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.