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Jupiter Trial

What a joke. Roughly 100 people need to treat at 2 years to prevent 1 MI. So they extrapolate the data to 5 years and state the NNT is 25?

The cost at 2 years to prevent 1 MI. Let's see, 4 dollars a day, 100 people, 400 dollars a day for 2 years is a grand total of 285000 dollars!!

Not to mention the increase in DM.
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Interventional and EP - when to apply??

EP: you can apply at the end of your second/beginning of your third year.

Interventional: is a pain. Some programs go through ERAS and most do not, so you will have 2 waves of applications. The first will be in the middle of your second year through ERAS (I still have nightmares from my residency and fellowship applications), then rest will be paper applications at the end of your second year. So be prepared for 2 waves of letters or recommendation requests to your attendings. There is not a great place for information on all these programs, I will try to put something on this blog soon.

Right Sided EKG for Inferior MI?

How many times have you been asked to get right sided EKG for an inferior MI? I am sure many, but I think it is complete waste of time and at best, a mental exercise. It makes does not make any difference in management or treatment modalities. More than likely, you will manage based on symptoms and not what the EKG shows, so why waste time? If the patient is hypotensive, then you will give fluids, if not, you won't and you are off to the cath lab. So next time you get asked about the right sided leads, stand up for yourself and ask why?

CABG vs. PCI? Yet another study that supports the idea surgery is not better!

Don’t be fooled by the recent study published in Circulation: The end point of CV death in the PCI arm had more deaths due to non-cardiac causes. The numbers need to be looked at a bit more closely to see if indeed that one would still find a difference if you look at only CV causes of death. As these results are very different from previous studies which have looked at CABG vs. PCI.

Randomized, Controlled Trial of Coronary Artery Bypass Surgery Versus Percutaneous Coronary Intervention in Patients With Multivessel Coronary Artery Disease
Six-Year Follow-Up From the Stent or Surgery Trial (SoS)

Background— The Stent or Surgery Trial is a randomized, controlled trial comparing percutaneous coronary intervention with coronary artery bypass grafting (CABG) for patients with multivessel disease. Initial results at a median follow-up of 2 years showed a survival advantage for patients randomized to CABG. This article reports survival outcome at a median follow-up of 6 years.

Methods and Results— A total of 988 (n=488 percutaneous coronary intervention, n=500 CABG) patients were randomized at 53 centers during the period from 1996 to 1999. Investigators established survival status from hospital or community medical records or national databases or by direct contact with patients and their relatives. All-cause mortality was compared with hazard ratios and confidence intervals calculated from Cox proportional hazards models. Prespecified subgroup analyses for diabetes mellitus, angina grade, and angiographic severity of coronary disease at baseline were performed with tests for interaction. At a median follow-up of 6 years, 53 patients (10.9%) died in the percutaneous coronary intervention group compared with 34 (6.8%) in the CABG group (hazard ratio 1.66, 95% confidence interval 1.08 to 2.55, P=0.022). Little evidence was found that the treatment effect on mortality differed between subgroups according to baseline angina grade (interaction test P=0.52), the severity of coronary disease (P=0.92), or diabetic status (P=0.15).

Conclusions— At a median follow-up of 6 years, a continuing survival advantage was observed for patients managed with CABG, which is not consistent with results from other stent-versus-CABG studies.

Fellowships

When to apply for fellowship is the next question in your training? For those who want EP and Interventional fellowships, you will apply at the start of your third year in fellowship. This process should be a bit easier than you might think as there are not that many fellows applying for another fwllowhip at the end of training. As always, research helps, but I think your letters and your program director's phone call will make all the difference in the world. Will have a post later on ERAS spots, NRMP programs, etc.

I am Back

I am back...a little time off, now back to blogging!

STEMI – the role of the fellow.

You are rounding on a weekend, STEMI in the ED, more than likely you will be the first one on the scene to see the patient as most of the staff and interventionalist are at least ½ hour away. You should keep a few things in mind as your role:

1. Make sure the cath lab team is activated, call the operator just to see if all the calls went out.
2. Get a pertinent history from the patient about the event, when it started, quality, etc.
3. Make sure you get history about any bleeding problems in the past or planned surgeries in the future (if something big coming up soon, you may need to place a bare metal stent).
4. NEVER EVER EVER EVER hold up transport to the lab for any reason. Do not waste time getting right sided leads if the patient is about to go up, if you have some time, it would be a nice academic exercise.
5. Try to help the team to set the patient up on the table and get ready with your lead to get started. You do not want to be the last person in the room with your lead on, as everyone will be doing things and will not have time to help you get ready.
6. In the lab, try you best to stay out of the way and help when asked. More often than not, it is high stress environment and the artery has to be opened up ASAP, so the adrenaline is flowing.
7. Never ever let go of the wire, if you are asked to hold it in place. Just stare at it once it is between your hand and the table, glance at the monitor as well to make sure it is not moving, but do not let go.
8. After the case, always keep an eye on the groin and document it in the chart, with date and time.

A STEMI is a time to observe and take in everything happening around you, do not get too discouraged if you do not get to do a lot, you will in due time...

HR 150-ish – Flutter or VT (narrow or wide complex)?

You will see this problem quite a bit. With a HR around 150, always make sure you are not missing flutter with wide complex tachycardia (could have baseline BBB). Even if you do not see the flutter wave, look for them with your calipers. Measure the R-R interval with the calipers; place them on the ECG grid lines; take half of that measurement and start looking for bumps along the T-wave for the flutter wave. If you see a clear P-wave, try to march out the flutter waves with the calipers from above measurement. Hope this makes sense, can catch it more than a few times if you look for Flutter whenever you see a HR of 150.

1st Year Cardiology Fellowship: What to read?

There is a lot of material out there to read. Question is what to read your first year as a good foundation. I suggest Braunwald’s Heart Disease. It is by far the most complete text out there for anyone to read. There are also specialty texts out there for each sub-specialty (echo, nuclear, cath) but you can get into those texts later on in your training. There is no need to try and read everything out there on a particular rotation, just make sure you read something basic to get an understanding of things.

More importantly in the 1^st year, make sure you are exceptional with your clinical decision-making. At the end of the day, no matter what or how much you read, if you cannot be a sound clinician then everything else does not really matter much.

How do you tell who is a 1st year fellow?

Check to see who has a bruise on his/her left shin! (oooo the pain of the camera smacking me in the shin)

Always keep one eye on the camera as its in motion most of the time and if you lose track of where it is headed next, you will take it on the left shin. Very painful at times...no worries, it happens.

Research Ideas – How to Start?

As research is a key component for your CV, you have to get an early start in residency. The sooner you know you want to do cardiology, the better. You have to start right away in your intern year with research so you can get some abstracts/posters done prior to completing your 1st year. As you know, your applications go out in the middle of your second year, so not that much time to polish your CV and get things done.

What type of research? A double-blinded, randomized anything will be very difficult to do for most people, some might get in on something at big research intuitions, but most will not and should not try to get something like this started.

What I suggest is chart review. This allows some great options to look for trends at your hospital for what you are looking to investigate. Chart review provides you with a fairly larger n (can go back as long as you like), it gives you all the data in hand and if you put together a team, lots of manpower to look at all the data. Just look for simple and clean ideas for your research, only concentrating on 1 variable, this will allow you to come up with many ideas.

Good Luck.

Cardiology Fellowship – How to Get In?

American Medical Graduates (AMG) – you have worked hard and you deserve an easier path to fellowship. You still have to be pretty good, not exceptional like FMGs, but good. Then all you have to do is wake up on a fine day, fall out of bed and more than likely you will be able to get a cardiology fellowship unless you are a complete fool and really get the program director upset with your interview. Other than a few rare circumstances you can pretty much get a fellowship if you chose to do so. But this is great for you, as you have worked hard over the years to secure admission into a great medical school and residency and you deserve the fruits of your labor.

Foreign Medical Graduates (FMG) – this is a whole different kettle of fish. Get ready to show yourself to be great. Average, even good will not do, you have to set yourself apart from all the others trying to get the very limited spots out there. So here are some thoughts – the Real Deal (no sugar coating).

1. Every Problem has a Solution. Stay true to those words, as there will be a few set backs before you get your spot. Be prepared for “what if.” If you do not get a spot in your first try, do not get caught off-guard and be prepared for the next step. Have something else lined up, applications ready for the extra year or research or another fellowship.
2. Extra Steps/Work Needed. As a FMG, you can get lucky and get a position without much research or an extra year. You will need to do research or Chief Resident year to make your application stand out from the rest.
3. Build Connections. The best chance you likely will have is at your own hospital, so make sure you stay involved with your cardiology department from the beginning of your residency.
4. Research. This is almost a must; it helps a great deal to be a first author on a published manuscript. You can get by with some abstracts or posters but you will need some papers published to make a real impression on you CV. AMGs do not need much research.
5. Make yourself “appear” special – even though most doctors are not (AMGs or FMGs). The easiest way to do this is through hard work, which could have a lot of different applications. Doctors are somewhat smart, but most work hard to get where they are. So, if you take the extra steps just by putting in the extra work (cardiology morning reports, going to cardiology conferences, looking at cases in the cath lab, etc), you can thus make yourself standout from the rest.

Last thing, if this is what you really want....Never, Ever, Ever, Ever Give Up! Will write more on the tpoic some other time.

Femoral Artery Access – Some Thoughts

One of my main goals in the first few months in the cath lab was to get access without any complications or help (although, one always could use the help). One of the tricks that I learned is where and how I felt the artery. Four fingers on the pulse, now here is what I think made it easier: After you feel the pulse move your fingers form lateral to medial direction and then back. This way you will get your fingers where the pulse is the strongest. My first few times, I would make the mistake of just feeling the pulse and going in with the needle, which at times would cause me to miss the artery as I was too medial or lateral. Now, I can get access most of the time (knock on wood) with my first attempt as I know where the pulse is the strongest.

Also, once you are advancing the needle, at times you can feel the needle pulsate in your fingers as you approach the artery. This was another little trick taught by one of my attendings, as you are advancing the needle slowly and if you are not sure where you might be, just stop for a second, hold the needle lightly and see if you can feel the pulsations of the artery in your fingers.

Good Luck. Would love to read more from others…

First Note

Hope all is well out there. This is the first post in this blog. I hope to write here often. Just want a forum to post my day-to-day activity as a cardiology fellow. I hope others can add there experiences and we all can learn a bit from each other. So lets see how things go...