Adham Karim is a 3rd year resident going into cardiology. He plans to join the burgeoning field of cardiology critical care, and when he's not taking H&P's, he's outdoors trying to get as much sunlight as possible. Adham enjoys rock climbing, soccer, and the occasional Spartan Race. For more articles by Adham, check out his blog www.critcarecardio.com. Follow on Twitter: @critcarecardio
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What will training look like in the post-pandemic era?

Adham Karim, MD

I remember my first week of internship very clearly – I was a part of my first code blue as a physician. Later that week, I had to have a goals of care discussion with a patient who had been in the hospital for 3 weeks (longer than I had been a doctor at that point). These were new experiences that I was eager for, but I was fortunate to have my routine that maintained a sense of normalcy for me, very much like naptime to my toddler. I was diligent in pre-rounding and seeing all my patients before my attending showed up, and would have formed a plan for their care before 8 AM.

Once the COVID-19 pandemic was in full swing here in the US, a lot of these things that were part of my routine as an intern suddenly went to the wayside. At my institution, interns were instructed not to pre-round on patients such as to minimize contact and potential infection transmission. Family meetings could only be conducted via telephone, or in some cases, video conference. Code blues were no longer a mad dash to the patient’s room, but rather, different hospital wards had different teams, such that a provider taking care of COVID+ patients does not go to a code blue for non-COVID patients and vice versa.

Rounding on these revamped inpatient teams has been…interesting to say the least. I can’t tell you the amount of times I or an attending will ask the patient a question about the patient and the response is “I don’t know, I haven’t seen them.” It’s great that interns are more comfortable admitting they don’t know something rather than lie about it, but at the same time, I can’t help but feel a sense of lack of ownership on their behalf.

Everybody will tell you that intern year sucks, and it’s rough, and they would hate to go back and do it again. But many people will also admit that they are impressed with how much they have learned and managed to push themselves beyond their perceived level of comfort during that time frame. I didn’t particularly enjoy coming to the hospital early each day I was on an inpatient service just to see my patients and review their charts, or going to the patient’s room for the umpteenth time in a day, but there have been a number of times where something meaningful was gleaned, and my ability to think critically and manage patients independently grew a little that day.

The thing that bothers me the most about these precautions is the huge change to goals of care discussions and family meetings. The logic behind it – minimizing spread of infection and exposures – makes sense and I agree with it completely. But it’s hard to develop good rapport with an individual only over the phone, and similarly, it’s difficult to comfort another human being digitally. There’s something about the physical presence of another person, the eye contact, and even the slightest gestures, that can help make the worst day of someone’s life a little less painful.

It’s quite fortunate that these protocol changes came more than halfway through the academic year, when interns at least have a handle on what things to look out for and have developed their own sense of alarm from glancing at the chart. I can’t imagine starting intern year where I only physically interact with “my” patients during rounds with my attending, or via telephone, unless there is some kind of emergency.

On the other hand, this is accelerating our embrace of telemedicine on the outpatient side, which is good for both patients and providers in many cases, and from my anecdotal experience, has resulted in a lot fewer “no-shows.” Interns are afforded more sleep, and arguably learning to pay more attention to vital signs changes and lab value changes – or at least they’re getting a better sense of when they should actually get up and go see the patient (sometimes at the urging of their senior 😊). This could simply be an inevitable step in the evolution of medical education that was accelerated by the pandemic, but I can’t say I feel that all these changes should be here to stay.

Whether it was fumbling through morning rounds and trying to formulate a new plan based on overnight events, or developing my emotional intelligence and flexing that empathy muscle, these were formative experiences for me during my intern year that have significantly contributed to my development as a clinician. These could just be the ramblings of a dinosaur, much akin to the older physicians talking about their paper charts, fibrinolytics and 48 hour calls, but I do hope some of these changes can be undone soon, for the sake of our trainees as well as our patients and their families.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”
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Physicians Shouldn’t Be Heard Only During a Pandemic

Adham Karim, MD

I know that COVID-19 has dominated the headlines for quite some time, and I’m sorry in advance, but yeah, this is another COVID-19 article. I’m not an infectious disease expert, and I’m not here to talk about the possible health benefits of black seed oil, vitamin C, or Alex Jones’s anti-covid toothpaste.

The anti-vaxxer movement and the virulent spread of e-cigarettes helped highlight what happens when physicians and scientists are silent on social media – pseudoscience and flat out bad advice rise to fill the void. Of course both of these movements have swung in the other direction as more knowledgeable voices found prominence, but that’s not without many unfortunate cases of measles and vape induced lung injury first causing people to second guess the misinformation.

With our current situation, there are a LOT of learning points. Chief amongst them is what happens when doctors stay out of (or get involved in) public policy. The national stockpiles were woefully understocked. The pandemic response team was dismantled (in 2018). The CDC lost huge amounts of funding. The list goes on and on. On the other hand, having an experienced physician in the room where decisions are made has had a significantly positive impact. Of course, like vaccines, statins, and social distancing, it’s difficult to quantify the impact of something when all you’re left with is the absence of a bad outcome.

What’s not difficult, is to learn from what happened with this outbreak. We’ve seen a rapid shift towards telemedicine adoption, and a lag in the deployment of testing kits. We’ve also seen that rapid adoption of a potential wonder drug treatment (hello Hydroxychloroquine) might actually result in MORE deaths, and make it difficult for people with lupus and rheumatoid arthritis to get refills on their HCQ prescriptions. Society as a whole has come to realize.

As a trainee, I’ve read heart wrenching stories about people in my position forced to work with inadequate PPE, and ultimately succumbing to this virus. I agree that medicine is a field that demands sacrifice, but I disagree that someone who signed up for this job should accept improper protection at the risk of their own life. In my own program, residents have come down with the coronavirus despite adequate PPE; so I can only imagine how those with less equipment must feel like. Having spent time on the Covid unit myself, I got a taste of what my friends in New York and Chicago were dealing with on a larger scale, and an every day basis for the past several weeks. Of course, I’m fortunate enough to work in a state that was not in the top 3 hit by coronavirus, and whose leadership includes a pro-active governor and an experienced physician.

We need to be more vocal on the policy level – and while it may not be as sexy as deploying a stent into a thrombosed LAD or as intellectually titillating as making a breakthrough in the science of atherosclerosis, it is arguably just as necessary. We don’t need to be running for office, but it certainly wouldn’t hurt to write to one’s Congress representative (https://www.house.gov/representatives/find-your-representative), and sign with your name and job title. Let them know how many people’s lives you impact, and tell them to provide you with aid. I’m not just talking about masks and gowns. I’m talking about hazard pay and disability benefits. If I suffer complications related to coronavirus, I most likely got it because of my job, not because I went to the grocery store one time last week. I want to know my family won’t get sacked with a huge bill because of that. As a physician, I’m fortunate enough to expect an increase in pay when I finish training, but I work alongside many other healthcare providers who are not so fortunate – they shouldn’t have to worry about financial calamity just for doing their job and helping their fellow countrymen.

Several iterations of coronavirus relief aid have been put out by Congress, and trillions of dollars have been disbursed. I’m glad to know that Shake Shack was able to secure 10 million dollars to pay its employees, but I’d like to know what has been done for the residents in NY who died from complications relating to Covid. What’s more is that we are now starting to see the consequences of the Covid scare – the dramatic down tick in strokes, STEMI activations and other acute illnesses doesn’t mean America suddenly got healthier – it means that a lot of these people were staying home, and our hospitals will need to be prepared to deal with the sequelae of these conditions as people start to come out of the woodwork.

In a climate where the aid given to businesses and Wallstreet far outweighs that given to the front line providers, I can only say that we physicians are not blameless. Ultimately, these are just the frustrated ramblings of another trainee who has seen so many of his colleagues impacted negatively one way or another, all while the public is more concerned with being able to mow their lawn than the wellbeing of those on the front line. As Dr. Fauci (who, by the way, might be getting nominated to be Vanity Fair’s Sexiest Man Alive) once said: “you just have a job to do. Even when somebody’s acting ridiculous, you can’t chide them for it. You’ve got to deal with them. Because if you don’t deal with them, then you’re out of the picture.”

Sources

https://www.ama-assn.org/delivering-care/public-health/residency-pandemic-how-covid-19-affecting-trainees

http://www.onlinejacc.org/content/early/2020/04/07/j.jacc.2020.04.011

https://www.medscape.com/viewarticle/928337

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

 
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On teaching Professionalism

Adham Karim, MD

Professionalism is a multi-faceted concept that carries different meanings to different people; it ranges from a physician’s bedside manner and acknowledging mistakes, to how one interacts with their peers and if they show up on time. Not only that, but this all-encompassing term is cited as a core competency by the American Association of Medical Colleges. It is also a part of the American Medical Association’s code of ethics and explicitly mentioned in the syllabi of most medical schools and training programs across the U.S. Despite the broad acceptance of professionalism as a key character component of a well-rounded clinician, there is a significant difficulty experienced in trying to teach this to trainees. This may seem a little long-winded, but this is a subject that really resonated with me, and with JAMA instituting a professionalism section a few years ago, there have been more and more pieces published on the topic; I’m happy to see that this is gaining more traction. Everybody will tell you that administrative burdens and needing to deal with insurance providers for prior auths and the like definitely contribute to burnout, but having unprofessional colleagues can be just as burdensome and unsafe for patients!

I recently came across an excellent piece in the New England Journal of Medicine titled “Responding to Unprofessional Behavior by Trainees – A “Just Culture” Framework” wherein Dr. Wasserman, Redinger, and Gibb attempted to tackle the difficult yet important concept of professionalism in medical training. The article made a strong case for treating lapses in professionalism as if they were medical errors of varying severity, and they included an infographic, as well as gave several examples to go with this framework. In my opinion, professionalism is one of those behaviors that is nearly impossible to teach in a classroom and is often developed through a mix of modeling behaviors from more senior physicians, as well as a little bit of one’s own personality/temperament mixed in.

There was an example cited by the authors that centers around a medical student who has begun a collaboration with a mentor on some database analysis. The mentor states this is an IRB-exempt study and urges the student to begin analysis immediately, but the student’s research office instructs her not to download the data until getting an official exemption was issued by the IRB. The mentor pressures the student into downloading it anyways, and the student gets reprimanded for this. Wasserman et al suggest this is a lapse in professionalism at the lowest level – “no-fault suboptimality” resulting from the student’s faulty understanding that the supervisor (mentor) is right. They focus on teaching the student “strategies for diplomatically addressing her mentor” and acknowledge it is a difficult situation. What they don’t do, however, is acknowledge the context of this lapse of professionalism; they make no mention of addressing the mentor’s behavior or holding them accountable.

By all means, I agree that the student’s incorrect logic needs to be addressed. But, by not addressing the lapse in the professionalism of the mentor, I think the authors missed an opportunity to strengthen the analogy of professionalism and medical errors. In the “Just Culture” movement, physicians were just as accountable as nurses, who were as accountable as medical students for speaking up against unsafe practices. In this scenario, I would argue that the mentor is more liable, and should be held even more accountable than the medical student. As the authors have already made clear, trainees are still developing their understanding of professionalism, but this mentor is arguably an individual who has completed their training and should have a stronger grasp of professionalism than a mere medical student.

I concede that their article was aimed moreso at addressing lapses in professionalism of trainees, but this circles back to my personal view of how professionalism is developed. As others have stated, ensuring an individual trainee’s “competence in the area of professionalism requires the concerted efforts of many.” However, what about non-trainees? You could assume that a hospital board or professional society will self-govern to ensure professional behaviors, but with a term that is so loosely defined, and with financial incentives on the line, how much would someone be able to move the needle? I think most of us can remember at least one time (or many), when a senior physician tore into a helpless colleague, or became frustrated and lost their temper. How often do you think these individuals get a time-out or get part of their wages withheld as a punishment?

This brings me to my point: if the system is flawed, how does putting additional pressure on trainees fix that? The “do as I say, not as I do” approach has never been tested in a randomized trial, but conventional teaching theory (and common sense) will tell you that this is not effective. I myself am a trainee still (you’re reading the Fellows In Training blog, duh), so I certainly do not have all the answers.

From my time spent in developing medical school curricula, and sitting on academic disciplinary committees, I’ve come away with a few insights that I think might help. When the issue is a systems issue – such as “well everyone in my class skips grand rounds, I thought it was ok” the individual who got caught usually got caught due to chance, and reprimanding them would be unfair. Wasserman et al mentioned that the system needs to be changed, but didn’t talk about how. I’m gonna piggyback on that, because systems changes are difficult, and can be nuanced depending on the problem.

I think that lapses in professionalism should be addressed, but a better approach would be one that relies on positive feedback rather than only mentioning professionalism when it is missing. For example, in my medical school, and most training programs, at the middle and end points of a rotation, mentors would take the medical students for some formative “feedback”. Sometimes they were going off a form issued by the medical school, other times they would go off what they felt should be emphasized. If throughout a trainee’s career, different levels of professional behavior are emphasized by instructors, this could go a long way.

One example of this would be that mentors are instructed to focus on the aspect of timeliness and respectfulness with first-year students, making sure to comment on these in each student’s feedback; but when they give feedback to third years, they emphasize other aspects of professionalism, such as truthfulness, admitting to mistakes, knowledge gaps, etc.

Many theories have been put forth as to why professionalism can be such a difficult concept to teach and practice, but I think a critical shortcoming we have to acknowledge is the disconnect between the two worlds that trainees must straddle: the world in which we teach professionalism, and the world in which they practice.

 

References:

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”
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To Stent or not to Stent?

Adham Karim, MD

In the wake of the ISCHEMIA trial results being published, and the media firestorm that ensued, I’ve run into some interesting scenarios, including STEMI patients saying they don’t want to be revascularized because they heard on the news that stents are useless (oh boy!). However, after a robust discussion with an intern, I decided to do a quick n dirty rundown of who does and does not need immediate revascularization, and which strategy to go with.

If there’s one thing you should know about the ISCHEMIA trial, it is that this study sought to answer the question of whether or not STABLE ischemic heart disease would benefit from an aggressive revascularization strategy vs a conservative strategy of goal-directed medical therapy. This had nothing to do with patients who had ACS. I will also add that with long-term followup, the results might change, nobody knows for certain. The reason I say this is because the PCI arm had a signal towards harm in the first 6 months after revascularization, but as they approached 4 years, the mortality curves started to separate in favor of the aggressive revascularization arm. As it stands, their conclusions were not in favor of an aggressive strategy over a conservative one. Interestingly, these results didn’t differ very much from the COURAGE trial, where they found no significant difference between optimal medical therapy vs PCI for stable ischemic heart disease. Differences to note include the fact that COURAGE did NOT use FFR, and did not have routine use of DES.

Keep in mind, patients with left main stenosis > 50% were excluded from both of these trials, as were those who had recent revascularization within the past 6 to 12 months (PCI or CABG). The reason I mention this is because some people thought these results contradicted the findings of the COMPLETE trials – but no, these trials looked at different sets of patients altogether!

A few big wins for the ISCHEMIA trial:

  • CT-angiography was shown to be very reliable
  • FFR-guided PCI is becoming more routinely accepted as the preferred method of PCI
  • Optimal medical therapy really helps…even if there turns out to be a mortality benefit in favor of early-PCI, the fact that it takes several years to emerge is a statement about how helpful these medications truly are.

 

With regards to stable ischemic heart disease, clear indications for revascularization include left main stenosis > 50%, proximal LAD with >50% stenosis, or multi-vessel disease with signs of impaired ventricular function. Typically, cardiologists will employ the SYNTAX score, which is a validated system used to grade the severity and complexity of lesions. Typically, SYNTAX scores < 23 are amenable to PCI and non-inferior to CABG. The typical scenario for PCI is when you have isolated disease in only 1 or 2 vessels, and this is amenable to stenting.

Once you have significant left main disease, especially in conjunction with 2-3 vessel disease, the SYNTAX score is > 32, and CABG is superior.

Until very recently, it was generally accepted that isolated left main disease could be treated by PCI or CABG. However, some controversy has erupted recently after the results of the EXCEL trial were published. Specifically, the EXCEL trial had a composite endpoint of stroke, MI, or death, and there was no statistically significant differences between the two groups. Surgeons will tell you that the higher rates of the composite endpoint were driven by excess all-cause mortality in the PCI arm, as compared to peri-procedural MI in the CABG arm…in other words, while the composite endpoints were similar in both groups, the individual endpoint of mortality was higher with PCI, whereas peri-procedural MI was higher with CABG. This can certainly be a bit contentious, especially if you wonder what the clinical significance of a troponin elevation is after CABG. Nonetheless, the trial was powered to detect differences in the COMPOSITE endpoint, not in the individual endpoint of mortality.

The STICH trial demonstrated a significant benefit (albeit 10 years out) in favor of revascularization (this study only looked at CABG) for patients with ischemic heart failure. The FREEDOM trial took it one step further and tried to compare DES to CABG for mutli-vessel CAD in diabetics. The findings were strongly in favor of CABG over PCI, and this has become the accepted paradigm.

 

When you’re not sure, if they have funky looking anatomy AND they’re diabetic, you can make a safe gamble and ask your attending if they think this patient is a CABG candidate. 9 times out of 10, you’ll look like a genius.

In Conclusion:Stable ischemic heart disease has some controversy surrounding the role of revascularization, but ALL patients should be on optimal medical therapy

Patients with significantly reduced EF, Left main, proximal LAD disease, all should warrant a closer look at whether or not they would benefit from revascularization

Always try to involve a multi-disciplinary team when thinking about revascularization, at the end of the day, we are in the business of do no harm, so a second set of eyes can be beneficial.

 

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.

 

References:

https://www.ischemiatrial.org/

Boden, W. E., O’rourke, R. A., Teo, K. K., Hartigan, P. M., Maron, D. J., Kostuk, W. J., … & Chaitman, B. R. (2007). Title LM, Gau G, Blaustein AS, Booth DC, Bates ER, Spertus JA, Berman DS, Mancini GB, Weintraub WS; COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med, 356(15), 1503-16.

Campos, C. M., van Klaveren, D., Farooq, V., Simonton, C. A., Kappetein, A. P., Sabik III, J. F., … & Serruys, P. W. (2015). Long-term forecasting and comparison of mortality in the Evaluation of the Xience Everolimus Eluting Stent vs. Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial: prospective validation of the SYNTAX Score II. European heart journal, 36(20), 1231-1241.

Stone, G. W., Kappetein, A. P., Sabik, J. F., Pocock, S. J., Morice, M. C., Puskas, J., … & Banning, A. (2019). Five-year outcomes after PCI or CABG for left main coronary disease. New England Journal of Medicine, 381(19), 1820
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AHA19 Reflection

Adham Karim, MD

“Half of what we will teach you in medical school is right, and half of it is wrong – the problem is we don’t know which is which.” This quote, or some variation of it, is relayed by many educators at medical schools across the globe. At AHA19, these words rang in my ears as my head was spinning from attending lecture after lecture being given by experts in the field of cardiology. What I found to be most educational (and hilarious), were the debates on controversial topics.

The debates I attended ranged from the age-old IABP vs impella in cardiogenic shock patients, to thought-provoking jabs at conventional practice, such as whether or not sodium restriction is necessary in acute decompensations of heart failure. However, I’m not here to convince you that one form of mechanical circulatory support is superior to another, or that perhaps some of the things we put a lot of stake in (hello salt restriction), might not be true in all cases.

With each debate, when a physician explained their reasoning for being Pro-X or Anti-Y, I couldn’t stop nodding in agreement. Gaining insight into their reasoning was thought provoking in and of itself! I found myself agreeing, disagreeing, and scratching my head at different concepts. It helped me discover gaps within my own knowledge, and pushed me to review the primary literature in a way that no amount of pimping on the wards ever could.

One of my favorite debates was watching Dr. Gregg Stone debate with Dr. Obadia on the merits of mitral valve clipping for secondary mitral regurgitation (the lead investigators of 2 separate trials that basically showed totally different results). Neither physician said the other was wrong! In fact, they both more or less agreed with one another, and helped highlight key differences that a discerning physician should look for when faced with such discrepancies.

And the lectures that weren’t meant to be debates ended up sparking hot debates anyways! I’m looking at you #ISCHEMIA trial. The #Cardiotwitter explosion that began that ensued has been so eye-opening to me as a trainee. Not only did it help highlight some details of landmark trials I might have missed, but it gave me a great window into the line of thought of many skilled clinicians.

Coming through college, medical school, and residency, I’ve been exposed to many different styles of teaching, and I’ve seen conventional medical education evolve from a bunch of disjointed sciences taught in school to a formal systems-based curriculum. Social media has changed the landscape of many fields, and medical education is not immune to its effects. FOAMed (Free open access medical education) and social media have become staples in how some trainees learn, and we must embrace that. The way that the AHA sought to integrate this into their programming was a great experience that truly helped to cement new knowledge for me, and ultimately improve my patients’ care. And as I’ve come to learn, when it comes to these debates, it’s not about who is right or wrong, it’s about how much you can learn form hearing both perspectives.

 

 

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.
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A Few Things the Critical Care Cardiologist Might Have Missed While Talking About the #ISCHEMIA Trial

Adham Karim, MD

The ISCHEMIA trial definitely caused quite a chatter, and congratulations to the authors on a thought provoking and interesting study. I’m fascinated and can’t wait to do a deep dive on my own time. BUT, that’s for stable ischemic heart disease. There’s a time and a place for that, but that place is certainly not the ICU.

With that in mind, I’m going to briefly highlight a few presentations at this year’s AHA conference, and throw out a few breadcrumbs to pique your interest and hopefully encourage you to look into the primary literature.

 

Utilization and Outcomes of Impella vs IABP Among Patients with AMI Complicated by Cardiogenic Shock Undergoing PCI

In this talk, Dr. Sanket Dhruva and friends took data from the NCR CathPCI Registry, and created a linked cohort with the Chest Pain MI Registry. Out of 28,304 patients with AMI and CS, 8,471 received IABP only, 1,768 received Impella only. They were able to propensity match 1,680 (95%) of the Impella patients to IABP patients. The results were staggering: 45.0% mortality rate for Impella vs 34.1% with IABP. Major bleeds (as defined by the NCDR) occurred in 31.3% of Impella and 16.0% of IABP patients. They also stratified the patient event rates for pre and post-PCI initiation of mechanical circulatory support. Study perior was 10/2015 – 12/2017

Pre-PCI initiation of MCS:

  • Mortality 45.6% vs 36.8% Impella vs IABP
  • Major bleeding 27.4% vs 16.6% Impella vs IABP

Post-PCI initiation of MCS:

  • Mortality 44.0% vs 32.2% Impella vs IABP
  • Major bleeding 34.4% vs 15.7% Impella vs IABP

ischemia

Comments:

This was a historical cohort, this is observational data, and I think this highlights a need for a prospective RCT looking at the use of Impella vs IABP in patients with AMI and cardiogenic shock. Because of the nature of the dataset, the definitions of events were standardized across the board. I will also add that these patients were not stratified using the SCAI schema for cardiogenic shock (hard to use it when it wasn’t released during the study period!).  Is it possible that the sicker patients got Impella more frequently? Sure, but, Dr. Dhruva noted that most of the Impella devices used were the small 2.5, and not the 5.0. A study I was a part of looking at trends in utilization and mortality with MCS published earlier this year also found similarly increasing trends in utilization of MCS, but no difference overall with regards to mortality. That paper, too, performed retrospective data analysis, and carries many of the same limitations as this study.

 

1 year outcomes of the COACT: Coronary Angiography after Cardiac Arrest Trial

You are the physician on-call at your ICU. You hear of a patient who had an out-of hospital cardiac arrest, the rhythm was VT, ROSC was obtained in the field, and the post-ROSC ECG showed no STEMI. Do you take them to the cath lab, or do you just focus on targeted temperature management & stabilize the patient? What if it was an electrically silent MI!?

This study sought to provide some guidance for scenarios such as the one above. Followup was assessed at 90 and 365 days for the 538 patients enrolled in this study.

Exclusion criteria was STEMI, obvious non-coronary cause of arrest, delivery of electric shock

Inclusion criteria: Initial shockable rhythm, comatose after ROSC (GCS < 8) , and no ST elevation on post-ROSC ECG.

End-result, 61.4% of patients in the immediate angiography and 64.0% in the delayed angiography group were alive 1 year post-arrest. No significant difference in rates of revascularization, MI, or hospitalization for heart failure or ICD shocks between either group.

Comments:

Looking at the details, I saw roughly similar rates of PCI in both groups, I am curious if PCI utilizing FFR would have had different results in the delayed angiography group. Overall, I think this provides solid evidence to support the importance of focusing on stabilizing the post-cardiac arrest patient, and looking for other, non-cardiac causes of the arrest (assuming no obvious signs of MI).

 

Session on Hemodynamics in Cardiogenic Shock

This has a lot of buzz words that I like, and I’m a huge geek for physiology, so I basically camped outside the room in anticipation of this session.

The speakers were an all-star lineup, including Dr. Hall from Baylor University, Dr. van Diepen from University of Alberta, Dr. Wong of the University of British Columbia, Dr. Kapur from Tufts, and Dr. Thiele from the University of Leipzig.

 

My breadcrumb summary:

  1. The old definition of cardiogenic shock is not very helpful (sustained SBP < 90 mm Hg for at least 30 minutes and CI < 1.8 L/min/m2 along with elevated fillings pressures of LV, RV, or both).
  2. The newly released scheme from the SCAI is more useful, and helps to better standardize and stratify patients across the spectrum of CS (and this was already validated in a huge cohort).
    scai
  3. The duration and type of CS matters! Cardiogenic shock in a patient with ADHF is different than the patient with acute myocardial infarction!
  4. When considering what device to use for MCS, it is important to consider a few things, namely, what is your center most familiar (and therefore best) at doing? How much volume/flow do you anticipate needing?
    acuity
  5. The existing literature regarding MCS and CS associated with AMI is lacking in sample size, and we need more data.

 

Neurologic Function and Outcome After Cardiac Arrest

I’m not an expert, so I’m going to shamelessly regurgitate what the experts said. Namely, multi-modal imaging approaches can, with good specificity (but poor sensitivity), prognosticate poor chances of neurologic recovery 0 a very meaningful endpoint for these patients.

Similarly, there are a few biomarkers that may serve as standard serum measurements in the future, as we study them more.

Lastly, intranasal evaporative cooling (sounds super cool doesn’t it?) is a method of targeted temperature management that can improve neurologic outcomes after cardiac arrest.

summary

Check my references below for more reading, I highly recommend doing a deep dive, as I could not possibly do these excellent physicians justice on their expert summaries.

 

References:

  1. Dhruva SS. Utilization and outcomes of Impella vs IABP among patients with AMI complicated by cardiogenic shock undergoing PCI. Presented at: AHA 2019. November 17, 2019. Philadelphia, PA.
  2. Panhwar, Muhammad Siyab, et al. “Trends in the Use of Short-Term Mechanical Circulatory Support in the United States–An Analysis of the 2012–2015 National Inpatient Sample.” Structural Heart (2019): 1-8.
  3. Lemkes J.One Year Outcomes of Coronary Angiography After Cardiac Arrest. Presented at: AHA 2019. November 17, 2019. Philadelphia, PA.
  4. Lemkes JS, Janssens GN, van der Hoeven NW, et al. Coronary Angiography After Cardiac Arrest Without ST-Segment Elevation. N Engl J Med 2019;380:1397-407.
  5. Schrage, Benedikt, et al. “Impella Support for Acute Myocardial Infarction Complicated by Cardiogenic Shock: Matched-Pair IABP-SHOCK II Trial 30-Day Mortality Analysis.” Circulation10 (2019): 1249-1258.
  6. Thiele, Holger, et al. “Intraaortic balloon support for myocardial infarction with cardiogenic shock.” New England Journal of Medicine14 (2012): 1287-1296.
  7. Van Diepen, Sean, et al. “Contemporary management of cardiogenic shock: a scientific statement from the American Heart Association.” Circulation16 (2017): e232-e268.
  8. Baran, David A., et al. “SCAI clinical expert consensus statement on the classification of cardiogenic shock: This document was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), the Society of Critical Care Medicine (SCCM), and the Society of Thoracic Surgeons (STS) in April 2019.” Catheterization and Cardiovascular Interventions(2019).
  9. Jentzer, Jacob C., et al. “Cardiogenic shock classification to predict mortality in the cardiac intensive care unit.” Journal of the American College of Cardiology17 (2019): 2117-2128.
  10. Nordberg P, Taccone FS, Truhlar A, et al. Effect of Trans-Nasal Evaporative Intra-arrest Cooling on Functional Neurologic Outcome in Out-of-Hospital Cardiac Arrest: The PRINCESS Randomized Clinical Trial. 2019;321(17):1677–1685. doi:https://doi.org/10.1001/jama.2019.4149

 

 

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