Thread by @MartyTamMD

1/ Running list of #ActionableKnowledgeItems (AKIs per @keaglemd) from the @ACCinTouch #BigSky19 Conference

2/ From Dr. Greg Hundley @VCUHealth

✔️Cardiac MRI for HF evaluation VERY useful
✔️LGE patterns suggestive for specific diagnoses
✔️T2 images find the "water" --> identify active inflammation/edema (acute injury, myocarditis)

3/ From @keaglemd @umichCVC

✔️Be vigilant for recurrent CV events after Takotsubo/stress CMP (common!)
✔️Might be a role for continued HF medical therapy after "recovery"

4/ From @MeneesMD at @umichCVC

✔️TAVR: new indications? -> studies in low risk, asymptomatic, new disease states
✔️TMVR: future may be combining techniques to address root causes
✔️Food for thought: How do we train future "structuralists" (both surgeons and cardiologists)?

5/ From Dr. Pat O'Gara @BrighamWomens

Primary MR:
✔️Still a surgical disease...when the risk level is not prohibitive and appropriate center/surgeon outcomes.

Secondary MR:
✔️MitraClip story is evolving. Image below gives a new way to look at patient selection.

6/ From Dr. Jim Froehlich at @umichCVC

Consider DOACs in APPROPRIATELY selected patients with:
✔️Need for extended VTE treatment
✔️CAD/PAD (though increased bleeding and not common practice)

*Not all DOACs are equal, so please refer to the individual studies

6.5/ Bonus: Great audience question ➡️ impromptu poll+lively discussion. #CardioMedEd at it’s best!

The question(some artistic license): Patient with stable CAD (>12mo from a stent, on ASA only). Develops new AF (C2V of 3). Low bleeding risk. What regimen would you recommend?

Thoughts? @keaglemd @MeneesMD @YogenKanthi @GBarnesMD

7/ From Drs. Estes, Vogel, Hundley

Syncope in young athletes:
✔️DURING exercise ➡️ NOT NORMAL ➡️ assume cardiac
✔️Cardiac MRI ➡️ info on coronary anatomy/anomalies, etiologies of RV/LV CMP, fibrosis
✔️AFTER exercise > consider BP/HR changes a/w abrupt activity cessation

8/ From Dr. Estes @PittCardiology

Atrial fibrillation + obesity:
✔️Weight loss is key
✔️Ideally >10% + sustained loss
✔️Detect and treat OSA

9/ From Dr. Mollie McDermott @UMneurosciences

Ischemic stroke tips for the cardiologist:
✔️Permissive hypertension
✔️Immediate ASA
✔️Defer AF anticoag for days ➡️ risk of hemorrhage >> recurrent stroke
✔️Stroke during an PCI? ➡️ STAT CT head + check ACT for bleeding risk

10/ From Dr. Vogel

Medical PAD management:
✔️Focus on smoking cessation + structured exercise
✔️Include anti platelets + statins
✔️Consider rivaroxaban, PCSK-9 inhibitors
✔️Be careful with BP goals! ➡️ too low or high = more PAD events (see below)

11/ Dr. Froehlich

Asymptomatic but significant carotid stenosis:
✔️Several treatment options ➡️ variation in practice (see image)
✔️Better to know risks/benefits of the options
✔️CEA ➡️ more MIs, better for older patients
✔️CAS ➡️ more stroke, better for young

12/ Dr. Vogel

Lipid management:
✔️Consider the MESA risk calculator ➡️ includes CCS, family hx, race/ethnicity
✔️Nice summary for non-LDL treatment options (see image)

13/ Dr. Froehlich

DOAC safety points:
✔️Don't bridge with heparin ➡️ just stop and restart if needed
✔️HASBLED score made for warfarin ➡️ not completely applicable for DOACs
✔️Apixaban used in ESRD and obesity ➡️ levels less predictable ➡️ watch for AEs

14/ Dr. Vogel

Diet and exercise recommendations. I can't say it better than this image!

15/ From Dr. Yancy @NMHheartdoc

HFmrEF: mid range EF (40-49%)
✔️Not quite HFrEF or HFpEF - we need to better understand
✔️Ex) post MI

HFiEF
✔️HFrEF with improved EF (>40%)
✔️Do not stop GDMT ➡️ high likelihood to relapse
✔️LV strain and genetic profiles predict outcomes

16/ From Dr. Hundley

Updates in cardio-oncology:
✔️See image for history/guideline overview (many opinions)
✔️Check point inhibitors ➡️ risk of myocarditis
✔️CAR-T ➡️ massive cytokine release ➡️ AFib and major hemodynamic changes

17/ From Dr. Yancy @NMHheartdoc

Cardiac amyloidosis:
✔️Under-diagnosed ➡️ consider in HFpEF and LF/LG AS
✔️Tafamidis for mutant/wild-type TTR ➡️ reduces mortality + improves function/QOL

Cardiac sarcoidosis:
✔️Steroid/immune therapy commonly used but evidence lacking

18/ From Dr. McCord @HenryFordNews

Outpatient uses of hs-troponin
✔️No standardization in assays btw centers ➡️ interpret with CAUTION
✔️Chronic elevation is bad ➡️ increased MACE ➡️ consider CV RF mod
✔️May provide prognostic info on AF stroke/bleeding risk (ESC class IIb)

19/ From @MeneesMD

Flow and CTO:
✔️iFR compared to FFR ➡️ non-inferior ➡️ faster, cheaper, less AEs (no adenosine needed)
✔️CTO ➡️ new techniques/technology/strategy + safer ➡️ consider to improve QOL/ischemia in SELECTED patients
✔️CTO on MACE still TBD

20/ From Dr. Estes

WCDs after MI with ⬇️EF:
✔️VEST trial did NOT show reduction in primary endpoint (SCD)
✔️VEST lingering Qs ➡️ why the mortality (and stroke) reduction ➡️ extra monitoring/care?
✔️Shared decision making is KEY as always! ➡️ "You guide, the patient decides"

21/ From @MeneesMD

AMI with cardiogenic shock:
✔️Culprit vessel >> multi vessel PCI (CULPRIT SHOCK)
✔️Timing, type, and benefit of temp MCS still unclear

22/ From Dr. McCord

What is an MI in 2019??
✔️Many will have detectable hs-trop ➡️ need corroborating evidence to be MI
✔️The DELTA is important ➡️ rise/fall in trops points to MI
✔️Use cutoff values with caution ➡️ 99% somewhat arbitrary + centers deviate from this (image)

23/ From @keaglemd

Risk stratification for non-cardiac surgery:
✔️Most important test still H&P ➡️ find ACTIVE CV disease
✔️No active CV disease ➡️ most can go to surgery w/o further testing
✔️Testing for few patients ➡️ high risk surgery + high risk patient + poor function

24/ From Dr. McDermott

PFO closure:
✔️PFOs very common ➡️ ~25% population ➡️ closure selection should be multi disciplinary
✔️Consider in true cryptogenic CVA + large shunt/ASA
✔️TIA only without brain imaging findings ➡️ unclear benefit

@threadreaderapp unroll

Fin/

Here are the combined #ActionableKnowledgeItems from this years #ACCBigSky19 cardiology conference! #CardioMedEd

@ACCinTouch @keaglemd @NMHheartdoc @MeneesMD

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