disease in HIV patients. Circulation. 2013;128(8):814–22. [PubMed] [Google Scholar] ** Cancer with hx of radiation to the chest Exam Neurological neurologic deficit may point to aortic dissection Friction rub may be heard New murmur associated with papillary muscle rupture. Diagnostics Telemetry ECG. Patterns to know… Troponin... you should get it Scoring systems Heart Score Grace TIMI Imaging in the ED CXR CT angiography, CT PE, CCTA Echocardiography - POC or formal Part 6: Medications Oxygen (if sat

Randy Iwasaki, Executive Director of Contra Costa Transportation Authority (CCTA), is the newest GRIDSMART Hall of Fame-er and we’re very excited to have him with us on our first special INTERSECT19 edition of POLICYSMART!   Everyone knows that Bay Area traffic is heavy—it’s a popular place to live, after all. The good thing is that the Bay Area also happens to be one of America’s most innovative places, if not THE most innovative. That being said, what is CCTA doing to innovate in transportation?   CCTA was recently awarded a $7.5 million grant from USDOT. They’re using it to work on three cool demos as a part of a four-year Automated Driving System (ADS) pilot program. Randy talks about these demos with us. Tune in to find out more about these AV, CAV, SAV (and more!) initiatives.   LINKS: Randy Iwasaki Contra Costa Transportation Authority News release: Contra Costa Transportation Authority Wins $7.5 Million USDOT Grant for Automated Driving Systems Pilot Program INTERSECT19 conference

The Role of CCTA in the Evaluation of Chest Pain in the ED by UC Department of Emergency Medicine

Three Important Leadership Lessons from Randy Iwasaki: As a leader, know when to step back and rather than do everything, motivate your team to do things in innovative ways. (4:18) As a leader, be willing to take risks. (17:50) Take time out of your day to think about and look towards the future. (29:30) This episode features an audio interview between host Sue Dyer and guest Randy Iwasaki, Executive Director of the Contra Costa Transportation Authority. Before coming to CCTA in 2010, he was the Director of the Department of Transportation in California (CalTrans). He is a licensed civil engineer who has won several awards and is one of the leaders in the world on autonomous vehicles. Subscribe to Construction Dream Team The following show notes are a transcription from the Construction Dream Team Podcast episode 13 audio interview between Sue and Randy. Please subscribe to Construction Dream Team for the latest episodes on our website, iTunes or Stitcher! We would LOVE a 5-star rating to help us show up in the search engines so more of Construction Nation can listen to industry leaders and experts on their computers, phones, or tablets! Randy's Leadership Journey Randy was hired by CalTrans in the early ’80s as an entry level civil engineer after college. He left 27 years later as the director of the department. His time spent at CalTrans helped prepare him for success as Executive Director of Contra Costa Transportation Authority. Strengths As A Leader At CCTA, they employ great people by spending a lot of time in the hiring process. They look for people with the entrepreneurial spirit, who are able to deal with change and risk-taking. Randy thinks his greatest strength in his current role is that he is a good motivator; he sets standards for employees on how to make decisions that will make the company better partners providing exceptional customer service. Another strength is the very diverse group of people that they have employed who provide many different perspectives. Randy sets the end goal, but the employees ultimately decide how to get there. At CCTA, there are about 20 employees that manage multi-million dollar projects and programs. The greatest strengths of Randy and CCTA are the people and motivation. These strengths help create an environment and culture of innovation. In particular, the leader needs to be able to lead more with motivation rather than by trying to do everything themselves. It is important for leaders to step back and let go, allowing members of the team to figure out how to do business in different ways (it doesn’t always have to be done the way the leader has done it). Importance of Vision You need to be able to articulate to your team what the vision of the company is in order to lead them on the right path. The vision of CCTA is to be the best transportation agency and the team really believes in this vision which improves performance and opens up the conversation about change. They spend a lot of time making sure their team understands the vision and where they are headed as an agency. Leadership Pitfalls to Avoid The main issue with leaders is when they aren’t willing to take risks. If you aren’t willing to take risks, you probably have issues with motivating employees. Employees look up to leaders for guidance, so if their leader doesn’t take risks, the employee will probably not feel as confident in taking risks. Leaders should try to lead by example, which will motivate employees to be better and want to be more like their leader which can end in a better future.  Advice to Live By One of the best pieces of advice Randy had gotten was from his boss, and the advice was basically to think, use your brain, delegate tasks to the team, and look towards the future. Listener Resources Randy suggests that Construction Dream Team listeners take time to listen to Ted Talks; they can be really relevant and can teach you about what others do to motivate and lead. Watch the TED Talk about How Great Leaders Inspire Action by Simon Sinek The second resource Randy suggests is the book Steve Jobs by Walter Isaacson because Steve Jobs and his innovative approach to product development, technology, leadership, and business changed the world. Get the book Steve Jobs (affiliate link): Contact Randy!             -Email: Riwasaki@ccta.net             -LinkedIn: Connect with Randy             -Twitter: @Riwasaki2 Parting Advice Take 5 minutes out of your day and think about the future; if you can see a future, you need to find a way to get buy-in from your employees and talk to them about that future and how to get there! Construction Nation! Dream Teams don’t just happen they are built one step at a time. Why not send out this episode to your team, so they can help you. The more people you have helping – the faster you can build your Construction Dream Team. You can’t have your dream until you build your team! Please head on over to ConstructionDreamTeam.com to sign up for our newsletter and don’t forget to subscribe on iTunes, Stitcher, Google Play, or Spotify!

Today I am back in the Passat with another automotive podcast. I get asked about carbon buildup on direct injection engines all the time. Generally they are asking about the newer VW engines the TSI. That would be engine codes CCTA and CBFA. These direct injection engines are developing issues with carbon on the back […]

The nation's first driverless shuttle pilot program started in California earlier this week, thanks to the efforts of Contra Costa Transportation Authority (CCTA). At the 2018 TRB Annual Meeting we spoke with Randy Iwasaki, Executive Director of Contra Costa Transportation Authority, and Tim Haile and Linsey Willis from his team. Randy is the visionary behind GoMentum Station, a designated USDOT AV Proving Ground that has become a testbed for numerous AV developers. Sign up for CCTA's 2018 Redefining Mobility Summit here: http://gomentumstation.net/registration/ And keep up with Randy and CCTA/GoMentum Station on Twitter: @CCTA @GoMentum @RIwasaki2

Join us for this recap of the key clinical pearls and favorite fan voted episodes from 2017 including: lipids, asthma, diuretics, hyponatremia, CKD, vertigo, and dizziness. Plus, Picks of the Year, exciting announcements for 2018, and Paul reveals that he has a wife! Matt, and Paul are joined by Curbsiders Correspondent, Dr. Chris Chiu, who wrote and produced this episode. Stuart was out with the Man Flu. My apologies to Dr. Bryan Brown whose name I forgot to shout-out when listing our Correspondents. Thanks to Kate Grant for her beautiful cover image. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps  00:00 Intro 01:18 Getting to know Chris Chiu introduction 03:07 Picks of the week and 06:10 Picks of the year and discussion of vancomycin and pip-tazo causing AKI 11:41 Recap of Scott Weingart and EM vs IM episode 17:45 Discussion of Lipids, PCSK9, CAC, CCTA 27:10 Asthma pearls recapped 32:43 Dizziness and vertigo recapped 38:40 Diuretics, diuretic resistance, and secondary hypertension diagnosis and treatment 44:35 Diuretic dosing 46:25 Hyponatremia, volume status, solute loads and SIADH 50:08 CKD, when to refer, and an argument about low protein diets 54:25 Matt, Paul, and Chris reflect on important lessons learned from 2017 59:32 Listener questions and comments 63:35 Wrap-up, and shout outs 66:22 Announcements for 2018 67:25 Outro Tags: hyponatremia, salt, kidney, ckd, asthma, vancomycin, zosyn, injury, weingart, emcrit, emergency, lipids, pcsk9, statin, dizziness, vertigo, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, meded, medical, medicine, practitioner, professional, primary, physician, resident, student

VW 2.0 TSI intake manifold failure is SUPER common. In fact they have a warranty extension on them. But how exactly do these intake manifold fail? Join me today as we look at some ways the CCTA intake manifolds fail. This is not only an VW issue, but an Audi issue as well. It has […]

It's been a while but we're back! Hear about how the summer has progressed, fire scares, kidding results, our CSA and special projects in this supersized episode. A podcast about starting a small homestead livestock ranch from scratch.

Master the evaluation of acute and chronic chest pain with coronary CT angiography (CCTA). We deconstruct this game changing technology w/experts from the Society for Cardiovascular Computed Tomography (SCCT), Dr. Todd Villines and Dr. Ahmad Slim. We’ve got answers on what to do when a patient with chest pain has a prior CAC score of zero, and/or a CCTA with non-obstructive disease. Plus: how to select, prepare, and counsel patients; how to interpret reports; choosing between myocardial perfusion study and CCTA, and more! Special thanks to Dr. Emilio Fentanes from SCCT for setting up this interview. Full show notes available at http://thecurbsiders.com/podcast Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Case: 45 yo F active duty Colonel with chronic chest pain syndrome despite negative conventional stress test and CAC score of zero. Time Stamps 00:00 Intro 04:00 Rapid fire questions 08:23 Book recommendations 10:14 Defining terms CCTA vs CAC 12:47 Script for counseling patient about CCTA 14:34 Prep for CCTA 16:40 Why is CCTA controversial? 19:37 Patient selection for CCTA both acute and chronic 25:20 Chronic chest pain and CCTA 27:58 CAC and CCTA in high risk occupations 33:25 Clinical case 36:10 Acute chest pain in patient w/CAC score zero 39:18 Acute chest pain in patient w/CAC score zero and previous CCTA w/non-obstructive CAD 41:22 How to read a CCTA report 45:48 CCTA versus conventional testing and risk MI, death 49:18 Use of CCTA in outpatients 52:16 Plaque characteristics and risk ACS 55:51 CCTA w/non-obstructive disease in patients with acute chest pain 58:14 When is myocardial perfusion scanning better? 61:00 Listener question on small vessel disease 62:09 Take home points 65:00 Curbsiders recap 69:33 Outro

Commentary by Dr. Valentin Fuster

Speaking at the annual conference of the National Association of Small Trucking Companies in Nashville in November 2014, Joe Rajkovacz detailed the status of legal challenges to the California Air Resources Board's in-use emissions regulations. With his California Construction Trucking Association's own appeal long delayed in the Ninth Circuit, OOIDA's intention to appeal after its lawsuit was dismissed on the same technical "buzzsaw" CCTA ran into and more, Rajkovacz offers tough advice to those who've held out hope the lawsuits would give them a lifeline. With prolonged legal dealys, the rules are going hardfast -- small fleet owners and owner-operators will need to "bring your fleets into conformance."

Commentary by Dr. Valentin Fuster

This week we're going back to review The Fault in Our Stars. We'll also be giving our take on the Critics' Choice Television Awards, which aired on the 19th, and covering some indie releases in theaters - We are the Best!, I Am I, and Obvious Child. A busy week, we'll also be getting to some listener questions, sharing interview clips with the stars of The Fault in Our Stars, and previewing coming attractions.

On Monday, March 17th, CCTA bus drivers began their strike against unsafe working conditions and predatory management practices, like surveillance and unfair discipline, and the threat of part-time status. Drivers were joined by community members, union members, and many other supporters in an informational picket that demonstrated the strong support for the drivers from members of the community. Jim Foutz, a CCTA driver, spoke about the unsafe and unjust working conditions faced by the drivers and how they are asking for a fair contract that would allow them to work safely and with dignity. Joshua Chasin, a participant in the rally and social justice leader in the community, spoke about his support for the drivers and about management's lack of respect for the drivers. The CCTA drivers will continue their strike until management offers them a fair contract that allows them to have dignified jobs and safe working conditions. In order to ensure that the drivers are given a fair contract, the community must come together to show support for the drivers and to put pressure on management to compromise and meet their demands. For more information on the strike or to get involved, go to http://support-ccta-drivers.weebly.com/

In the first of two podcasts on CARB's 11th-hour flexibility maneuvering, Joe Rajkovacz of the CCTA urged operators around the nation to get involved in the process, as potential new compliance options aren't yet set in stone. Call 530-40-VOICE, 530-408-6423, state your name and location and speak your piece on CARB's emissions regs to contribute to our next podcast on the subject. Find more on several public meetings scheduled for early December 2013 via this link: http://overdriveonline.com/podcast-carb-compliance-flexibility-or-lack-thereof-not-set-in-stone

08/06/2012 | Contrast Type and Administration: Optimizing CCTA

Guest: Seth Baum, MD Host: Alan S. Brown, MD, FNLA This program reviews the guidelines for determining which patients should receive coronary CT angiography (CCTA), highlights the differences between CCTA and coronary calcium testing, and explores the overall radiation risk of serial CCTA. Dr. Alan Brown talks to guest Dr. Seth Baum, expert on electrophysiology, interventional cardiology, coronary CT angiography, and clinical lipidology, and a founding member of the Society for Cardiovascular CT.