Podcasts about stemi

Gianluca Campo and C. Michael Gibson compare complete versus culprit-only revascularization in older STEMI patients.

The chain of survival for ACLS is the same as was learned in your BLS class.The beginning steps of the Cardiac Emergency and Stroke chain of survival.ACLS's timed goals for first medical contact to PCI for STEMI and door-to-needle for ischemic stroke. Characteristics of areas that have significantly better stroke and out-of-hospital cardiac arrest outcomes.Good luck with your ACLS class!Links: Buy Me a Coffee at https://buymeacoffee.com/paultaylor Practice ECG rhythms at Dialed Medics - https://dialedmedics.com/Safe Meds VIP - Learn about medication safety and download a free drug discount card to save money on prescription medications for you and your pets: https://safemeds.vipPass ACLS Web Site - Episode archives & other ACLS-related podcasts: https://passacls.com@Pass-ACLS-Podcast on LinkedIn

In Episode #37 of EM Logic, Dr. Pregerson discusses a paper by Dr. Stephen W. Smith on hyperacute T-waves. STEMI misses 30% to 40% of acute coronary occlusions that would benefit from emergent revascularization. Read more details here in the Show Notes. 

Rapid response nurses don't just handle codes — they help prevent them from happening. Contrary to popular belief, Rapid Response Nursing is not just sprinting from code blue the next and neither is ER nursing. While there are a lot of similarities between these two specialties in Nursing, there are a lot of differences too. In this episode, Aidan RN shares what it was like to transition from the fast-paced ER to the world of rapid response.We discuss what sets rapid response apart, the mindset shifts that helped him make the switch, and break down cases where their quick action made all the difference — including a subdural hematoma caught just in time, a STEMI with an unusual presentation, and a patient whose only symptom was neck pain.Whether you're calling rapid response or considering the role yourself, don't miss this conversation on the skills and challenges that define rapid response nursing!Topics discussed in this episode:Why transition from ER to rapid response?Differences between ER and rapid response nursingCase study: discovering a subdural hematomaThe role of intuition in rapid response nursingBest practices to work with rapid response nursesAdvice to nurses considering Rapid Response NursingLearn more about what it's like to be a Rapid Response Nurse!https://www.aacn.org/blog/exploring-the-world-of-rapid-response-nursesMentioned in this episode:CONNECT

CardioNerds (Dr. Rick Ferraro and Dr. Dan Ambinder) join Dr. Sri Mandava, Dr. David Meister, and Dr. Marissa Donatelle from the Columbia University Division of Cardiology at Mount Sinai Medical Center in Miami. Expert commentary is provided by Dr. Pranav Venkataraman.   They discuss the following case involving a patient with cardiac sarcoidosis presenting as STEMI:  A 57-year-old man with a history of hyperlipidemia presented with sudden onset chest pain. On admission, he was vitally stable with a normal cardiorespiratory exam but appeared in acute distress and was diffusely diaphoretic. His ECG revealed sinus rhythm, a right bundle branch block (RBBB), and ST elevation in the inferior-posterior leads. He was promptly taken for emergent cardiac catheterization, which identified a complete thrombotic occlusion of the mid-left circumflex artery (LCX) and large obtuse marginal (OM) branch, with no underlying coronary atherosclerotic disease. Aspiration thrombectomy and percutaneous coronary intervention (PCI) were performed, with one drug-eluting stent placed. An echocardiogram showed a left ventricular ejection fraction (EF) of 31%, hypokinesis of the inferior, lateral, and apical regions, and an apical left ventricular thrombus. The patient was started on triple therapy. A hypercoagulable workup was negative. A cardiac MRI was obtained to further evaluate non-ischemic cardiomyopathy. In conjunction with a subsequent CT chest, the results raised suspicion for cardiac sarcoidosis with systemic involvement. In view of a reduced EF and significant late-gadolinium enhancement, electrophysiology was consulted to evaluate for ICD candidacy. A decision was made to delay ICD implantation until a definitive diagnosis of cardiac sarcoidosis could be established by tissue biopsy. The patient was started on HF-GDMT and discharged with a LifeVest. Close outpatient follow-up with cardiology and electrophysiology was arranged.  US Cardiology Review is now the official journal of CardioNerds! Submit your manuscript here. CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls - Cardiac Sarcoidosis Presenting as STEMI Cardiac sarcoidosis can present with a variety of symptoms, including arrhythmias, heart block, heart failure, or sudden cardiac death. Symptoms can be subtle or mimic other cardiac conditions.  Conduction abnormalities, particularly AV block or ventricular arrhythmias, are common and may be the initial indication of cardiac involvement with sarcoidosis.  The additive value of Echocardiography, FDG-PET, and cardiac MR is indispensable in the diagnostic workup of suspected cardiac sarcoidosis.  Specific role of MRI/PET: Both cardiac MRI and FDG-PET provide a complementary role in the diagnosis of cardiac sarcoidosis. Cardiac MRI is an effective diagnostic screening tool with fairly high sensitivity but is limited by its inability to decipher inflammatory (“active” disease) versus fibrotic myocardium. FDG-PT helps to make this discrimination, refine the diagnosis, and guide clinical management. Ultimately, these studies are most useful when interpreted in the context of other clinical information.  Primary prevention of sudden cardiac death in cardiac sarcoidosis focuses on risk stratification, with ICD placement for high-risk patients. For patients awaiting definitive diagnosis, a LifeVest may be used as a temporary measure to protect from sudden arrhythmic events until an ICD is placed.  Notes - Cardiac Sarcoidosis Presenting as STEMI 1. Is STEMI always a result of coronary artery disease?  By definition, a STEMI is an acute S-T segment elevation myocardial infarction. This occurs when there is occlusion of a major coronary artery, which results in transmural ischemia and damage,

" I remember I was working a morning shift and it was 7 or 730 and I remember exactly where I am because I have a special memory and I was in between these two rooms. One had a STEMI and I was trying to get him to the cath lab, the other had a stroke I was trying to administer tpa and I get a phone call and the nanny is calling out."This episode is with Dr. Camie Sorenson who is an Emergency Medicine physician in Fresno, California. In this episode we talk about:- Meeting her husband and the decision not to factor in where he was living when she made her rank list- Making a long distance relationship work- Infertility and how she thinks her job contributed to this- How she managed to undergo fertility treatments- Being the first woman at her job to take maternity leave- Going on to have 4 children and what that looks like today now that they are a little older- Quitting her job when it wasn't working for her- Advocating for yourself and knowing your worthand so much more! Connect with Moms of Medicine:- Instagram @moms_of_medicine- Momsofmedicine@gmail.com

N Engl J Med 2001;344:1879-1887Background: Acute coronary syndrome is broadly categorized into unstable angina, non-ST-elevation myocardial infarction (NSTEMI) and ST-elevation myocardial infarction (STEMI). In unstable angina, there is no rise in cardiac biomarkers, although some challenge this clinical entity in the current era of high sensitivity troponins. In NSTEMI, there is elevation of cardiac biomarkers but no ST segment elevation on the electrocardiogram. In STEMI, there is an ST segment elevation on the electrocardiogram as well as a rise in cardiac biomarkers.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.In patients with STEMI, percutaneous coronary intervention (PCI) significantly improves outcomes. However, its role in acute coronary syndrome without ST-segment elevation is less clear for several reasons. Patients with NSTEMI tend to be older and have more comorbidities, increasing procedural risks. This also means that they have competing risks for mortality, potentially reducing the benefit of PCI. Another key challenge is that NSTEMI patients frequently have multivessel disease, making it more difficult to identify the culprit lesion; since there is usually only partial occlusion of the culprit coronary artery. In contrast, there is usually complete occlusion of a coronary artery in STEMI and ST-segment elevation on the electrocardiogram helps localize the infarcted area, making it relatively easy to identify the culprit artery.The findings from previous randomized trials of revascularization in unstable angina and NSTEMI, have been inconsistent. The TACTICS–Thrombolysis in Myocardial Infarction 18 trial sought to compare early invasive vs conservative strategy in patients with unstable angina or NSTEMI.Patients: Eligible patients had angina within 24 hours that was: >20 minutes in duration, accelerating angina, or recurrent episodes at rest or with minimal effort. Patients also had to have one of the following: ST-segment depression of at least 0.05 mV, transient ( 2.5 mg/dL.Baseline characteristics: The trial randomized 2,220 patients – 1,114 randomized to early invasive strategy and 1,106 randomized to conservative strategy.The average age of patients was 62 years and 66% were men. Approximately 28% had diabetes and 39% had prior myocardial infarction.Troponin T levels were elevated (>0.01 ng/ml) in 54% of the patients.Procedures: Patients were randomly assigned in a 1:1 ratio to undergo early invasive vs conservative strategy.Patients received aspirin 325 mg daily, intravenous unfractionated heparin (5000U bolus, followed by an infusion at 1000U/ hour for 48 hours), and intravenous tirofiban (0.4 μg/kg/minute for 30 minutes followed by an infusion of 0.1 μg/kg/minute for 48 hours or until revascularization with tirofiban administered for at least 12 hours after PCI).Patients in the early invasive arm underwent coronary angiogram between 4 and 48 hours after randomization and underwent PCI as appropriate. Patients in the conservative arm were treated medically. If stable, they underwent an exercise-tolerance test before discharged (83% of these tests were with nuclear perfusion or echocardiography imaging). Patients in the conservative arm underwent coronary angiography with PCI if they had angina at rest associated with ischemic EKG changes or elevation in cardiac biomarkers, had clinical instability or had ischemia on their stress test.Endpoints: The primary outcome was a composite of death from any cause, nonfatal myocardial infarction, and rehospitalization for an acute coronary syndrome, at six months.The estimated sample size to provide 80% power was 1,720 patients. This assumed that 22% of the patients in the conservative arm would experience the primary outcome and that the early invasive strategy would result in 25% relative risk reduction in the primary outcome. The sample size was later increased to 2,220 patients.Results: In the early invasive strategy, 97% of the patients underwent coronary angiogram after a medium of 22 hours after randomization, and 60% underwent PCI or CABG. In the conservative arm, 51% underwent coronary angiogram and 36% underwent revascularization during the index hospitalization.The primary composite endpoint was lower with the early invasive strategy (15.9% vs 19.4%, odds ratio: 0.78, 95% CI: 0.62 - 0.97; p= 0.025). The Kaplan-Meier curves started to separate at approximately one week. This benefit was driven by lower myocardial infarction and lower rehospitalization for an acute coronary syndrome with the early invasive strategy; (4.8% vs 6.9%) and (11.0% vs 13.7%), respectively. There was no difference in all-cause death (3.3% vs 3.5%).There were 3 important subgroup interactions. First is based on ST changes where patients with ST changes at presentation had all the benefit with an early invasive strategy (16.4% vs 26.3% [for patients with ST changes] and 15.6% vs 15.3% [for patients without ST changes]). Second is based on Troponin T levels where patients with troponin T> 0.1 ng/mL had significantly more benefit with an early invasive strategy (16.4% vs 24.5% and 15.1% vs 16.6%). The third is based on TIMI score where patients with higher TIMI score had more benefit with an early invasive approach. For a high TIMI score of 5-7, the event rate was 19.5% with early invasive vs 30.6% with conservative approach. Patients with TIMI score of 0-2 had no benefit with an early invasive strategy (12.8% with early invasive vs 11.8% with conservative strategy).Note to readers: TIMI score is a risk stratification tool used to predict 14-day adverse outcomes in patients with unstable angina or NSTEMI. The score ranges from 0 to 7 with higher scores indicating worse prognosis.Conclusion: In patients with unstable angina or NSTEMI, an early invasive strategy reduced the composite endpoint of death from any cause, nonfatal myocardial infarction, and rehospitalization for an acute coronary syndrome at six months with a number needed to treat of approximately 29 patients.The subgroup analysis of this trial is particularly important and biologically plausible, as the presence of ST changes and level of cardiac biomarkers elevation indicate more significant myocardial ischemia or necrosis. Patients without ST changes comprised 62% of the study participants, while those with negative cardiac biomarkers made up 59%, and the study results should not be generalized to these subgroups.Another key consideration is the lack of detailed criteria for what was deemed ‘appropriate' revascularization. Only 60% of patients in the early invasive strategy group underwent revascularization, underscoring that not all patients with unstable angina or NSTEMI benefit from coronary angiography and that further risk stratification is necessary.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber. Get full access to Cardiology Trial's Substack at cardiologytrials.substack.com/subscribe

The chain of survival for a cardiac emergency and stroke start the same: 1. preparedness & recognition of an emergency; 2. activation of EMS; 3. delivery of Advanced Life Support; and 4. transporting to the most appropriate facility.ALS ambulances are staffed with paramedics who have training in ACLS skills. Why EMS "Destination Protocols" for suspected stroke and STEMI make a difference.ACLS's timed benchmarks for:point of first medical contact to PCI for ST elevation MI;door to tPA for ischemic stroke; andonset of symptoms to EVT for LVO strokes.Why EMS should bypass a close hospital to transport a STEMI or suspected stroke patient to a hospital capable of 24/7 PCI or a certified stroke center. Check out the Pod Resource page at passacls.com for links to the "EMS On Air" podcast for links to episodes that look at EMS's role in stroke outcomes in the rural vs urban area.Connect with me:Website: https://passacls.com@Pass-ACLS-Podcast on LinkedInGive Back & Help Others: Your support helps cover the monthly cost of software and podcast & website hosting. Donations at Buy Me a Coffee at https://buymeacoffee.com/paultaylor are appreciated and will help ensure others can benefit from these tips as well.Good luck with your ACLS class!Helpful Listener Links:Practice ECG rhythms at Dialed Medics - https://dialedmedics.com/

Chest pain? Check. Sus ECG? Check. STEMI? Not check. A very tired Chris and a nerded out Spencer (12-leads... go figure) give MAXIMUM effort in today's call with a curious conclusion.

N Engl J Med 2024;390:1481-1492Background: In patients with ST-elevation myocardial infarction (STEMI), opening the culprit artery improves outcomes. Nearly half of STEMI patients have disease in other coronary arteries. Whether revascularizing these non-culprit arteries improves outcomes remained uncertain. The PRAMI trial showed improvement in outcomes with complete revascularization but was relatively small, included 465 patients, and did not require the use of fractional flow reserve (FFR).Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.The FFR-Guidance for Complete Nonculprit Revascularization (FULL REVASC) trial sought to assess if FFR-guided completed revascularization improves outcomes compared to culprit-only percutaneous coronary intervention (PCI).The COMPLETE trial was not published by the time the FULL REVASC trial started enrolling patients.Patients: Eligible patients had STEMI and were undergoing PCI or had high risk NSETMI undergoing urgent PCI. High risk NSTEMI included patients with dynamic ST–T-wave changes, ongoing chest pain, acute heart failure, hemodynamic instability independent of electrocardiographic changes, or life-threatening ventricular arrhythmias.Eligible patients had to have multivessel coronary artery disease, defined as one or more lesions in a nonculprit artery with a diameter of ≥ 2.5 mm and a visually graded stenosis of 50 - 99%.Patients were excluded if they had previous CABG, left main disease or cardiogenic shock.Baseline characteristics: The trial randomized 1,542 patients – 778 randomized to culprit-only PCI and 764 randomized to complete revascularization. Patients were recruited from 32 centers in 7 countries.Approximately 91% of the patients had STEMI and 9% had high risk NSTEMI.The average age of patients was 65 years and 76% were men. Approximately 51% had hypertension, 16% had diabetes, 23% were on treatment for hyperlipidemia, 8% had prior myocardial infarction, and 35% were current smokers.The number of residual coronary arteries with stenosis of 50-99% was 1 in 72% of the patients and 2 or more in the rest.Procedures: Patients were randomly assigned in a 1:1 ratio to undergo culprit-only PCI or FFR-guide complete revascularization. The study was open label.Patients in the culprit-PCI only group did not receive further revascularization during the index hospitalization. Patients in the FFR-guided complete revascularization could receive further revascularization during the index procedure or during the index hospitalization. PCI of non-culprit lesion was recommended if FFR was 0.80 or less.Endpoints: The primary outcome was a composite of death from any cause, myocardial infarction, or unplanned revascularization. The main secondary outcomes were a composite of death from any cause or myocardial infarction and unplanned revascularizationAnalysis was performed based on the intention-to-treat principle. The estimated sample size to achieve 80% with a two-sided alpha of 0.05 was 4,052 patients. This sample size would detect 0.75 risk ratio for the composite outcome of death or myocardial infarction at 1-year assuming 9.9% event rate in the culprit-only PCI. After the publication of the COMPLETE trial, the trial was stopped early due to ethical and feasibility concerns. Consequently, the original key secondary outcome (death from any cause, myocardial infarction, or unplanned revascularization) became the new primary outcome, and events after 1 year of follow-up were included in the primary analysis.Results: The trial was stopped after randomizing 38.1% of the original sample size. Among the patients assigned to the FFR-guided complete-revascularization arm, the procedure was followed in 95.9% of the patients, and among these patients, 17.9% underwent FFR-guided complete revascularization of non-culprit lesions during the primary PCI and the rest during the index hospitalization. Among the patients assigned to culprit-only arm, the assigned strategy was followed in 99.6% of the patients. The median follow-up time was 4.8 years.FFR was 0.8 or less in 392 (47.3%) of non-culprit vessels assessed, and PCI was performed in 369 (94.1%) of these vessels. In total, PCI was performed in 18.8% of the total non-culprit vessels. The average number of stents during the index hospitalization was 1 in the culprit-only PCI group and 2 in the complete revascularization group.The primary composite outcome was not significantly different between both treatment groups (19.0% with complete-revascularization vs 20.4% with culprit-only PCI, HR: 0.93, 95% CI: 0.74 - 1.17; p= 0.53). There were also no significant differences in composite endpoint of death from any cause or myocardial infarction (16.5% with complete revascularization vs 15.3% with culprit-only PCI) or unplanned revascularization (9.2% with complete revascularization vs 11.7% with culprit-only PCI).Stent thrombosis and stent restenosis were significantly more frequent in the complete revascularization arm (2.5% vs 0.9%, HR: 2.80, 95% CI: 1.18 – 6.67) and (4.2% vs 2.3%, HR: 1.84, 95% CI: 1.03 – 3.28), respectively.Baseline risk or coronary anatomy did not significantly affect subgroup interactions for the primary outcome.Conclusion: In patients with STEMI or high risk NSTEMI, FFR-guided complete revascularization compared to culprit-only PCI, did not improve the outcomes of death from any cause, myocardial infarction, or unplanned revascularization, over a median follow up time of 4.8 years. Complete revascularization resulted in more stent thrombosis and stent restenosis.The study lost some statistical power by stopping early, resulting in a final power of 74%. We disagree with the authors' decision to halt the trial prematurely based on the findings of the COMPLETE trial. COMPLETE was the first large trial to demonstrate a benefit in hard outcomes when revascularizing stable plaques, and its results warrant further confirmation. Furthermore, COMPLETE used different strategy as FFR was not required.Note to readers: Power measures the study's ability to avoid a Type II error (false negative) and it equals 1 - β with β being the probability of a Type II error. In other words, power represents the probability of correctly rejecting the null hypothesis (H₀) when the alternative hypothesis (H₁) is true. Most clinical trials aim for 80% or 90% power. For example, a study with 80% power has a 20% risk of failing to detect a real effect.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber. Get full access to Cardiology Trial's Substack at cardiologytrials.substack.com/subscribe

N Engl J Med 2019;381:1411-1421Background Percutaneous coronary intervention (PCI) had been clearly established as the standard of care for ST elevation myocardial infarction. Yet many patients taken for PCI have multiple lesions in addition to the culprit. The benefit of routinely treating additional significant lesions has been unclear, with previous smaller trials showing reductions in composite outcomes primarily driven by reduced revascularization rates.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.The COMPLETE (Complete vs Culprit-Only Revascularization Strategies to Treat Multivessel Disease after Early PCI for STEMI) trial investigated whether performing percutaneous coronary intervention (PCI) on non-culprit lesions reduces cardiovascular risk in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease.Patients The trial enrolled 4,041 patients from 140 centers in 31 countries between February 2013 and March 2017. Eligible patients had STEMI with successful culprit-lesion PCI and at least one non-culprit coronary artery lesion with ≥70% stenosis (or 50-69% stenosis with FFR ≤0.80) in a vessel ≥2.5mm in diameter. Patients were randomized within 72 hours after successful culprit-lesion PCI. Exclusion criteria included planned surgical revascularization and previous coronary bypass surgery.Baseline Characteristics The mean age was approximately 62 years, with about 80% being male. Approximately 19% had diabetes, 8% had previous MI, and 7% had previous PCI. Over 90% of patients underwent primary PCI (vs. pharmacoinvasive or rescue PCI), with 80% using radial access.The groups were well-balanced, with similar SYNTAX scores at baseline and similar culprit and non-culprit lesion characteristics. About 76% had one residual diseased vessel and 24% had two or more. Guideline directed medical therapy was robust and balanced, including more than 99% on dual antiplatelet therapy, 98% on statins, 88% on beta blocker, and 85% on ACEi or ARB.In patients in the complete revascularization group designated for non-culprit PCI during index hospitalization, the mean time to PCI was 1 day. In the group designated for non-culprit PCI after discharge, the mean time was 23 days.Trial procedures Patients were randomized to complete revascularization (n=2,016) or culprit-lesion-only PCI (n=2,025). In the complete revascularization group, investigators specified before randomization whether non-culprit PCI would occur during index hospitalization or after discharge (within 45 days).Everolimus-eluting stents were recommended for all procedures. Both groups received guideline-based medical therapy including dual antiplatelet therapy with aspirin and ticagrelor for at least one year.Endpoints The first coprimary outcome was cardiovascular death or new myocardial infarction. The second coprimary outcome was cardiovascular death, myocardial infarction, or ischemia-driven revascularization. Secondary outcomes included individual components of the composite outcomes, all-cause mortality, and safety outcomes like major bleeding, stroke, and stent thrombosis.Trialists estimated that a sample of 4000 patients would give 80% power to detect a 22% lower risk of the composite of cardiovascular death or myocardial infarction in the complete-revascularization group than in the culprit-lesion-only PCI group, assuming an event rate of 5% per year in the culprit-lesion-only PCI group. The first coprimary outcome was tested at a P value of 0.045 and the second at a P value of 0.0119.The co-primary endpoints were analyzed according to the time to first event approach. Confidence intervals for secondary and exploratory efficacy outcomes were not adjusted for multiple comparisons, and therefore inferences drawn from these intervals may not be reproducible.Results Over a median follow-up of 36.2 months, the first coprimary outcome occurred in 7.8% of the complete-revascularization group versus 10.5% of the culprit-lesion-only group (hazard ratio 0.74, 95% CI: 0.60-0.91; p= 0.004). Benefit was driven by reduced myocardial infarction rates (5.4% vs 7.9%) while cardiovascular death rates were similar (2.9% vs 3.2%).The second coprimary outcome was also reduced with complete revascularization (8.9% versus 16.7%, HR: 0.51, 95% CI: 0.43-0.61; p

N Engl J Med 2013;369:1115-23Background: The COURAGE trial was published in 2007. It compared up-front PCI to medical therapy alone in patients with stable CAD. Preventive PCI did not reduce the chance of dying or having a heart attack over a median follow up time of 5 years. The results rocked the cardiology world because for years prior to the publication of COURAGE, the standard of care called for revascularization of obstructive coronary stenosis. Despite what we would consider minor criticisms of COURAGE, the results have held over time as a preventive PCI strategy has failed repeatedly to reduce death or MI compared to medicine alone in subsequent large trials (BARI 2D, FAME 2, ISCHEMIA and ISCHEMIA-CKD) involving patients with stable CAD. But what about patients with acute coronary syndromes who have, a clearly defined “culprit” lesion and stable coronary stenosis of a non-infarct vessel? On the surface, the answer might seem simple - treat the “culprit” lesion with PCI and leave the stable disease alone. Continue optimal medical treatment of stable CAD indefinitely with consideration of revascularization only if new symptoms arise. But what if a stable coronary stenosis behaves differently in a patient with an acute coronary syndrome than in patients without it? Are these patients predisposed or particularly susceptible to acute plaque rupture and thrombogenesis to such an extent that they would benefit from a preventive revascularization strategy? The Primary Angioplasty in Myocardial Infarction (PRAMI) trial sought to test the hypothesis that immediate preventive PCI of non-culprit vessels plus the culprit vessel compared to culprit vessel only PCI would improve outcomes in patients with a STEMI and coronary stenosis of a non-infarct related artery.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.Patients: From 2008 through 2013, patients were enrolled from 5 coronary care centers in the United Kingdom. Patients could be any age with acute STEMI and multivessel CAD detected at the time of emergency PCI. The trial was limited to patients with STEMI because ST-segment elevation, unlike ST-segment depression, localizes the area of ischemia in the myocardium and an “infarct-artery” is usually easy to distinguish. Clinically stable patients were considered for eligibility after undergoing PCI of the infarct artery while they were in the catheterization lab. They were eligible if successful PCI of infarct artery was performed and there was stenosis of 50% or more in one or more non-infarct arteries. Exclusion criteria included cardiogenic shock, previous CABG, had left main or significant disease in the ostia of both the LAD and circumflex vessels, or if the only non-infarct stenosis was a chronic total occlusion.Baseline characteristics: The trial screened 2,428 patients and randomized 465 patients (19%) with 234 to preventive PCI and 231 to no preventive-PCI. The majority of patients were excluded for single vessel disease (1122/1922 [58%]). The average age of patients was 62 years and more than 75% were men. Close to 50% were current smokers. The infarct artery was anterior in 35%, inferior in 60% and lateral in 5%. Approximately 65% of patients had 2 vessel disease and 35% had 3 vessel disease.Procedures: After completion of PCI in the infarct artery, eligible patients were randomized and those assigned to the preventive-PCI group underwent the procedure immediately in all non-infarct arteries with a coronary stenosis >50%. PCI was discouraged at a later date (sometimes this strategy is referred to as “staged PCI”) in the no preventive-PCI group unless it was symptom driven. Any patient in the trial with subsequent symptoms of angina that were not controlled with medicine was required to undergo objective assessment of ischemia to secure a diagnosis of refractory angina. Follow-up information was collected at 6 weeks and then yearly thereafter.Endpoints: The primary endpoint was a composite of death from cardiac causes, nonfatal MI, or refractory angina. Secondary outcomes included the individual components of the composite endpoint along with noncardiac death and repeat revascularization. Myocardial infarction was defined as symptoms of cardiac ischemia and a troponin level >99% URL. However, within 14 days after randomization, MI diagnosis also required ECG evidence of new STE or left bundle branch block and angiographic evidence of coronary artery occlusion (essentially this makes it so only in-stent thrombosis or spontaneous STEMI count and other causes of peri-procedural MI do not - this would bias the trial in favor of the preventive-PCI group).Refractory angina was defined as angina despite medical therapy and objective evidence of myocardial ischemia (i.e., ischemia on ECG during spontaneous episode of pain or abnormal results on functional testing).It was determined that 600 patients would be needed to achieve 80% power to detect a 30% relative reduction in the preventive-PCI group, at a 5% level of significance, assuming an annual rate of the primary outcome of 20% in the control group. Stopping criteria were prespecified if the results from the trial showed a primary outcome difference at the 0.001 level of significance. Results: The trial was stopped early based on a significant difference (P50%, preventive PCI significantly reduced a primary composite outcome of cardiac death, nonfatal MI and refractory angina in the PRAMI trial with an estimated NNT of 7 patients over 2 years. Individual components of the primary endpoint that were significantly reduced included nonfatal MI and refractory angina by similarly large margins. These results may seem impressive at first glance but we urge extreme caution in their interpretation. First, this is a relatively small trial with a historically large effect size, especially when considering hard endpoints like cardiac death and nonfatal MI were included. Such results are often later found to be falsely positive when larger, confirmatory studies are conducted. Second, the trial was stopped early and early stopping is prone to yield false positive and/or exaggerated results. Third, inclusion of refractory angina in the primary endpoint, an endpoint susceptible to bias in an unblinded study (see earlier discussion of “faith healing” and “subtraction anxiety” in FAME 2; consideration also must be given to nocebo effects in patients who know they have “untreated blockages”), clouds the main findings by inflating the effect size and making the trial susceptible to large differences in underpowered endpoints before sufficient data can be accumulated on hard outcomes. For example, if the trial had sought to detect a conservative difference of 30% in a primary composite endpoint that only included cardiac death or nonfatal MI, based on an event rate of 12% in the control group (the actual event rate in the trial), over 2,200 patients would be needed for 80% power at a 5% level of significance. The estimated number of actual events would be around 230. However, only 47 events occurred in PRAMI making the results highly susceptible to noise.While results of PRAMI suggest a beneficial role for preventive-PCI in patients with STEMI, more evidence is needed to confirm the results.Thanks for reading Cardiology Trial's Substack! This post is public so feel free to share it. Get full access to Cardiology Trial's Substack at cardiologytrials.substack.com/subscribe

Blanking period after AF ablation, periprocedural MI after PCI in non-STEMI, predicting AF after ischemic stroke, and the proper standards for mitral valve repair in primary mitral regurgitation are the topics John Mandrola, MD, discusses in today's podcast. This podcast is intended for healthcare professionals only. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I AF blanking period CIRCA DOSE Research letter https://www.ahajournals.org/doi/10.1161/CIRCEP.124.013232 Circa-Dose https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.119.042622 COMPARE CRYO  https://doi.org/10.1016/j.jacep.2024.03.021 Mohanty et al  10.1016/j.hrthm.2024.08.011 Ruzieh, Foy, Mandrola Patients' Lives Don't Pause for Blanking Periods https://doi.org/10.1016/j.ahjo.2024.100497 II Periprocedural MI and Future events Circulation paper https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.124.070729 III AI to detect AF related stroke eClinical Medicine Paper  https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(25)00050-1/fulltext IV Mitral Valve Repair JACC paper -- https://doi.org/10.1016/j.jacc.2024.10.108 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

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Could a massive stimulus check be on the way? Trump and Musk are shaking things up with a bold proposal—what does it mean for the economy, inflation, and YOUR wallet? Tune in for the full breakdown!

We often discuss "one in a million" and "once in a career" cases in emergency medicine and EMS, and do we ever have one of those for you in this episode! MCHD Captain, Jason Jones, joins Dr. Patrick to discuss an exeedingly rare STEMI/chest pain presentation with lessons that we can all apply to our daily care. REFERENCES 1. https://www.mchd-tx.org/wp-content/uploads/2025/02/SITUS-Fig-1.pdf 2. https://www.mchd-tx.org/wp-content/uploads/2025/02/SITUS-Fig-2.pdf 3. https://montgomerycountypolicereporter.com/mchd-celebrates-survival-of-one-in-a-million-patient-first-responders-please-read/ 4. https://pubmed.ncbi.nlm.nih.gov/34317454/

N Engl J Med 2013;369:1587-1597N Engl J Med 2014;371:1111-1120Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.Background: In the TAPAS trial, thrombus aspiration in patients with ST elevation myocardial infarction (STEMI) improved coronary reperfusion as evident by coronary blush grade and electrocardiogram. The improvement in these surrogate endpoints was large and generated enthusiasm within the cardiology community regarding the potential of thrombus aspiration. While the trial demonstrated a trend toward improvement in clinical outcomes, this was not statistically significant and the trial was not powered for these clinical outcomes.The Thrombus Aspiration in ST-Elevation Myocardial Infarction in Scandinavia (TASTE) trial was designed to assess the impact of thrombus aspiration in patients with STEMI, and was powered to detect differences in clinical endpoints.Patients: Patients were included if they had chest pain suggestive of myocardial ischemia for at least 30 minutes but less than 24 hours before hospital admission, and if the EKG showed new ST-segment elevation or left bundle-branch block.Patients were excluded if they couldn't provide informed consent or if they needed emergency coronary artery bypass grafting.The trial enrolled patients from all 29 PCI centers in Sweden, 1 in Iceland and 1 in Denmark.Baseline characteristics: The trial randomized 7,244 patients – 3,621 randomized to thrombus aspiration and 3,623 randomized to conventional PCI.The average age of patients was 66 years and 75% were men. Approximately 42% had hypertension, 12% had diabetes, 21% had hyperlipidemia, 12% had prior myocardial infarction, and 31% were current smokers.Procedures: Patients were randomly assigned in a 1:1 ratio to undergo thrombus aspiration follow by PCI or conventional PCI. The study was open label.The use of anticoagulants during PCI was left to the discretion of the treating physician. Stenting was encouraged with the type of stent left to the discretion of the physician. The administration of P2Y12 inhibitors was also left to the discretion of the physician. Lifelong treatment with aspirin was recommended in all patients.Endpoints: The primary end point was all-cause death at 30 days. Data on mortality were obtained from the national population registry. The secondary end points, which were obtained from the SWEDEHEART registry and the national discharge registry, included 30-day rates of hospitalization for recurrent myocardial infarction, stent thrombosis, target-vessel revascularization, target-lesion revascularization, and the composite of all-cause mortality or recurrent myocardial infarction.Analysis was performed based on the intention-to-treat principle. To achieve 80% power with a two-sided alpha of 0.05, a total of 4,886 patients would be needed to detect a hazard ratio for death of at least 1.30 with PCI alone as compared with PCI plus thrombus aspiration. This calculation assumed the 30-day mortality with PCI alone to be 6.3%. Due to lower than expected mortality rate, the sample size was increased to 7,138 patients. The new sample size would detect an odds ratio for death with PCI alone as compared with PCI with thrombus aspiration of at least 1.5, assuming the 30-day mortality in the conventional PCI group to be 3.5%.Results: Out of the 11,709 patients with STEMI in Sweden or Iceland, 4,697 (40.1%) were not enrolled in the trial. Of these patients not enrolled, 1,162 (24.7%) underwent thrombus aspiration. The median time from onset of symptoms to PCI was approximately 3 hours. No patients were lost to follow up with respect to the primary outcome. Among patients assigned to thrombus aspiration, 93.9% of the patients underwent the procedure. Among patients assigned to conventional PCI, 4.9% underwent thrombus aspiration.The primary outcome of all-cause death at 30-days was similar between both treatment groups (2.8% with thrombus aspiration vs 3.0% with conventional PCI, HR: 0.94, 95% CI: 0.72 - 1.22; p= 0.63).There were no statistically significant differences in any of the secondary outcomes at 30-days (incidence for thrombus aspiration mentioned first): Hospitalization for recurrent myocardial infarction (0.5% vs 0.9%), stent thrombosis (0.2% vs 0.5%), target-vessel revascularization (1.8% vs 2.2%), target-lesion revascularization (1.2% vs 1.6%), and the composite of all-cause death or recurrent myocardial infarction (3.3% vs 3.9%).There was no difference in the incidence of stroke or neurological complications (0.5% in both groups), and no difference in the incidence of perforation or tamponade (0.4% in both groups).Authors published a 1-year follow up study. At 1-year, there was no significant difference in all-cause death (5.3% with thrombus-aspiration group vs. 5.6% with conventional PCI, HR: 0.94, 95% CI: 0.78 - 1.15; p= 0.57). Similarly, no significant differences were observed for any of the secondary endpoints (incidence for thrombus aspiration mentioned first): Hospitalization for recurrent myocardial infarction (2.7% in both groups), stent thrombosis (0.7% vs 0.9%), target-vessel revascularization (4.4% vs 4.9%), target-lesion revascularization (3.2% vs 3.5%), and the composite of all-cause death or recurrent myocardial infarction (7.7% vs 8.1%).There were no significant subgroup interactions for the primary outcome.Conclusion: In patients with ST elevation myocardial infarction, thrombus aspiration during PCI as compared to conventional PCI, did not improve the primary outcome of all-cause at 30-days. It also did not significantly reduce the secondary outcomes at 30-days which included hospitalization for recurrent myocardial infarction, stent thrombosis, target-vessel revascularization, target-lesion revascularization, and the composite of all-cause death or recurrent myocardial infarction. Results remained unchanged at 1-year.The TAPAS and TASTE trials highlight a critical lesson in research: Reliance on surrogate endpoints to guide medical practice can be misleading, even when surrogate outcomes suggest a substantial benefit, as seen in the TAPAS trial. Therefore, positive findings based on surrogate endpoints should always be validated by larger trials powered to assess clinical outcomes, before adopting them into clinical practice.The TAPAS trial did impact clinical practice, with approximately 1 in 4 patients with STEMI in Sweden during the TASTE study period, who were not enrolled in the TASTE trial, underwent thrombus aspiration.Another key takeaway is that results from smaller trials are not always replicated in larger studies. In TAPAS, thrombus aspiration was associated with a reduction in 30-day mortality, with a number needed to treat of approximately 53 patients. However, this finding was not statistically significant, raising questions about whether a larger sample size could have demonstrated a significant benefit. This assumption was refuted by the TASTE trial, highlighting the potential pitfalls of prematurely adopting interventions without robust evidence from sufficiently large trials.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber. Get full access to Cardiology Trial's Substack at cardiologytrials.substack.com/subscribe

N Engl J Med 2008;358:557-567Background: ST-segment elevation myocardial infarction (STEMI) is caused by disruption of an atherosclerotic plaque, leading to intraluminal thrombosis that partially or completely blocks the coronary artery. Opening the blocked artery using percutaneous coronary intervention (PCI) restores blood flow and is the standard of therapy for these patients. In many patients, spontaneous embolization or embolization caused by thrombus fragmentation during PCI can lead to small thrombi migrating distally and obstructing the coronary microcirculation. This is associated with increased infarct size, reduction in left ventricular recovery and increased risk of mortality.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.Several devices designed to retrieve intracoronary thrombus have been developed and have demonstrated improved coronary reperfusion in small studies. The Thrombus Aspiration during Percutaneous Coronary Intervention in Acute Myocardial Infarction Study (TAPAS) sought to compare the efficacy of thrombus aspiration versus conventional PCI in patients with STEMI.Patients: Eligible patients were recruited from a single center in Netherlands. Patients had STEMI with symptoms lasting more than 30 minutes but less than 12 hours. The EKG criteria were ST-segment elevation of >1mm in at least two leads.Patients were excluded if they had rescue PCI after thrombolysis or if life expectancy was less than 6 months.Baseline characteristics: The trial randomized 1,071 patients – 535 randomized to thrombus aspiration and 536 randomized to conventional PCI.The average age of patients was 63 years and 70% were men. Approximately 35% had hypertension, 12% had diabetes, 25% had hyperlipidemia, 10% had prior myocardial infarction, and 47% were current smokers.Infarct-related vessel was the left anterior descending artery in 43% of the patients, the left circumflex artery in 17% and the right coronary artery in 38%.Procedures: Patients were randomly assigned in a 1:1 ratio to undergo thrombus aspiration during PCI or conventional PCI. All placed stents were bare-metal stents.Before PCI, patients received 500 mg of aspirin, 600mg of clopidogrel and 5000 IU of heparin. Patients also received the glycoprotein IIb/IIIa inhibitor abciximab, if not contraindicated, and additional heparin during the procedure.Endpoints: The primary end point was the postprocedural frequency of a myocardial blush grade of 0 or 1. Secondary end points included complete resolution of ST-segment elevation and the absence of persistent ST-segment deviation. Clinical endpoints were also assessed as part of the secondary endpoints and included target-vessel revascularization, reinfarction or death, at 30 days.A 12-lead EKG was obtained at presentation and again at 30 to 60 minutes after PCI, and the ST-segments on the postprocedural EKG were compared with those at presentation.Not to readers: Myocardial blush is a qualitative angiographic method used to assess microvascular perfusion during coronary angiography. It evaluates how well contrast dye penetrates the myocardium. The grading of myocardial blush was: 0: no myocardial blush, 1: minimal myocardial blush or contrast density, 2: moderate myocardial blush or contrast density but less than that obtained during angiography of a contralateral or ipsilateral non–infarct-related coronary artery, and 3: normal myocardial blush or contrast density, similar to that obtained during angiography of a contralateral or ipsilateral non–infarct-related coronary artery. Persistent myocardial blush suggests leakage of contrast medium into the extravascular space and was given a grade of 0.Analysis was performed based on the intention-to-treat principle. To achieve 80% power with a two-sided alpha of 0.05, a total of 1,080 patients would be needed to detect a 25% reduction in the primary endpoint with thrombus aspiration compared to conventional PCI. This calculation assumed a 30% rate of myocardial blush grade 0 or 1 in the conventional PCI group.Results: Among the 1,161 patients screened for inclusion, 1,071 (92.2%) were randomized. Approximately, 94% of the patients in both groups underwent PCI. Among patients who underwent PCI in the thrombus aspiration group, 89% underwent thrombectomy. Among the patients who underwent thrombus aspiration, histopathological examination showed atherothrombotic material in 331 (72.9%) patients.The primary outcome of myocardial blush grade 0 or 1 was significantly lower in the thrombus aspiration group (17.1% vs 26.3%, RR: 0.65, 95% CI: 0.51 - 0.83; p

N Engl J Med 2013;368:1379-1387Background In 2013, it had been established that primary PCI for STEMI was the preferred strategy. Yet many patients did not have prompt access to primary-PCI capable hospitals and transfer delays could impact outcomes. The vast majority of patients with STEMI who present to non-PCI facilities do not subsequently get primary PCI within recommended times.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.Delays led to the development of prehospital care, such as ECGs in the ambulance, and pre-hospital delivery of fibrinolysis. The Strategic Reperfusion Early after Myocardial Infarction (STREAM) study evaluated whether a fibrinolytic-therapy approach consisting of prehospital or early fibrinolysis with contemporary antiplatelet and anticoagulant therapy, coupled with timely coronary angiography, provides a clinical outcome similar to that with primary PCI in patients with STEMI who present early after symptom onset.Patients Eligible patients had a) STEMI within three hours, b) could not have primary PCI within one hour of first medical contact. No formal exclusion criteria were listed in the main manuscript.Baseline Characteristics A total of 1892 patients underwent randomization in 1:1 fashion. The mean age of patients was 59 years. Less than 15% of both groups were older than 75 years. Females were 20%. More than 90% of patients were Killip class 1. Less than 10% of enrolled patients had had prior CHF, MI, or PCI.Procedures Patients were randomized in a 1:1 ratio to fibrinolysis followed by timely coronary angiography or primary PCI. All patients were transferred to a PCI-capable hospital; for all non-PCI community hospitals participating in the study, a well-developed hub-and-spoke relationship with a PCI-capable site was required.The fibrinolytic strategy included early use of concomitant antiplatelet and anticoagulant medications, as well as additional discretionary glycoprotein IIb/IIIa antagonists. Tenecteplase was administered in a weight-based dose and was combined with low-molecular-weight enoxaparin, weight and age adjusted.Antiplatelet therapy consisted of clopidogrel in a 300-mg loading dose (omitted for patients ≥75 years of age) followed by 75 mg daily and aspirin (150 to 325 mg) immediately followed by 75 to 325 mg daily. Urgent coronary angiography in the fibrinolysis group was permitted at any time in the presence of hemodynamic or electrical instability, worsening ischemia, or progressive or sustained ST-segment elevation requiring immediate coronary intervention, according to the investigator's judgment.Endpoints The primary end point of the trial was a 30-day composite of death from any cause, shock, congestive heart failure, or reinfarction. Single efficacy end points as well as safety end points consisting of ischemic stroke, intracranial hemorrhage, nonintracranial bleeding, and other serious clinical events were recorded.The statistical analysis plan was complicated. A sample size of 1000 patients per study group was planned, and the rate of the primary end point in the primary PCI group was projected to be 15.0%. After one-fifth of patients had been enrolled, trialists amended the protocol to reduce the dose of tenecteplase by 50% in patients older than 75 years because of excess ICH. ECG criteria for inferior MI was also changed to require at least 3 mm (up from 2) of ST elevation in two contiguous leads.This trial was designed as a proof-of-concept study. All statistical tests were of an exploratory nature.Results The median time delay from the onset of symptoms to first medical contact and randomization was similar in the two groups ( 61-62 minutes). The median times between symptom onset and start of reperfusion therapy (bolus tenecteplase or arterial sheath insertion) were 100 minutes and 178 minutes, respectively (P

V najnovšej epizóde podcastu Rozhovory MD sme sa rozprávali s Davidom Liškom, primárom kardiológie a akútnej kardiológie v Cinre, ktorý bol pri samotnom vzniku tejto kliniky a od roku 2018 rozbiehal jej kardiologický program. Dnes je Cinre významnou nemocnicou s viac ako 300 zamestnancami aktuálne sídliacou v Nemocnici Bory. V rozhovore sa dozviete viac o intervenčnej kardiológii, ako sa Cinre dopĺňa s Národným ústavom srdcových a cievnych chorôb (NUSCH), a ako v praxi aplikujú najnovšie medzinárodné odporúčania. Diskutujeme tiež o akútnych intervenciách po infarktoch a ako sa posunula starostlivosť v tejto oblasti. David Liška sa podelil o svoje odporúčania pre mladých začínajúcich kardiológov, ako aj o svoj pohľad na budúcnosť intervenčnej kardiológie a inovácie, ktoré môžeme očakávať v najbližších rokoch. (01:17) Privítanie (03:49) Vznik Cinre (12:00) Akútne intervencie po infarktoch – kam sme sa posunuli (18:57) Vzťahy s NÚSCH (26:17) Odporúčanie pre mladých kardiológov (28:50) Implementácia guidelinov (39:13) Budúcnosť intervenčnej kardiológie (43:33) Krátke otázky na záver Už 13. 2. nás čaká druhý online kurz na ChatGPT pre lekárov, kde sa dozviete, ako si ušetriť čas, či sa oplatí používať aj iné AI nástroje, ako si vytvoriť vlastného AI chatbota pre pacientov a ako kombinovať medicínske databázy s AI pre rýchlejšiu a kvalitnejšiu diagnostiku. Prihlásiť sa dá ešte tu: https://lu.ma/jfhhw7oh?utm_medium=email&utm_source=substack Prajeme príjemné počúvanie alebo sledovanie!

N Engl J Med 2006;355:2395-407Am Heart J 2011;161:611-21Background: Registry data suggests that 10-20% of patients with a STEMI present more than 12 hours after the onset of symptoms. The optimal treatment for such patients is unknown. In some cases, the inciting event may have occurred weeks prior and been mistaken for indigestion or another non-life threatening condition. Such patients may present to the hospital with a new diagnosis of congestive heart failure or atrial fibrillation. Echocardiography often reveals a a large wall motion abnormality, perfusion testing demonstrates an infarct with peri-infarct ischemia and an occluded vessel is seen on angiography. Should we try to open it? On the one hand, the damage has been done. Attempting to open an occluded vessel is associated with higher procedural risks and the patient's themselves are more often than not sub-optimal candidates for intervention; often having some combination of heart failure, LV dysfunction, older age, multimorbidity and hemodynamic instability. But on the other hand, revascularization restores blood flow and that has to count for something, right?The Occluded Artery Trial (OAT) tested the hypothesis that a strategy of routine PCI for total occlusion of the infarct-related artery 3 to 28 days after AMI would improve cardiac outcomes compared to medical therapy alone.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.Patients: Patients were eligible if coronary angiography, performed 3 to 28 days after MI, showed a total occlusion of the infarct-related artery with poor antegrade flow and either an EF less than 50% or the occlusion was in the proximal portion of a major coronary vessel with a large risk region, or both. The qualifying period of 3 to 28 days was based on calendar days with day 1 being the onset of symptoms and thus, the minimal time from the AMI to angiography was just over 24 hours. [This is important, readers should not take the inclusion criteria of 3 to 28 days to mean that patients were not eligible if angiography was performed 2.5 mg/dl, left main or 3 vessel disease, angina at rest, and severe ischemia on stress testing (stress testing was required if the infarct zone was not akinetic or dyskinetic).Baseline characteristics: The trial included 2,166 patients - 1,082 randomized to PCI and 1,084 to medical therapy. The average age of patients was 59 years and 78% were men. Over 80% were white. The median time between AMI and randomization was 8 days. Patients had normal kidney function with an average GFR of 81 ml/min. The mean EF was 48% with 20% of patients having an EF

The chain of survival for ACLS is the same as was learned in your BLS class. The beginning steps of the Cardiac Emergency and Stroke chain of survival. ACLS's timed goals for first medical contact to PCI for STEMI and door-to-needle for ischemic stroke. Characteristics of areas that have significantly better stroke and out-of-hospital cardiac arrest outcomes.Connect with me:Website: https://passacls.com@Pass-ACLS-Podcast on LinkedInGive Back & Help Others: Your support helps cover the monthly cost of software and podcast & website hosting so that others can benefit from these ACLS tips as well. Donations via Buy Me a Coffee at https://buymeacoffee.com/paultaylor are appreciated.Good luck with your ACLS class!

Darshan H. Brahmbhatt, Podcast Editor of JACC: Advances, discusses a recently published original research paper on Improving STEMI Management Internationally, an Initial Report of the American College of Cardiology-Global Heart Attack Treatment Initiative.

THE LANCET 2011;377:1409-1420Background: When patients undergo coronary angiography, a hollow tube called a sheath is inserted into an artery. The primary function for the sheath is to provide a stable entry point into the artery, allowing for the safe navigation of instruments to the coronary arteries. Traditionally these sheaths were inserted into the femoral artery. One of the common complications associated with this approach is bleeding which is associated with worse outcomes. An alternative approach is inserting the sheath into the radial artery which is more superficial and more readily compressible compared to the femoral artery.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.Small randomized trials suggested that a radial artery access is associated with less bleeding with possible reduction in death and myocardial infarctions but also a signal of increased percutaneous coronary intervention (PCI) failure.The RIVAL trial sought to assess if radial artery access is superior to femoral artery access in patients with acute coronary syndrome (ACS) undergoing coronary angiography.Patients: Patients had acute coronary syndrome and an invasive strategy was planned. Dual circulation of the hand, as assessed by an Allen's test, had to be intact.Patients were excluded if they had cardiogenic shock, severe peripheral vascular disease precluding a femoral approach, active bleeding or high bleeding risk, or prior coronary artery bypass grafting (CABG) with the use of more than one internal mammary artery graft.Baseline characteristics: The trial randomized 7,021 patients in 32 countries – 3,507 randomized to radial access and 3,514 to femoral access.The average age of patients was 62 years and 73% were men. Approximately 60% had hypertension, 21% had diabetes, 18% had prior myocardial infarction, 2% had prior CABG, 2% had peripheral vascular disease, and 31% were current smokers.The diagnosis at admission was unstable angina in 45% of the patients, NSTEMI in 27% and STEMI in 28%.The use of antiplatelet and anti-thrombotic drugs was not significantly different between both groups.Procedures: The RIVAL trial initially enrolled patients within the CURRENT-OASIS 7 trial which was a trial of antiplatelets therapy in ACS. After the conclusion of the CURRENT-OASIS 7 trial, RIVAL enrolled additional patients.Patients were assigned in a 1:1 ratio to undergo femoral or radial artery access. The use of anti-thrombotic regimen at the time of PCI as well as femoral artery closure devices was at the discretion of the treating physician.Endpoints: The primary outcome was a composite of all-cause death, myocardial infarction, stroke, or non-CABG related major bleeding, within 30 days. Secondary outcomes included the components of the primary outcome as well as major vascular access site complications and PCI procedural success.The components of the primary outcome were adjudicated by a central committee blinded to the treatment assignment. Major vascular access site complications and PCI procedural success were reported by the investigators.Analysis was performed based on the intention-to-treat principle. Due to low event rate, the sample size was increased from 4,000 to 7,000. This new sample size would provide 80% power to detect 25% relative risk reduction in the primary endpoint assuming 6% event rate in the femoral access arm.The study had six prespecified subgroup analysis: Age (< 75 vs older), sex, body mass index, STEMI vs no STEMI, operator's annual radial PCI volume and center's median operator's radial PCI volume.Results: Among the 7,021 randomized patients, 99.8% underwent coronary angiography. The rate of crossover was 7.6% in the radial group and 2.0% in the femoral group. Most of the crossover in the radial group was due to failure of the coronary angiogram using the radial approach. There was no significant difference in the number of PCI catheters used between both groups. Fluoroscopy time was higher in the radial group (7.8 minutes vs 6.5 minutes; p< 0.001).The primary composite outcome at 30-days was not significantly different between both groups (3.7% with radial vs 4.0% with femoral, HR: 0.92, 95% CI: 0.72 – 1.71; p= 0.50). All of the components of the primary outcome were not significantly different between both groups: 1.3% vs 1.5% for death, 1.7% vs 1.9% for myocardial infarction, 0.6% vs 0.4% for stroke, and 0.7% vs 0.9% for non-CABG related major bleeding.PCI procedural success was 95% in both groups. Major vascular complications were lower using the radial approach (1.4% vs 3.7%; p< 0.001). Major vascular complications were defined as pseudoaneurysms needing closure, large hematoma, arteriovenous fistula, or an ischemic limb needing surgery.There were no significant subgroup interactions based on age, sex, body mass index or operator's radial PCI volume. There was significant interaction based on STEMI vs no STEMI (p for interaction= 0.025) and center's radial PCI volume (p for interaction 0.021), such as patients with STEMI and patients in centers with the highest tertile for PCI volume had reduction in the primary outcome with radial access.Significantly more patients in the radial group said to prefer radial approach if they need a future coronary angiography (90.2% vs 50.7%; p< 0.001).Conclusion: In patients with acute coronary syndrome undergoing coronary angiography, a radial approach compared to femoral approach, did not improve the primary composite outcome of all-cause death, myocardial infarction, stroke, or non-CABG related major bleeding, at 30 days. A radial approach reduced major vascular complications with a number needed to treat of approximately 43 patients. A radial artery approach was more commonly preferred by patients for future coronary angiography.One of the limitations of this trial is that the outcome of major vascular complications is subject to bias as it was reported by the investigators rather than centrally adjudicated.Given that this trial compares two approaches with similar costs, the observed reduction in vascular complications justifies an increased adoption of the radial approach. The safety of the radial approach has likely improved over the years as centers and operators have gained more experience. Moreover, patients have shown a clear preference for the radial approach, which is an important win as well.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber. Get full access to Cardiology Trial's Substack at cardiologytrials.substack.com/subscribe

N Engl J Med 2009;360:213-24Lancet 2015;386:1853-60Background: Fractional flow reserve (FFR) is a measure of the physiologic significance of a coronary stenosis that is defined as the ratio of maximal blood flow in a stenotic artery to normal maximal flow. It is measured during coronary angiography by calculating the ratio of distal coronary pressure measured with a coronary pressure guidewire to aortic pressure measured simultaneously with the guiding catheter. FFR in a normal coronary artery equals 1.0 whereas a value 90% and is similar to information obtained with stress imaging studies.For patients with multivessel coronary disease, it can be a challenge in the cath lab to differentiate between blockages causing ischemia and those that are not and this may be especially challenging when patients have not undergone stress imaging prior (e.g., patients presenting with acute coronary syndromes without ST segment elevation). The FAME trial sought to test the hypothesis that revascularization guided by FFR would be superior to revascularization guided by angiography alone in a broad cohort of patients with multivessel disease in whom revascularization with PCI was indicated.Patients: Patients with multivessel CAD of at least 50% of the vessel diameter in at least 2 of the 3 major epicardial coronary arteries in whom PCI was indicated. Patients with a STEMI could be included if the infarction occurred at least 5 days before PCI. Patients with a NSTEMI could be included earlier than 5 days. Patients who had undergone previous PCI could be included.Patients were excluded if they had left main coronary disease, previous CABG, cardiogenic shock, extremely tortuous or calcified coronary arteries, a life expectancy less than 2 years, a contraindication to the placement of drug-eluting stents, or if patients were pregnant.Baseline characteristics: Information is not provided on patients screened to enrolled. The average age of patients was 64.5 years and approximately three quarters were men. It is not clear from the main manuscript how many patients presented with acute MI's. It appears that approximately one third of patients presented with unstable angina and about half of these patients had dynamic ECG changes. More than half of patients in the trial had class 2 angina or below. Approximately 25% of patients had diabetes and over 60% had hypertension. The average EF was 57%.The mean number of lesions per patient was 2.8. About 40% of blockages were estimated to be in the 50-70% range, another 40% were in the 71-90% range, 15% were 91-99% narrowed and 3% were chronic total occlusions. The minimal luminal diameter was 1.0 mm, mean reference vessel diameter was 2.5 mm, mean lesion length was 12.5 mm and the SYNTAX score was 14.5.Procedures: Patients were randomized after they were found to have multivessel disease, meeting the study criteria, and were thought to require PCI. Patients assigned to angiography-guided PCI underwent stenting of all indicated lesions with drug-eluting stents. Those assigned to FFR-guided PCI underwent FFR in each diseased coronary artery and drug-eluting stents were placed in lesions with FFR that was /=50% in 2 of 3 major epicardial coronary arteries) and an indication for PCI, that FFR-guidance may reduce stent use and improve outcomes over short-term follow-up. However, more data is needed to confirm this result and to distinguish patient populations most likely to benefit based on clinical indication for PCI and complexity of coronary anatomy.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber. Get full access to Cardiology Trial's Substack at cardiologytrials.substack.com/subscribe

In this episode, Dr. Valentin Fuster discusses a comprehensive network meta-analysis published in JACC, which evaluates the optimal strategy for complete revascularization in patients with STEMI and multi-vessel disease. The study concludes that both immediate and staged complete revascularization improve patient outcomes over partial revascularization, with no significant advantage between angiographic and functional guidance, suggesting that angiographic guidance alone may be sufficient in clinical practice.

In this episode, Dr. Valentin Fuster discusses five key studies from the January 2025 JACC issue, covering advancements in coronary angioplasty, revascularization strategies for STEMI, machine learning for ICD patient outcomes, thromboxane's link to heart failure, and TAVR valve types and anesthesia approaches. These studies provide valuable insights into improving cardiovascular care and treatment.

N Engl J Med 2016;375:1242-1252Background: The first drug-eluting stent (DES) was approved by the FDA in 2003 following the publication of the RAVEL trial. Since then, newer generations of DES were developed and were tested in clinical trials. The majority of trials comparing DES to bare-metal stents (BMS) showed reduction in repeat revascularization with DES but no significant reduction in death or myocardial infarction. Following these publications, the use of DES grew rapidly and was used in more than two thirds of percutaneous coronary interventions (PCI) by 2010.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.These trials, however, were very selective, had short follow up time (TAXUS-IV followed patients for 9 months and SPRIT IV followed patients for 12 months), and had limited power to assess hard outcomes.The NORSTENT trial investigators sought to compare DES to BMS in a more pragmatic design and follow patients for longer time.Patients: All patients who were undergoing PCI in Norway were assessed for enrollment. Patients had stable angina or acute coronary syndrome. Lesions were in native coronary arteries or bypass grafts.Patients were excluded if they had prior coronary stents, bifurcating lesions requiring a two-stent technique or life expectancy less than 5 years due to a medical condition other than coronary artery disease. Patients were also excluded if they had contraindications to dual antiplatelets or were taking warfarin.Baseline characteristics: The trial randomized 9,013 patients – 4,504 randomized to receive a DES and 4,509 to receive a BMS.The average age of patients was 63 years and 75% were men. Approximately 42% had hypertension, 54% had hyperlipidemia, 10% had prior myocardial infarction, 7% had prior CABG, 12% had diabetes, and 35% were current smokers.The indication for PCI was stable angina in 29% of the patients, unstable angina in 12% and STEMI or NSTEMI in 58%.Procedures: The study was open-label but outcomes assessment was blinded. Patients were randomly assigned in a 1:1 ratio to receive DES or BMS. Patients could receive several stents as clinically indicated but can only receive the assigned stent type during the index procedure.In all patients, aspirin 75 mg daily was given indefinitely while clopidogrel 75 mg daily was given for 9 months.Follow up visits were done as clinically appropriate without specification from the study protocol. Similarly, no routine follow up coronary angiography was performed.Endpoints: The primary outcome was a composite of all-cause death or spontaneous myocardial infarction. Secondary outcomes included repeat revascularization, stent thrombosis, major bleeding and health status based on the Seattle Angina Questionnaire.Clinical outcomes were collected by linking each patient unique national identification number to the Norwegian national patient registry.Analysis was performed based on the intention-to-treat principle. The study planned to enroll 8,000 patients to be followed for a median of 5 years. Assuming the 5-year event rate of the primary outcome to be 17%, the study would provide 93% power to detect 3% absolute risk difference between the study groups (rate ratio: 1.18). Due to lower than expected mortality, the sample size was increased to 9,000 patientsResults: Among the 20,663 patients who were assessed for eligibility, 12,425 met inclusion criteria. Among patients who met inclusion criteria, 9,013 were randomized. Figure 1 in the manuscript provides details for excluding patients and for not randomizing patients who met eligibility criteria. The most common reason for exclusion was prior PCI.The number of stents implanted per patient was 1.7 and more than 98% received the assigned stent type. The median follow up time was 5 years.The primary composite outcome of all-cause death or nonfatal spontaneous myocardial infarction was not significantly different between both treatment arms (16.6% with DES vs 17.1% with BMS, HR: 0.98; 95% CI: 0.88 - 1.09; p= 0.66).For the secondary outcomes – Hospitalization for unstable angina was similar between treatment groups (5.2% vs. 5.7%; p= 0.21). Stent thrombosis was lower with DES (0.8% vs 1.2%; p= 0.05). Target-lesion revascularization was also lower with DES (5.3% vs 10.3%; p< 0.001). Bleeding Academic Research Consortium (BARC) 3, 4 or 5 was similar between groups (5.5% vs 5.6%; p= 0.88).There was no significant difference in health status based on the Seattle Angina Questionnaire.There were no significant subgroup interactions.Conclusion: In patients undergoing PCI, the use of DES did not reduce the composite endpoint of death or spontaneous myocardial infarction compared to BMS. Target-lesion revascularization was reduced with DES with a number needed to treat of 20 patients.The findings of this study align with the results of other trials comparing DES to BMS. We have reviewed several key trials and included links to additional studies in this field below. Overall, DES significantly reduce target-lesion revascularization without significant effect on all-cause mortality or myocardial infarction.An important consideration in this and other related trials is that both stent types were studied using similar durations of dual antiplatelet therapy (DAPT) following PCI. For patients with stable angina, BMS typically require only one month of DAPT, while DES often necessitate three to twelve months. Since shorter durations of DAPT are generally safer for patients, a trial comparing DES with three to twelve months of DAPT compared to BMS with one month of DAPT would be insightful.A final teaching point is that less than 50% of screened patients were ultimately enrolled in this pragmatic trial, which had minimal exclusion criteria. It's not uncommon for trials to enroll less than 5% of screened patients which limits their external validity.* Other trials of DES vs BMShttps://pubmed.ncbi.nlm.nih.gov/21080780/https://pubmed.ncbi.nlm.nih.gov/22951305/Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber. Get full access to Cardiology Trial's Substack at cardiologytrials.substack.com/subscribe

The chain of survival for a cardiac emergency and stroke start the same:1. preparedness & recognition of an emergency;2. activation of EMS; 3. delivery of Advanced Life Support; and 4. transporting to the most appropriate facility.ALS ambulances are staffed with paramedics who have training in ACLS skills. Why EMS "Destination Protocols" for suspected stroke and STEMI make a difference.ACLS's timed benchmarks for: point of first medical contact to PCI for ST elevation MI;door to tPA for ischemic stroke; andonset of symptoms to EVT for LVO strokes.Why EMS should bypass a close hospital to transport a STEMI or suspected stroke patient to a hospital capable of 24/7 PCI or a certified stroke center. Check out the Pod Resource page at passacls.com for links to the "EMS On Air" podcast for links to episodes that look at EMS's role in stroke outcomes in the rural vs urban area.Connect with me:Website: https://passacls.com@Pass-ACLS-Podcast on LinkedInGive Back & Help Others: Your support helps cover the monthly cost of software and podcast & website hosting so that others can benefit from these ACLS tips as well. Donations via Buy Me a Coffee at https://buymeacoffee.com/paultaylor are appreciated.Good luck with your ACLS class!

Contributor: Travis Barlock MD Educational Pearls: What is the ST segment? The ST segment on an ECG represents the interval between the end of ventricular depolarization (QRS) and the beginning of ventricular repolarization (T-wave).  It should appear isoelectric (flat) in a normal ECG. What if the ST segment is elevated? This is evidence that there is an injury that goes all the way through the muscular wall of the heart (transmural) This is very concerning for a heart attack (STEMI) but can be occasionally caused by other pathology, such as pericarditis What if the ST segment is depressed? This is evidence that only the innermost part of the muscular wall of the heart is becoming ischemic This has a much broader differential and includes a partial occlusion of a coronary artery but also any other stress on the body that could cause a supply-and-demand mismatch between the oxygen the coronaries can deliver and the oxygen the heart needs This is called subendocardial ischemia What else should you look for in the ECG to identify subendocardial ischemia? The ST-depressions should be at least 1 mm The ST depressions should be present in leads I, II, V4-6 and a variable number of additional leads. There is often reciprocal ST elevation in aVR > 1 mm The most important thing to remember when you see subendocardial ischemia is…history Still, keep all cardiac causes on your differential, such as unstable angina, stable angina, Prinzmetal angina, etc. Also consider a wide array of non-cardiac causes such as severe anemia, severe hypertension, pulmonary embolism, COPD, severe pneumonia, sepsis, shock, thyrotoxicosis, stimulant use, DKA, or any other state that lead to reduced oxygen supply to the subendocardium and/or increased myocardial oxygen demand. References Birnbaum, Y., Wilson, J. M., Fiol, M., de Luna, A. B., Eskola, M., & Nikus, K. (2014). ECG diagnosis and classification of acute coronary syndromes. Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and Noninvasive Electrocardiology, Inc, 19(1), 4–14. https://doi.org/10.1111/anec.12130 Buttà, C., Zappia, L., Laterra, G., & Roberto, M. (2020). Diagnostic and prognostic role of electrocardiogram in acute myocarditis: A comprehensive review. Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and Noninvasive Electrocardiology, Inc, 25(3), e12726. https://doi.org/10.1111/anec.12726 Cadogan, E. B. a. M. (2024, October 8). Myocardial Ischaemia. Life in the Fast Lane • LITFL. Retrieved December 7, 2024, from https://litfl.com/myocardial-ischaemia-ecg-library/#:~:text=ST%20depression%20due%20to%20subendocardial,left%20main%20coronary%20artery%20occlusion. Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce & Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

In Part 2 we discuss sports medicine and the hyperthermic patient, importance of EMS documentation, anaphylaxis in pediatric care, dosing, shock, RSI, cardiac arrest care, STEMI care and EMS, and patient capacity in psychiatric emergencies

In the November issue of the Annals of Emergency Medicine podcast, Ryan and Rory discuss time to targeted temperature management, PE diagnostic pathways, AI assistant STEMI recognition, and much much more.

JACC: Associate Editor Celina Yong, MD, interviews author Jacob Eifer Møller, PhD about his DANGER SHOCK paper presented at AHA and published in JACC. The DanGer Shock trial demonstrated reduced mortality in patients with STEMI-related cardiogenic shock treated with a microaxial flow pump (mAFP). This secondary analysis assessed whether age affected survival benefits. Mortality increased incrementally with age, and age was independently associated with outcome. Spline analysis suggested that the risk of mortality was higher in the standard-care group for patients below 77 years, whereas patients aged 77 or older had a higher predicted risk in the mAFP group. Thus, elderly patients may not attain the same benefit from routine treatment with a mAFP as younger patients.

N Engl J Med 2022;386:128-137Background: Patients with three-vessel coronary artery disease have better outcomes when revascularization is performed using coronary artery bypass grafting (CABG) compared to percutaneous coronary intervention (PCI), as seen in the SYNTAX and FREEDOM trials. Fractional flow reserve (FFR) was not required and was not routinely performed in these trials.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.The Fractional Flow Reserve versus Angiography for Multivessel Evaluation (FAME) 3 trial sought to compare the outcomes of FFR-guided PCI vs CABG in patients with three-vessel coronary artery disease.Patients: Eligible patients had three-vessel coronary artery disease defined as 50% or more stenosis, by visual estimation, in any of the three major coronary arteries or major branches. Lesions had to be amenable to revascularization by PCI and CABG as determined by the heart team.Major exclusion criteria were left main disease, cardiogenic shock, STEMI within 5 days, active NSTEMI with cardiac troponin still rising, left ventricular ejection fraction

In this episode, Dr. Valentin Fuster discusses a pivotal study on revascularization strategies in older patients with myocardial infarction, comparing complete versus culprit-only approaches. The findings suggest that physiology-guided complete revascularization significantly reduces adverse outcomes in both STEMI and non-STEMI patients, emphasizing its potential benefits across a diverse patient population.

The chain of survival for ACLS is the same as was learned in your BLS class. The beginning steps of the Cardiac Emergency and Stroke chain of survival. ACLS's timed goals for first medical contact to PCI for STEMI and door-to-needle for ischemic stroke. Characteristics of areas that have significantly better stroke and out-of-hospital cardiac arrest outcomes. Connect with me:Website: https://passacls.com@Pass-ACLS-Podcast on LinkedInGive Back & Help Others: Your support helps cover the monthly cost of software and podcast & website hosting so that others can benefit from these ACLS tips as well. Donations made via Buy Me a Coffee at https://buymeacoffee.com/paultaylor are appreciated.Make a difference in the fight against breast cancer by donating to my Men Wear Pink fundraiser for the American Cancer Society (ACS) at http://main.acsevents.org/goto/paultaylor Every dollar helps in the battle with breast cancer.Good luck with your ACLS class!

N Engl J Med 2012;367:2375-2384Background: The first large trial to compare PCI vs CABG was SYNTAX. In the subgroup of patients with diabetes, which made up approximately 25% of the trial population, PCI was associated with a higher rate of adverse events compared to CABG, primarily driven by higher rates of repeat revascularization in the PCI group.The Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) trial sought to assess the optimal revascularization strategy for patients with diabetes and multivessel coronary artery disease.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.Patients: Eligible patients had diabetes and multivessel coronary artery disease defined as a stenosis of 70% or more in two or more major coronary arteries supplying at least two separate territories.Patients with left main stenosis of 50% or more were excluded as well as patients with severe congestive heart failure, prior CABG or valve surgery, stroke within 6 months, significant bleeding within 6 months, 2 or more chronic total occlusions in major coronary territories that are targets for revascularization, and patients with STEMI within 72 hours.Baseline characteristics: The trial randomized 1,900 patients – 953 randomized to PCI and 947 to CABG.The average age of patients was 63 years and 71% were men. The average HbA1c was 7.8 and 32% were using insulin. Approximately 26% had prior myocardial infarction and 16% were current smokers. The average left ventricular ejection fraction was 66%.Approximately 83% had three vessel disease and 6% of the lesions were classified as chronic total occlusions. The SYNTAX score was low (22 or less) in 35% of the patients, intermediate (23 - 32) in 45% and high (33 or more) in 20%.Procedures: Patients were randomized in a 1:1 ratio to undergo CABG or PCI using drug-eluting stents. The use of arterial conduits was encouraged for patients undergoing CABG.Dual antiplatelet therapy with aspirin and clopidogrel was recommended for at least 12 months following PCI.Endpoints: The primary endpoint was a composite of death from any cause, nonfatal myocardial infarction, and nonfatal stroke. Secondary analysis was performed based on the SYNTAX score and study center location; north America vs not.Analysis was performed based on the intention-to-treat principle. The estimated sample size was 1,900 patients to be followed up for at least 2 years. This sample size would provide 80% power to detect a 27% relative risk reduction in one treatment group based on an estimated event rate of 21.5% in the arm with higher event rate.It's important to note that the initial sample size was 2,400 patients but this was amended twice due to slow recruitment.Authors performed 3 interim analyses and therefore, the p value to indicate statistical significance for the primary outcome was adjusted to be 0.044.Results: Among 32,966 patients who were screened for inclusion, 3,309 (10%) were found eligible. Among eligible patients, 1,900 consented to the trial and were randomized. The breakdown for excluding patients was not provided. The median follow up time was 3.8 years (interquartile range: 2.5 - 4.9). In the PCI arm, the average number of lesions stented per patient was 3.5 and 34% underwent a staged procedure. In the CABG arm, the average number of vessels grafted was 2.9 and 94% had a left internal mammary artery graft.At 5-years, the primary outcome was lower in the CABG arm (18.7% vs 26.6%, absolute difference 7.9%, 95% CI: 3.3 – 12.5; p= 0.005). All-cause death was lower with CABG (10.9% vs 16.3%; p= 0.049) as well as myocardial infarction (6.0% vs 13.9%; p< 0.001). When examining the Kaplan-Meier curves for the primary endpoint as well as death (figure 1 of the manuscript), the curves start to diverge, in favor of surgery, at approximately 2-years of follow up.Stroke was higher with CABG (5.2% vs 2.4%; p= 0.03). Excess stroke in the CABG arm was largely within 30-days after the procedure (1.8% vs 0.3%).Major bleeding within 30-days after revascularization was not significantly different between both treatment groups (3.6% with CABG vs 2.4% with PCI; p= 0.13). Acute renal failure requiring dialysis within 30-days after revascularization was higher with CABG (0.8% vs 0.1%; p= 0.02).There were no significant subgroup interactions that included the SYNTAX score, sex, 2- or 3-vessel disease and study center location; north America vs not.Conclusion: In patients with diabetes and multi-vessel stable coronary artery disease, CABG was superior to PCI in reducing the primary endpoint that consisted of death from any cause, nonfatal myocardial infarction, and nonfatal stroke with a number need to treat (NNT) of approximately 13 patients over an average follow-up period of 3.8 years. All-cause death and myocardial infraction were significantly lower with CABG with a NNT of approximately 19 and 13, respectively. Stroke was higher with CABG with a number needed to harm (NNH) of 36 patients. CABG also increased the risk of acute renal failure requiring dialysis within 30-days after revascularization with a NNH of approximately 143.A key difference between this trial and the early CABG trials is the frequent use of internal mammary grafts in FREEDOM (94% vs 10%). Internal mammary grafts are resistant to atherosclerosis and have high patency rates. One possible explanation for the divergent results between this trial and SYNTAX, which also used arterial grafts frequently, is the follow up time. In SYNTAX, patients were followed for 1 year while FREEDOM followed patients up to 5 years and the curves for the primary outcome and death favoring CABG started to diverge at approximately 2 years.When deciding between CABG and PCI for patients meeting the trial's eligibility criteria, it's important to consider the early risks associated with surgery, with the benefits of CABG becoming more apparent after 2 years. Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber. Get full access to Cardiology Trial's Substack at cardiologytrials.substack.com/subscribe

In this week's episode of Parallax, host Dr Ankur Kalra engages in a thought-provoking discussion with Dr Stephen Smith, a pioneer in electrocardiography and myocardial infarction diagnosis. They delve into the groundbreaking OMI/NOMI paradigm (Occlusion MI vs Non-Occlusion MI), challenging the traditional STEMI vs non-STEMI terminology that has long been the cornerstone of acute coronary syndrome management. Dr Smith presents compelling evidence highlighting the limitations of ST-elevation as a marker for acute coronary occlusion, discussing his recently published review paper: "From ST-Segment Elevation MI to Occlusion MI: The New Paradigm Shift in Acute Myocardial Infarction". The conversation explores the proposed shift to the OMI/NOMI terminology and the specific ECG criteria for diagnosing occlusion MI. Dr Smith discusses the challenges in disseminating this new paradigm and teaching these refined ECG interpretation skills to clinicians. Dr Kalra and Dr Smith explore exciting developments in AI-assisted OMI detection and ongoing studies aimed at validating the OMI/NOMI approach. How can clinicians effectively implement the OMI/NOMI criteria into daily practice? What challenges exist in teaching these new ECG interpretation skills, and how can they be overcome? What advice does Dr Smith have for our listeners? Full source library for this episode can be found on radcliffecardiology.com.

EARTH-STEMI – Complete vs. Culprit-Only Revascularization in Older STEMI Patients

The chain of survival for a cardiac emergency and stroke start the same: 1. preparedness & recognition of an emergency;2. activation of EMS;3. delivery of Advanced Life Support; and 4. transporting to the most appropriate facility. ALS ambulances are staffed with paramedics who have training in ACLS skills. Why EMS "Destination Protocols" for suspected stroke and STEMI make a difference. ACLS's timed benchmarks for: point of first medical contact to PCI for ST elevation MI;door to tPA for ischemic stroke; andonset of symptoms to EVT for LVO strokes.Why EMS should bypass a close hospital to transport a STEMI or suspected stroke patient to a hospital capable of 24/7 PCI or a certified stroke center. Check out the Pod Resource page at passacls.com for links to the "EMS On Air" podcast for links to episodes that look at EMS's role in stroke outcomes in the rural vs urban area.Connect with me:Website: https://passacls.com@Pass-ACLS-Podcast on LinkedInGive Back & Help Others: Your support helps cover the monthly cost of software and podcast & website hosting so that others can benefit from these ACLS tips as well. Donations made via Buy Me a Coffee at https://buymeacoffee.com/paultaylor are appreciated.Make a difference in the fight against breast cancer by donating to my Men Wear Pink fundraiser for the American Cancer Society (ACS) at http://main.acsevents.org/goto/paultaylor Every dollar helps in the battle with breast cancer.Good luck with your ACLS class!

In this episode, Dr. Valentin Fuster discusses a pivotal study comparing bivalirudin and heparin anticoagulation in STEMI patients undergoing primary PCI, highlighting that bivalirudin may reduce cardiac mortality and bleeding without increasing thrombotic events. While the findings challenge previous guidelines favoring heparin, limitations in the research prompt caution about immediate changes to clinical practice, emphasizing the need for further exploration of bivalirudin's role in diverse patient populations.

In this episode, Dr. Valentin Fuster summarizes the October 2024 issue of the JACC Journal, highlighting four pivotal studies on atrial fibrillation, anticoagulation strategies in STEMI, heart failure risk assessment, and the impact of urinary metal levels on coronary artery calcification. Emphasizing the increasing prevalence of atrial fibrillation and the critical role of biomarkers, he underscores the urgent need for enhanced prevention strategies and public health actions regarding environmental metal exposure.

The Laser Atherectomy for STEMI, PCI Analysis with Scintigraphy Study

10th ESC 2024: EARTH-STEMI meta-analysis

The JournalFeed podcast for the week of Sept 9-13, 2024.These are summaries from just 2 of the 5 articles we cover every week! For access to more, please visit JournalFeed.org for details about becoming a member.Monday Spoon Feed:There are an increasing number of water bead related injuries in children, with the majority occurring in children less than five. While most cases can be treated and released from the ED, water bead injury can be serious and even deadly.Friday Spoon Feed:These researchers developed and trained a deep ensemble artificial intelligence (AI) model to classify ECGs as STEMI versus non-STEMI. The AI performed well in both accuracy and in improving sensitivity.

Our final entry into the EKG Manifesto series moves into the STEMI/OMI world of acute coronary occlusion. Who do we activate and why? Where is the STEMI paradigm headed? Join Dr. Patrick and Dr. Dickson to refresh your EKG knowledge. REFERENCES 1. https://www.emdocs.net/ecg-pointers-stemi-equivalents-from-the-american-college-of-cardiology/

The chain of survival for ACLS is the same as was learned in your BLS class. The beginning steps of the Cardiac Emergency and Stroke chain of survival. ACLS's timed goals for first medical contact to PCI for STEMI and door-to-needle for ischemic stroke. Characteristics of areas that have significantly better stroke and out-of-hospital cardiac arrest outcomes.Connect with me:Website: https://passacls.com@Pass-ACLS-Podcast on LinkedInGive Back & Help Others: Your support helps cover the monthly cost of software and podcast & website hosting so that others can benefit from these ACLS tips as well. Donations made via Buy Me a Coffee at https://buymeacoffee.com/paultaylor are appreciated.Make a difference in the fight against breast cancer by donating to my Men Wear Pink fundraiser for the American Cancer Society (ACS) at http://main.acsevents.org/goto/paultaylor Every dollar helps in the battle with breast cancer.Good luck with your ACLS class!

MRAs in HF with renal dysfunction, coronary autoregulation, the hubris of US doctors, NSTEMI in older patients, survival after STEMI, and new leaders at JACC are discussed by John Mandrola, MD. This podcast is intended for healthcare professionals only. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I Listener Feedback Combined analysis (Matsumoto) II Coronary artery autoregulation with increasing stenosis NEJM Paper https://www.nejm.org/doi/full/10.1056/NEJMc2402216 III RECOVER IV Trial Gregg Stone, MD Tweet https://x.com/GreggWStone/status/1803583552354742416 DANGER-Shock Trial https://www.nejm.org/doi/full/10.1056/NEJMoa2312572 Impella Saves Lives in Cardiogenic Shock, but Patient Selection Key https://www.medscape.com/viewarticle/1000659 IV NSTEMI Elderly Main Paper Datamethods https://discourse.datamethods.org/t/random-vs-fixed-effects-meta-analysis/7361 O'Fee Paper https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2785560 V MI Survival Danish Paper https://doi.org/10.1016/j.jacc.2024.04.025 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

In this month's EM Quick Hits podcast: Megan Landes on the importance of diagnosing HIV in the ED, Jesse McLaren on the failed paradigm of STEMI criteria and ECG tips to identify acute coronary occlusion, Anand Swaminathan on evidence for non-invasive airway management in the poisoned patient, Brit Long and Hans Rosenberg on the identification, workup and management of spontaneous bacterial peritonitis, Matt Poyner on the most lucrative side-gig, DIY investing. To support EM Cases, please consider a donation here: https://emergencymedicinecases.com/donation/