John Mandrola, MD Profile picture
Heart rhythm doc, writer/podcaster for @Medscape, learner, cyclist, married to an #HPM doctor. #MedicalConservative. The more you see, the harder medicine gets
Steve Granier Profile picture 1 added to My Authors
Jul 18, 2021 6 tweets 2 min read
My colleague has an interesting idea on vax persuasion

But... Scott Alexander IDs a problem. All 4 folks he suggests are super smart & competent but they aren't optimized only for being correct, they are also optimized for keeping power.

See astralcodexten.substack.com/p/webmd-and-th…
1/ I discussed my experience in clinic with vaccine hesitant patients on This Week in Cardiology podcast
podcasts.apple.com/us/podcast/jul…

Point 1: ... patients don't make decisions like odds-ratio-calculating robots. People feel risk.

Some feel more risk from the vaccine than COVID
May 16, 2021 5 tweets 2 min read
When sacubitril/valsartan crushed it in 2014 in PARADIGM-HF for HFrEF, there were a few voices of criticism.

At #ACC21 the PARADISE-MI of entresto vs ramipril in post-MI patients w heart failure failed to show significance.

My summary
medscape.com/viewarticle/95…

Thread/ The specific message is obviously that based on this study, sac/val has no role over ACE/ARB in post-MI patients with heart failure and LV dysfunction.

We cannot ignore costs of care. And low BP was worse in the ARNI group.
Mar 13, 2021 5 tweets 2 min read
Pure gold in this convo on #covid19

Why has @youyanggu been so accurate modeling?

Go to 39-minute mark and replay his words 100x

“When the data do not fit what I expected, I change my beliefs”

If only this was allowed in COVID science!

Brief thread 👇 This principles in this podcast are so darn important for critical appraisal

@youyanggu lack of prior infectious disease knowledge is a feature not a bug.

It allows a dispassionate interpretation of evidence.

Say it w me: **content expertise is over-rated!**

2/
Mar 12, 2021 11 tweets 6 min read
Excited to share our recently published point-counterpoint paper on halting implantation of the @bostonsci subcutaneous-ICD

The paper is now open access.

A brief thread Background:
I have used the S-ICD. It has *potential* advantages over the traditional trans-venous ICD system

But it is the newcomer. A #MedicalConservative believes proponents of new stuff must show more than *potential* benefits over the tried and true.
Jan 30, 2021 18 tweets 7 min read
Ok at the request of @PerPersvensson let's do a
Bayes Analysis of the HERS trial circa JAMA 1999

Estrogen/progesterone vs Placebo for reduction of MI/CV death.

Here are the events to put in the 2x2 table and the published CI and RR

First just look at the data. No diff in outcomes and wide CI from 20% benefit to 22% harm.

Going to be hard for prior beliefs to budge our posterior

Posterior is jargon for after seeing the data. Image
Nov 18, 2020 10 tweets 4 min read
NEJM published 2 RCTs of #AFib ablation vs AF drugs.
The rub was that the ablation was done EARLY in the course.
Practice had been to try drugs first then do ablation.
EARLY AF and STOP AF studied the procedure early.
#AHA20 Thread and my column >> Both trials used the Medtronic cryoballoon system.
Medtronic participated in funding both trials.
STOP AF was 100% an industry trial. See pic.
Early AF had funding from many other sources
Sep 7, 2020 7 tweets 5 min read
Giving talks in which you don't have a slide deck already made is illuminating. Look what I found out about publication bias>
It was "discovered" in 1979 by Rosenthal content.apa.org/record/1979-27…
How did he do this?
Thread ... He used a variant of ...sit down for this...the Fragility Index, which we reported on in cardiology
ahajournals.org/doi/10.1161/CI…
The criticism was fierce. But I liked it. @ShahzebKhanMD
Aug 29, 2020 10 tweets 5 min read
Thread: To me, the most stunning report from #ESCCongress thus far: RATE-AF trial
Older pts w/ permanent AF + shortness of breath. (there are lots of these pts).
Rate control is crucial
In 2020, most receive beta-blockers.
But BB can cause dyspnea.
What about dig?
Gulp! 1/ Rate-AF randomized these pts to bb vs digoxin. Here is the protocol paper: bmjopen.bmj.com/content/bmjope…
Crucially they looked at quality of life. That's a really important outcome.
Jun 29, 2020 6 tweets 5 min read
Need help from trial methods people. I ran across this amazing paper by @phlegmfighter et al looking at consequences of recommendations in the design and interpretation of Non-inferiority trials. pubmed.ncbi.nlm.nih.gov/28875400/
THEY SUGGEST SYSTEMIC BIASES.
Thread Image If you put the new treatment on the left side of the interpretative diagram, there are four ways to make Non-inferiority. Scenarios 1-4. but.... Image
May 15, 2020 13 tweets 6 min read
Thread coming on one way docs might add value to the #COVID19 crisis: critical appraisal.
I wrote a critique of a flawed study published in a major journal. The study reported on the assoc of anticoagulant use and death in COVID pts.
medscape.com/viewarticle/93… It is an important topic b/c numerous studies have suggested a high rate of clot-related complications in acute #COVID19 illness. it makes sense to consider anti-coagulants...
May 7, 2020 6 tweets 5 min read
Oh my, @theheartorg and @Medscape are crushing it with not one but two great columns on the limits of testing for #covid19 --This is important on many levels, not just for the virus but also for literacy of medical testing.
Very Brief Thread -- I am excited In the first column, my friend @anish_koka a doc w #SkinInTheGame writes on why we can't test ourselves out of the #COVID19 crisis. medscape.com/viewarticle/92…
He debunks the Hammer/Dance figures with help from @AndrewFoy82 who does an actual correlation line --
May 1, 2020 11 tweets 4 min read
Short Thread on my latest column over at @medscape About #COVID19 -- My POV: I am a doc who treats real patients. Every Rx decision requires balances the risks of the disease against the risks and benefits of the intervention. 1/ But it is not pure arithmetic. You have to think about asymmetries --like a stroke is usually worse than a bleed (anticoagulation). You also have to consider different patients have different experiences and goals. (Eg. NY COVID not same Montana) 2/
Apr 8, 2020 7 tweets 2 min read
Paper from Prof. Ioannidis et al. <preprint>
They study the risk of #COVID19 death in younger vs older age groups from hotspot areas across the world.
I like this paper b/c it’s data rather than anecdotes.
medrxiv.org/content/10.110…
Thread The authors take current data -- imperfect as it is-- and use it to compare death rates across geographically separate cities, states and countries. They divide COVID deaths by population to get absolute death rates. (low for all ages.) New York data interesting.
Apr 7, 2020 6 tweets 3 min read
This may be one of the most important pieces of content @medscape has ever published. What if we are doing it wrong in the treatment of #COVID19? What if @cameronks is correct? medscape.com/viewarticle/92…
Thread It's not like the ICU mortality of intubated patients is good. In fact, it is terrible. There is no argument that #COVID19 behaves differently than other causes of respiratory failure.
Mar 24, 2020 6 tweets 2 min read
I have heard concern from many doctors in the #COVID19 front lines about early intubation. It is telling that some are afraid to speak publicly. I am not an expert. But would like to relay the worry about interaction bias in this setting. #Foamed One intensivist told me he saw a patient with clear-cut heart failure (pulmonary edema and pleural effusions and known LV dysfunction) intubated immed and placed on isolation. The patient had no C19 signs and stayed on the vent for days waiting for the negative test.
Feb 13, 2020 4 tweets 4 min read
Oh my. Important paper in JACC led by @GreggWStone
Events continue to accrue late after stent placement. Yes, even the anointed drug eluting variety. This is big because it provides plausibility to the lack of MI or death reduction in stent vs meds RCTs onlinejacc.org/content/75/6/5… 2/ the other notable feature is that it lends credence to the findings of NORSTENT nejm.org/doi/full/10.10…
which found no different in major adverse outcomes b/w bare metal stents and the more expensive drug eluters.
Nov 9, 2019 13 tweets 7 min read
Thread on my latest column @theheartorg on the faulty communication of the 5-year results of the EXCEL trial of Left Main PCI vs CABG

medscape.com/viewarticle/92…

A reader of the highly-influential NEJM manuscript would think the two treatments are similar That's important because any human being given the choice b/w a PCI or open-heart surgery will choose PCI b/c it's far less invasive.

But are the two treatments similar at 5 years? I use the data in the paper to show that, no, CABG looks better in the long-term.
Jul 17, 2019 10 tweets 3 min read
A few words on #prevention.
When I rail against prevention, some assume I am not interested in preventing disease.
This is not true. I am.
I found this paper from @JuanGrvas et al that helps explain my tension about prevention.
cadernos.ensp.fiocruz.br/csp/public_sit… This article discusses the precautionary principle as it relates to screening and prevention of disease. Here you have 2 concepts--additive preventive measures and reductive preventive measures--taken from G Rose.
Mar 14, 2019 18 tweets 8 min read
Twitter thread coming on what @adamcifu @VPrasadMDMPH @AndrewFoy82 and I think is the BEST approach to pt care. This is ...
The Case for Being a Medical Conservative.
amjmed.com/article/S0002-…
Thanks to the @amjmed for publishing this. This started when @AndrewFoy82 wrote me a rough sketch of the medical conservative's approach after a journalist criticized those of us who are too skeptical of new therapies.
Jul 26, 2018 18 tweets 20 min read
My #FITSurvivalGuide Tweetorial on the Dx/Rx of wide complex tachycardia: SVT vs VT
@dr_chirumamilla @Pooh_Velagapudi @bcostelloMD @majazayeri @fawazalenezi55 @SanChris999 @GuruKowlgi @Nidhi_Madan9 @mmamas1973 @CMichaelGibson @DocSavageTJU @rajivxgulati @SVRaoMD @MinnowWalsh Step 1 w WCT is to assess ABCs. If the pt is unstable or in shock, it doesn't matter what the rhythm is> just shock the patient #FITSurvivalGuide
@sabeedak1 @noshreza @chadialraies @mirvatalasnag @venkmurthy @fischman_david i @vietheartPA @DrKevinCampbell @krishmd @cardiodee
May 5, 2018 8 tweets 3 min read
Be ready all. I will show you how coronary artery calcium scans' ability to allay fear is counterbalanced by how it wrongly classifies people up in risk —> fear and increased likelihood of interacting w doctors
Slides by @AndrewFoy82
They involve math. One must remember that the benefit of CAC has to be additive to regular risk factors -- ones that do not include being radiated.