Thread by @boback

@DavidLBrownMD @BobDreyfuss2017 @iamritu @mad_sters @ProfDFrancis @rallamee @DrJHoward @mshunshin @MikeTPhD @drjohnm @rwyeh @imperialcollege Yeah, analysis does not adjust for changes in diagnostic sensitivity over time. We have trials included that span 1992 to 2019 and diagnostic criteria were likely more sensitive for inclusion in recent trials.

@DavidLBrownMD @BobDreyfuss2017 @iamritu @mad_sters @ProfDFrancis @rallamee @DrJHoward @mshunshin @MikeTPhD @drjohnm @rwyeh @imperialcollege Overall, the meta-analysis doesn't change the predominant dogma that we cannot save lives or prevent cardiac events in a stable CAD population. However, there are situations defined by acute or recent myocardial injury/infarction that benefit from revascularization with PCI.

@DavidLBrownMD @BobDreyfuss2017 @iamritu @mad_sters @ProfDFrancis @rallamee @DrJHoward @mshunshin @MikeTPhD @drjohnm @rwyeh @imperialcollege I'll transition to the case report by patient and investigative reporter/editor for the @thenation @BobDreyfuss2017

Reminds me of uncomfortable M&Ms I've attended with the patient/family present to recap how medical decisions were made and managed.

ahajournals.org/doi/10.1161/CI…

@DavidLBrownMD @BobDreyfuss2017 @iamritu @mad_sters @ProfDFrancis @rallamee @DrJHoward @mshunshin @MikeTPhD @drjohnm @rwyeh @imperialcollege @thenation Mr. Dreyfus (71yo) went for an annual physical with no real complaints. However, after a ROS, he reported occasional (3-4x a year) chest tightness with exertion. He's on a statin with additional risk factors mentioned but heart disease in father at 56 and mother 62.

@DavidLBrownMD @BobDreyfuss2017 @iamritu @mad_sters @ProfDFrancis @rallamee @DrJHoward @mshunshin @MikeTPhD @drjohnm @rwyeh @imperialcollege @thenation He's physically active and goes to the gym regularly without symptoms other than these rare occasions. EKG is normal. So #cardiotwitter what do you want to do next?

@DavidLBrownMD @BobDreyfuss2017 @iamritu @mad_sters @ProfDFrancis @rallamee @DrJHoward @mshunshin @MikeTPhD @drjohnm @rwyeh @imperialcollege @thenation He obtained an stress TTE and no symptoms were reported and surmise it was positive for anterior wall ischemia to at least a moderate degree.

@DavidLBrownMD @BobDreyfuss2017 @iamritu @mad_sters @ProfDFrancis @rallamee @DrJHoward @mshunshin @MikeTPhD @drjohnm @rwyeh @imperialcollege @thenation What do you next #cardiotwitter? What do you recommend (you can't time travel to cancel the stress test in this Choose Your Own Adventure)

@DavidLBrownMD @BobDreyfuss2017 @iamritu @mad_sters @ProfDFrancis @rallamee @DrJHoward @mshunshin @MikeTPhD @drjohnm @rwyeh @imperialcollege @thenation A week later Mr. Dreyfuss is referred for outpatient cath. He is found to have MVD with 100% CTO
of the mid-LAD with left-to-left and
right-to-left collaterals; 90% blockage in OM-1, and
70% RCA.

@DavidLBrownMD @BobDreyfuss2017 @iamritu @mad_sters @ProfDFrancis @rallamee @DrJHoward @mshunshin @MikeTPhD @drjohnm @rwyeh @imperialcollege @thenation How would you manage MVD with collateralization and normal resting LV function?

@DavidLBrownMD @BobDreyfuss2017 @iamritu @mad_sters @ProfDFrancis @rallamee @DrJHoward @mshunshin @MikeTPhD @drjohnm @rwyeh @imperialcollege @thenation Mr. Dreyfuss was electively admitted for CABG the next day. In his writing, it's clear he was startled by the rapid progression of medical discovery and recommendations. He also feared dying suddenly and now feels his disease was caught in time.

@DavidLBrownMD @BobDreyfuss2017 @iamritu @mad_sters @ProfDFrancis @rallamee @DrJHoward @mshunshin @MikeTPhD @drjohnm @rwyeh @imperialcollege @thenation However, based on what we know from RCTs. In time for what? Did we knowingly prevent anything along this diagnostic path?

Mr. Dreyfuss is an #ISCHEMIA patient. Moderate ischemia no left main. We now know that PCI/CABG were null interventions for hard outcomes.

@DavidLBrownMD @BobDreyfuss2017 @iamritu @mad_sters @ProfDFrancis @rallamee @DrJHoward @mshunshin @MikeTPhD @drjohnm @rwyeh @imperialcollege @thenation My own personal practice would have sent Mr. Dreyfuss in another direction. I might have been triggered to get a resting echo based on his minimal symptoms and excellent exercise tolerance but elevated CVD risk. If normal, continue monitoring on meds.

@DavidLBrownMD @BobDreyfuss2017 @iamritu @mad_sters @ProfDFrancis @rallamee @DrJHoward @mshunshin @MikeTPhD @drjohnm @rwyeh @imperialcollege @thenation Our best evidence tells us that hypertension control, lipid lowering therapies, and lifestyle modification are best means of reducing event risk. A stress test or cath would only be triggered based on changes in exertional capacity or progressive/refractory anginal symptoms.

@DavidLBrownMD @BobDreyfuss2017 @iamritu @mad_sters @ProfDFrancis @rallamee @DrJHoward @mshunshin @MikeTPhD @drjohnm @rwyeh @imperialcollege @thenation Well, that's a wrap. Hope you enjoyed the thread. There's 3 excellent editorials with varied perspectives of navigating uncertainty of CAD management by @bnallamo
@ajaykirtane and @webmd11

ahajournals.org/doi/10.1161/CI…

ahajournals.org/doi/10.1161/CI…

ahajournals.org/doi/10.1161/CI…

@DavidLBrownMD @BobDreyfuss2017 @iamritu @mad_sters @ProfDFrancis @rallamee @DrJHoward @mshunshin @MikeTPhD @drjohnm @rwyeh @imperialcollege @thenation @bnallamo @ajaykirtane @webmd11 @threadreaderapp unroll