Author: Amin H. Karim MD

Graduate of Dow Medical College Class of 1977.

To Treat or Not to Treat

A Panel Discussion Between Practicing and Experienced Cardiologists
on How to Tackle Risk Assessment in Asymptomatic People .

The case presentation and the comments that follow were interchanged on our WhatsApp groups APCNATeam in November 2024. This discussion presents an example of how experienced practicing cardiologist, faced with real life patients, navigate the findings on trials and papers and come to conclusion of what to tell the patient and how to proceed with the next preventive or therapeutic step. Please excuse any errors or omissions and will be happy to correct since the readers are themselves the Editorial Board. (Amin H. Karim MD)

Dr. Bashir Hanif
Need opinion on a 45 year old with positive family history of premature CAD. Asymptomatic. Very active, brisk walk n jog 45 minutes 6 days a week without symptoms.
CAC n Lipids are given below. What would you do next? Cath? Stress test? Or just Aspirin n high dose statins?

Abdul Hakeem
Where is the bulk of the calcium? If it’s a prognostically imp territory then I would get exercise MPS for further risk stratification. Agree with HD statin bring LDL<50 perhaps EPA
Salman Arain
I had the same question @Dr.Basheer Hanif – what is the distribution of calcium? 550 distributed over three vessels is less concerning than 350+ in the LM and proximal LAD. In the latter case, I may offer a stress test. Also, if the patient has a family history of premature CAD, then it may be reasonable to do a stress test.

Maryam Moten

Hussain Khwaja
I would do ASA and high dose statin to bring LDL between 25-50
Question is what we are going to do if stress test comes abnormal ?
Basheer Hanif
That was my problem too as this was the only report apparently they gave which doesn’t give distribution of calcium. He is completely asymptomatic despite heavy exertion.
Abdul Hakeem
So how does calcium scoring help in a very active asymptomatic person? Just creates a very pesky conundrum
Khurram Nasir
Preventive Management my friend, think beyond stenosis and intervention
Muhammad Saad
it can help to emphasize use of statins in asymptomatic patients
Khurram Nasir
Ldl below 55
Check Lpa if high family screening
ASA
SBP below 130
GLP1RA if diab pre diab
Further emphasize on diet and lifestyle
Abdul Hakeem
I have heard that and I’m sure there is some piece of evidence that it modifies human behavior but the consternation it causes seems to be its overwhelming impact!
Khurram Nasir
Few thoughts :
Make sure they’re not capturing any MAC

⁠ paradoxically the more number of vessels involved the more risk (prognostically) vs the more rationale thinking that if higher in one vessel possibly higher risk of stenosis or future risk

⁠ the relationship of high cac is not correlated with the stenosis in the same vessel, actually u may find often in the other with less score

⁠the issue is more distributive cac more turbulence in flow and more risk beyond plaque burden and rupture risk

⁠despite higher risk, majority don’t have event so no good way to assess who specifically is more at risk

⁠stress test not a bad idea in these uncertain cases
⁠hopefully pak Sehat with cac and CCTA in young Pakistanis will tell us what it means so kudos to bashir on leading the way

There is now huge body of evidence, actually, there is a meta-analysis from our group and JCC imaging that higher cac modifies, patient lifestyle, behavior, and attendance, and as well as physician behavior on prescription patterns

Also, as thought, from rationale thinking that it may increase anxiety and concerns, apart from few anecdotal cases, actually the evidence suggest otherwise

I see these patients all the time, it is how you message to them, that is great that you found out this,rather than waiting for an event to happen, and we have simpler an easier way to significantly modify the risk

Abdul Hakeem
Calcium score (in hugely asymptomatic)= demaagh me keera. The pt will find himself a Cardiol who will be more than happy to cath and stent him ( to prevent events
Khurram Nasir
I believe you; Well, just because there are bad practices, and some of these arguments have been made by long-term skeptics like David Brown even in the US, doesn’t mean that we stop doing the right thing

it means we start educating not only the patients, but also Cardiology community on what the best practices are

This is like saying we should stop screening for hypertension, because most of cardiologist will start on clonidine and may cause more harm

The same argument it’s gonna be made for anything
For deemagh me keera means more patient discussion and education and that means spending more time at the patient, unfortunately, that doesn’t exist much in most place even beyond Pakistan, and maybe that’s what we need to do, so we have more patient centric approach and care..
And btw asymptomatic doesn’t mean the person is not high risk for MI not only long term but also short term
Can’t think of any good rationale why the pt and pts physician wouldn’t want to know about so actually one can mitigate this totally preventable catastrophic complications and downstream issues like revascularization
Abdul Hakeem
I can’t agree more. I’m just saying unless we have solid evidence that “screening ca scores” in healthy asymptomatic individuals alters long term outcomes incrementally to usual practice we should be selectively doing calcium scores particularly in prevention rebellious pts
Khurram Nasir
First of all, this is old school, and things have changed: Let me help, explain,⁠ also, we need to put yourself in the patient’s shoes and ask ourselves whether we are better off in making a guess or knowing the actual risk and personalizing management accordinglyly

Cac test is no longer a screening test but more of a decision aid to guide risk and management, screening means that you do it for a person who is not candidate for a therapy, you find disease, intervene, and see if it improves. Here cac is also used for a lot of individuals who are already candidates for therapy, is to guide whether they need it or not and what intensity, so completely different philosophy.

⁠well proven to outperform any guesstimation approaches that you and Ion and others use in the clinic, and by the way, none of them have been tested in any randomized trial that using them improves outcome.. also by the way that I said I would be in a study that seeing a cardiologist improves outcome so maybe we can take everything with a grain of salt

⁠ as far as a pure screening approach and outcomes this concert there is a large study in Denmark, which is ongoing, and in the interim analysis has shhkwn 11% reduction in MI and stroke in the entire population, and three specified analysis, almost 11% all cosmetology reduction, and younger individuals
Abdul Hakeem
Thanks for the insightful comments khurram bhai. Always very scholarly and encyclopedic!
Syed Iqbal Rahmatullah
Repeat CAC to know the distribution or get the scan film to review.
High dose statin (goal LDL 30 to 40)
Aspirin
Lp a
Stress echo regardless of distribution
Life style adjustment. (Particularly dietary, HbA1c, BMI)

I had a similar patient yesterday, asymptomatic, played squash 5 days a week, and had very low LDL,
CAC 350, pakistani recently retired anesthesiologist, age 62, visiting his son here. No other risk factors.
SE showed anterior and inf wall hk, Rest echo 65%ef, post exercise 45%.
LHC showed discrete lesions but diffuse 3 vessel disease, extensive but good targets. Scheduled for cabg next week.
Farhan Katchi
I’ll just add that i use cac, as informed largely by Khurram’s body of work, and it has strengthened patient trust, buy in, compliance, and in my 7 years IMO better outcomes. My patients are more motivated to lose weight, eat better, exercise, and engage in escalating up medical preventative therapy when they know and understand the cac score concept (I show them the images in clinic on the screen so it’s concrete and not abstract). I have started to use LP(a) and ApoB in the same way that I use cac scores for risk adjudication, especially in women and the young where a cac of 0 may not tell the full longer term preventative story.
Bashir Hanif:


Syed Fazal:
Great discussion!
Now at the end of discussion, looks to like need one stent in type A lesion in mid cir, and all the above recommendations, for secondary treatment! Now he will need more anti platelets med for stent!
Bashir Hanif:
So who will put a stent and who would treat it medically. He is completely asymptomatic. It’s not a prognostic lesion!
Syed Arman Raza
Academic answer (in my view): no stent. Medical mgmt. Real world: stent + medical mgmt
Sabha Bhatti
Has he had functional testing ?If there’s ischemia in that territory you could consider stenting
Bashir Hanif:
You know functional study is going to be low risk and we are not going to change his prognosis/ risk of MI or mortality by putting a stent!!
Sabha Bhatti:
Yes but … Potentially that’s the bridge between academic and real world answer .. you have another justification for not stenting if there’s no ischemia
Bashir Hanif:
There will be ischemia. I can tell you what functional test is going to show. He jogs for 45 mins without symptoms. So it’s probably going to be medium size mild intensity ischemia at high work load. Will you send him to Hakim for stenting with this report?
Sabha Bhatti:
No one can do 45 min on a Bruce . Infact 16 min and few sec is the max I’ve seen . It helps to see symptoms , ECG and ofcourse vitals with exercise. No stent for now . Avoid oculostenotic reflex
Bashir Hanif:
I didn’t say 45 mins Bruce. I said jogs n brisk walk for 45 mins.
I advised him medical treatment. No stent
Ata Qureshi
This is a non prognostic, low risk lesion and I would manage it medically.
Syed Iqbal Rahmatullah
Bashir, was FFR done on left circ lesion? What was the rationale for doing cath, to begin with?
Bashir Hanif:
My point is it’s a non prognostic lesion pt is asymptomatic. Even if it had shown some ischemia or FFR was positive, in asymptomatic pt , would stenting change the risk of future MI or mortality??
I believe in CCS but if pt is symptomatic on GDMT or it’s a LM or may be Ostial LAD I would go for invasive approach and revasc. options. I don’t know about you and Hakeem but I had to relearn medical management of CCS when I moved back as lot of patients refuse to go for Revasc ( even LM n 3 VD ) and they are doing fine on medical management for years now. So as you said we need to resist oculostenotic reflex as much as possible!!( Disclaimer: I am an Interventionalist)
My 20 years of experience in Pakistan tells me Medical management can do wonders if done appropriately with belief!!
Abdul Hakeem
One our fellow intv cardiologist has classified this very well. Reasons for PCI in SIHD
if I can’t do it then GDMT
If I don’t do it someone else will
medical therapy until I return from vacation
Syed Fazal
I think most of us IC do lot more stents without evidence of mortality benefit.
Definitely there are regional differences for many other obvious reasons in different countries.
And as I said there is no consensus in this type A lesion.
Definitely in board exam don’t even think about stenting at this lesion!
Farhan Katchi
In cases of high cac, if I suspect LM or 3VD, I will Cath or CCTA to define anatomy for cabg referral. EXCEL and NOBLE and guidelines support revasc of this disease with cabg on account of its survival benefit even in asymptomatic patients. Now the ven diagram of asymptomatic and severe LM and significant 3VD is probably tiny especially if you consider 3V ischemic rather than anatomic disease and verify “asymptomatic” status on a treadmill
Haris Riaz:
I haven’t had a chance to follow this interesting discussion but ISCHEMIA trial frequently gets cited [sometimes even by people who haven’t actually read the full text or gone through the supplementary materials from nejm]. It might be interesting to note that:
One fifth patients in the conservative arm underwent revascularization
There are many other important limitations that need to be kept in mind before applicability. The trial [like COURAGE] reaffirms that medical management is effective in stable patients with stable symptoms compliant with GDMT.
Approximately one third of patients in ISCHEMIA had no angina in the last month before enrolment.
15% patients in ISCHEMIA had no objective evidence of ischemia on core lab assessment
One fifth patients in the invasive arm didn’t undergo revascularization


STEMI on the Forehead !

Amin H. Karim MD
Institute for Academic Medicine
Houston, Texas

Today a 65 year old patient showed up in the office. He had not seen me for last 5 years for whatever reason and now needed a surgical clearance. He worked as a RN at a Houston Hospital and subsequently at the VA Hospital;

I did a routine EKG as follows:

It was unchanged from his previous EKGs from years ago. When he was following with me, he had a cardiac workup including imaging tests showing normal coronaries.

On taking his interval history, I found some interesting facts. While working at the VA he had some atypical chest pain. He went to the ER and had an EKG and was seen by a cardiologist stat. He was rushed to the catheterization lab and had a diagnostic cardiac catheterization which showed normal coronaries. A few months later he had similar chest pain and again went to the ER at a premier hospital in town for evaluation. An EKG was done and STEMI was called immediately. He protested to the cardiologist that he had cardiac catheterization a few months ago and that it was normal! The cardiologist was insistent that he have another one since his EKG showed that he was having a heart attack and could die. His protests were to no avail and he was rushed to the lab and had another diagnostic cardiac study which of course showed normal coronaries. The cardiologist came and apologised to him for not listening to him.

Now it was my turn to beat him on the head and tell him: ” You have STEMI written on your forehead. Wherever, you go you will be treated with emergency response and the STEMI will be summoned and you will be rushed in an elevator with a security guard holding it! Once in the cath lab you will be surrounded by a frantic team counting minutes!

So this is what you are going to do. You will take a copy of your EKG, go to Office Depot and have it reduced and laminated; then carry it with you in your wallet and if you land in the ER and before they wheel you away to the cath lab, show them the EKG and tell them that your EKG is always abnormal and that they should compare to see if there are any changes. Otherwise you will someday end up with a clot in your hand or leg or some other complication!

I think he got the message.

No offence meant and take it in the lighter vein, but I am sure every interventional cardiologist taking emergency calls faces these alarms and the 90 minutes door to balloon time does not allow much margin to hunt for old EKGs!

Amin H. Karim MD
September 27 2024

Foot in the Door: A Complicated RCA!

By Salman Arain MD

Case of the Week – A Foot In The Door May Be All You Need!

Here is a complicated RCA intervention from this week with several discussion points. There is a bonus here – my technique for changing guides over a coronary wire. There are several sequences – but not as many as there could have been!

Baseline angio. 73 year old woman with severe angina – history of bypass with failed RCA graft. Has critical ISR at the RCA ostium. The referring had difficulty stabilizing a JR4 guide and was unable to wire the stenosis.

Here the initial wiring sequence. We used an AL1 to engage the ostium as best as we could. We used a Fielder XT to wire the ISR – it is the perfect wire to do this because of the tapered tip, the polymer jacket and the supportive shaft.

But that AL1 position is not ideal for working. The next is to build up support. We used a TurnPike LP to dilate the channel and switch out for an exchange length wiggle wire. TP LP is ideal because of its double nitinol braid – it can drive itself forward even when support is suboptimal. Once the wire is in, we can dilate with a long balloon. IVUS to follow.

Here is the initial IVUS. The entire RCA is diseased. There is likely geographic miss distally and an underexpanded stent, but they landed it perfectly at the ostium. An AL1 is not the best guide for the remaining sequence which involves engaging and disengaging the RCA ostium. So we decided to switch guides.

Here the entire sequence to switch the guides over a coronary wire. You need a long (preferably supportive) coronary wire, and exchange length 0.035 wire, and patience!!! The 0.035 wire straightens out the AL1 during transfer.

Here is the post IVL result by IVUS. The calcium ring is disrupted is several places!

After using a 4 mm NC balloon, we implanted a 4 x 48 mm SYNERGY. Here is the post stent IVUS. We post dilated with a 4 mm NC balloon.

Here is the final result! You can see the contrast in size between the stented segment and the native, diseased RCA. There is always a risk of ‘over stretching’ the vessel when IVUS measurements are strictly followed, but this is an acceptable ’step down’.

QUESTIONS:
AA Salman bhai, I had 3 questions for my own learning, not questioning. Angiographically its a beautiful result as expected from you.

is the stent truly undersized or just underexpanded (heavy calcium) in some areas by the original operator?

any for shockwave or laser (not great for calcium ) to help expand the calcium. on your post ivus the calcium appears to prevent expansion but angiographically looks awesome. risk (calcium perf ) /reward of expanding this area with a short 4.25 NC given his prior restenosis and ostial location. i would have left it as you did,

why wiggle wire? what other wire if not wiggle wire?

Good questions.

1) Undersized versus under expanded? Difficult to say. As you know, most stents between 2.5 and 3.5 mm are the same size. The difference is in the size of the balloon that they are mounted on. (@Waqas T. Qureshi MD Bhai can confirm or refute this). So, it is difficult to say whether the stent was just undersized from the get-go or not fully expanded. But it is clear that there is geographic miss and under preparation of the vessel.

2) Absolutely. I highly recommend aggressive post dilation after any atherectomy or IVL. You have to ensure the vessel will expand before the deploying another stent.

2b) This also highlights the limitation of angiography alone to gauge vessel size in diffusely diseased arteries.

2c) Post dilation options include noncompliant balloons and (now) OPN.

3) Any supportive wire may have worked. I like to use the wiggle when dealing with torturous RCAs or LADs. The wiggle portion often locks the wire in position, adding to the support provided by the wire. Of course, any other support wire may have also worked.

The LAD Challenge!

By Dr. Salman Arain MD

Challenge #1. Here is the baseline angio. The challenge here is wiring the mid LAD. The wire tip shape needed to cross it is different than the one needed to reach it. Our solution – a dual lumen catheter (Sasuke) in the mid LAD which allows us to secure the D2.

Challenge #2. We wired the D1 to secure it during provisional LAD stenting. There is plaque shift +/- thrombus which shuts down the D1 by the time we have treated the mid LAD. Luckily we still had the wire in place – so in goes the Sasuke again. We were able to guarantee that the wires did not end up behind the stent struts.

Challenge #3. We did a proximal POT, pulled the jailed wire, and passed it down the LAD. I did not want to keep working on the Fielder. Note the brief detour into D2. Alas, we ended up with a dissection! After this point the patient started vomiting and the ST were really deep. I felt that the 6 Fr guide was workkng against us. As you can see much of the LAD has shut down. Our solution – intubate, insert Impella, upsize to 7 Fr.

Challenge #4. Here is the groin angio through the 14 Fr Impella sheath. The leg will likely become ischemic during the case- so we put in a retrograde SFA sheath for future ‘external bypass’.

Challenge #5. Our first angio after Impella placement shows clot in the entire LAD!!! 😳😩 I called for Penumbra, but decided to make a pass with an Export while the cath lab was setting up. Surprisingly we were able to ‘uncork’ the LAD.

Challenge #6. The next step is to treat the D2 and optimize the mid LAD stent. There is stent recoil. IVUS showed a fibrotic lesion – we treated this with a cutting balloon and completed the LAD PCI. Or did we…

Challenge #7. The completion angio shows thrombus in the proximal LAD – address it with medications or aspirate? We tried PTCA but it embolized. Well, by this time the Penumbra was set up. We were able to complete the procedure (again!). This is the final coronary angio.

Challenge #8 (No more, I promise): How to keep the leg perfused while the Impella was in place? Here is a clip of the initial angio through the Impella sheath. The third clip is through the SFA sheath (using a micropuncture dilator) after the external bypass has been set up (right CFA -> left SFA). I do this to confirm pulsatility in the occluded leg.

This is what the set up looks like. There are several advantages to doing it this way. The retrograde sheath is easier to insert, doesn’t compromise antegrade flow to the leg, allows you to do an angio to confirm Impella sheath closure (if done), perform internal balloon tamponade on the proximal arteriotomy (if needed) and importantly – makes sure there is no dead zone in the CFA. As a bonus, you can close this with an AngioSeal later if needed.

The End.
Question: How would you take out the antegrade sheath? Manual and balloon tamponade the CFA from contralateral?
Answer: They are both retrograde. The angio shows it. It looks antegrade because of the body habitus.
The typical sequence is:
1) Remove Impella
2) Exchange Impella sheath for new sheath without flushing
3) You may do an angio from the lower (SFA) sheath at this stage. This is optional.
4) Treat the proximal arteriotomy with Manta or double Perclose.
5) Confirm closure with injection through the lower sheath.
5a) Consider balloon tamponade from the lower sheath if needed.
6) Close the lower arteriotomy if the SFA is ‘clean’ – you must use a device. It is too deep for manual hemostasis.
7) Confirm close from the contralateral side.

1) These are recommendations for Impella inserted in an emergency – and expected to stay in for some time. Usually there is no time for Preclose if the patient is crashing.
2) Also, I don’t Preclose unless I know the Impella is coming out within 6-12 hours.
2b) We have left the sutures in longer but management becomes an issue if the CCU stay is prolonged.
3) You don’t have to put a new Impella sheath in. Any 14 Fr sheath will do.
4) The idea is that there may be thrombus in the old sheath – in the space between the sheath and the Impella.
4b) Of course, you can hook it up to pressure to keep it open – but we have had thrombus form despite that too.
5) When the Impella comes out, you can use your favorite method to obtain hemostasis. Double Perclose is just one.
6) Stick the SFA in the cleanest part – avoid being too close to the Impella sheath. You don’t want the lower sheath tip ‘tucked under’ the Impella sheath.

We have left Impellas in upto 5 days with good leg perfusion using this method. The best part is that you can take it out yourself in the cath lab. No need for the OR.
Question: SA; trying to understand..
The need for# 6? Why is the SFA stick needed?
This is required when the Impella sheath is occlusive in the iliacs or the CFA. In such cases the leg with the Impella becomes ischemic.

One way to prevent this is to gain antegrade access into the CFA or SFA and create an ‘external bypass’. Usually this is done with US guidance and is a little tricky.

Our method makes it wasy because you can stick the SFA without changing the side you are standing on. Also, if you use a roadmap (like we did) you can do it without US. Because there is usually some flow via the profunda: CIA -> IIA -> PFA -> CFA/SFA.

Question: Also, for the SFA are you using an Arrow sheath ?
Answer: Yes, always an Arrow sheath. Given the depth of the vessel and the angles involved, you need a braided sheath. Non-braided sheaths will typically soften and kink.

Treating a Common disease in an Uncommon Country: Hepatitis A

By Syed Aman Ali
Medical Student, Jinnah Sindh Medical University, Karachi. Pakistan
Amin H. Karim MD, Houston, Texas

A condition that, once diagnosed in a young person, can be treated conservatively with diet and rest, can end up being treated expensively in a milieu where defensive medicine and financial incentive join together.
The case below is an example.

Case Presentation

A 20-year-old male student presented to the clinic with a 1-week history of abdominal pain and jaundice. He described the abdominal pain as a heaviness localized to the upper right quadrant, rating it 8 out of 10 on the pain scale. The patient also experienced mild fever, vomiting, and a headache. Patient later noticed jaundice, evidenced by icteric eyes and yellowing of the skin. He also reported dark urine and pale stools. He had recently traveled from Pakistan to the United States and went on a cruise approximately 2 weeks prior to the onset of symptoms.

On physical examination, the patient appeared generally well but jaundiced. Examination of the abdomen revealed tenderness in the upper right quadrant but no guarding and an enlarged liver. Patient was  advised bed rest and symptomatic treatment till he felt better and was sent home. 

Lab results were returned they showed that Hep A antibody was found to be reactive while Hep B and Hep C were non- reactive.  Patient had a high total bilirubin of 12.8 mg/dl and alkaline phosphatase was raised to 182 U/L. AST was raised to 4317 U/L and ALT was raised to 5340 U/L. Patient had an increased hemoglobin 17.8g/dl and hematocrit 55.9%. The plan from our end continued to be conservative and symptomatic.
At the insistence of parents, patient saw a gastroenterologist for a second opinion and was immediately sent to the emergency room where he was admitted to the hospital for three days. A second gastroenterologist was called upon to see the patient. All of the lab reports were repeated and more tests were done including Epstein Barr virus test, cytomegalovirus test, thyroid panel. Patient had an ultrasound of the abdomen showing normal results an abdominal CAT scan showing normal result to be followed by an MRI of the abdomen which was also normal. The rationale for doing all three tests with a low pre-test probability of finding anything of significance was not known, Liver function tests were repeated on a daily basis. Liver biopsy was contemplated but not done. Family was reassured by providers that all is being done to make sure the condition does not become worse and that no “other conditions” are being missed!

In summary, the overall cost for the patient’s treatment, considering all expenses, ranged from $20,000 to $24,000. This cost reflects the comprehensive management of a benign condition easily treated with supportive care.

Discussion

Hepatitis A is an acute viral infection caused by the Hepatitis A virus (HAV), transmitted primarily through contaminated food or water. This positive-sense, single-stranded RNA virus, belonging to the Picornaviridae family, primarily affects the liver. It is a significant global health issue, especially in areas with poor sanitation. Typical symptoms include jaundice, fever, abdominal pain, and fatigue. While often self-limiting, Hepatitis A can lead to serious complications in some cases.

Complications and Variants

  1. Cholestatic Hepatitis A: Characterized by prolonged jaundice and impaired bile excretion, leading to darker urine and pale stools. Recovery is often longer and more intense.
  2. Prolonged Hepatitis A: Symptoms such as fatigue and jaundice extend beyond the usual acute phase, requiring extended care.
  3. Relapsing Hepatitis A: Involves periods of improvement followed by recurring symptoms like jaundice and abdominal pain, complicating the clinical course.

The chances of the above complications not withstanding, the condition in young people is benign and self limiting with no sequalae, in fact long term resistance to repeat infection

An important factor is to enhance the protocols for diagnosis and therapy. Better resource management and lower total costs can be achieved by establishing standardized care standards that prioritize evidence-based, economical therapies and simplify diagnostic tests to prevent redundancy. Improving the infrastructure for healthcare is also essential. By investing in sanitation and hygiene improvements in high-risk areas, as well as expanding access to early treatment and preventive care through community health centers and mobile clinics, outbreaks can be avoided and the financial strain on the healthcare system can be minimized.

Lastly, encouraging innovation and research can lead to advancements in prevention and treatment. Encouraging research into new, cost-effective management strategies and adopting best practices based on research findings will contribute to better healthcare outcomes. By implementing these strategies into practice, we can improve patient care while lowering costs in a more effective and efficient healthcare system.

Conclusion 

In conclusion, this case study reveals a significant and somewhat ironic truth: treating Hepatitis A, a condition that often resolves on its own with minimal intervention, can still come with a hefty price tag of $20,000 to $24,000 in a milieu of defensive cum financially incentivized medical care. To address this, we should focus on preventive measures like vaccination and improved sanitation, which can help reduce both the incidence of Hepatitis A and the associated treatment costs. Additionally, refining diagnostic and treatment practices, investing in better healthcare infrastructure, and encouraging innovation in care strategies can lead to more efficient use of resources and reduced costs. By making these changes, we can enhance patient care and alleviate the financial strain on the healthcare system.

The Right Ventricular Branch: An Exception to the Rule!

By Dr. Salman Arain
Lately we have had several complex (and complicated) RCA interventions. In such cases we usually don’t worry about the RV branch – if it arises from a diseased segment we protect it, if it away we let it be. Also, the transient loss of an RVB is mostly (but not always) well tolerated. Here is a case that is the ‘exception to the rule’.
Introduction: 75 year old man with known CAD. History of RCA PCI (two?) years ago complicated by perforation and placement of a PTFE covered stent. The patient returns with progressive angina.

Interestingly there is severe ISR within the covered stent – which may explain the rather late presentation. Typical ISR presents within 6 to 12 months.

Our plan was to perform PTCA, hopefully provisionally but you can see the difficulty we had advancing even short balloons. We resolved the support issue with a buddy wire and a guide extender.

There was recoil and we decided to stent with an Orsiro (sirolimus based) stent but we had difficulty in advancing it. The RAO reveals why – a ledge of calcium in the mid RCA! We took care of it with lithotripsy (Shockwave).
Shortly after 10 placement, the patient started to complain of chest pain. He also had diffuse ST depression. We repeated the angiogram, but the flow looked good.

We admitted him to the CCU where he had a modest increase in his cardiac enzymes. The high sensitivity troponin went as high as 18,000(!). The levels started to come down on day 2.

The patient continued to complain of exertional jaw pain on day 3. We maximized his antianginals as much as a blood pressure allow, but he continued to be symptomatic. The echo showed normal LV function.

We took the patient back to the lab and found that his RCA was still patent. There is TIMI-2 flow possibly due to the recent PCI and large vessel diameter. However, we can see that there is a small RV branch that had a) disappeared during the first procedure and b) is trying to come back. We decided to open “”rescue it”.

However, this is where things became ‘interesting’. We had considerable difficulty engaging the jailed RVB ostium with multiple wires (both with and without a microcatheter). You can see the challenges here, which include lack of support and a predisposition for wire prolapse.
Some additional thoughts:
1) We took a picture of the left system and it was unchnaged from 3 days ago

2) There were several challenges in wiring: the ostium was jailed, embedded in disrupted calcium, retroflexed or at least perpendicular to the MB, and a relatively wide RCA lumen.
I tried multiple polymer jacketed (slippery) wires to no effect. I even tried a Fighter (0.008 tip) from Boston because it has a non-jacketed tip. For a different grip. But it did not work. With the blocking balloon technique, the wires just kept curling up in the RCA. Also, having a new stent struts did not help – too much exposed metal.
Case Resolution: The Micro JR4!
We decided to try a SuperCross 90 (angle tipped catheter). I gave it a small secondary bend to create a micro JR4, and to our pleasant surprise, it was able to engage the RVB ostium!

Here you can see the micro JR4 in action! We used an anchor balloon to drive the TP LP across the ostium, thus dilating it.

This then allowed us to insert a 1.5 and then a 2 mm ballon. The final angio shows brisk antegrade flow in the recovered RVB.
The patient’s angina resolved completely after the procedure. He felt great and wanted to go home the same day, but we kept him overnight just in case.

An interesting observation: The collateral from the LAD is what kept the distribution of the RVB alive. That is why he continued to have angina, even after the enzymes plateaued. I think it took a day for this collateral to plump up, which is why he suffered immediately after the branch went down.

THE END
What a nice case 👏👏 , masterfully done Salman bhai.
questions
1- would atherectomy have had a lower chance of shutting down side branch compared to lithotripsy
2- did you KISS or POT the RCA after this final ballooning or not needed ?

1) Possibly. Had we used atherectomy, we may have had less disruption at the RV ostium, and we would have cleaved the calcific plaque.

2) I don’t think we did. (Someone else asked and I said yes, but when I checked I couldn’t find the clip).

The goal of the SB balloon was to open the ostium and stretch the struts. Hopefully, the perpendicular takeoff minimized carina shift into the RCA proper.
Great questions Waleed Kayani Bhai. Sometimes we do things “in the heat of the moment” but looking at the case again (alone and with colleagues (like the Houston Cardios!) opens up other possibilities. 😀


A Diagnostic and Therapeutic Challenge

By Dr. Salman Arain MD

Here is a case I recently presented at CVI. I broke it up into different videos for teaching. A PDF of the complete presentation is included at the end.

62 year old man with HTN, DM2, and CKD 3. Presents with progressive angina for three months. Now CCS class 3. The referring MD sent him for a CTA – no stress test available. How would you approach this?

There are several notable features:

  1. Anonymous left main from the non-coronary cusp.
  2. Proximal LAD occlusion with a diseased mid segment.
  3. Bifurcation disease involving the high ramus/OM1.
  4. Patent LIMA, which supplies the distal LAD.
    4b. Patent intracostal branch from the LIMA, which may be causing a steel phenomenon.
  5. Moderate disease involving the takeoff of the high PDA.
  6. Occluded SVG to the PDA (not shown).

As such, it is difficult to determine the exact location of the ischemia. There is also a second diagonal branch, which is diffusely diseased and supplied by epicardial collaterals.

I asked the referring MD to get a stress test. The patient had ischemia in the basal and mid anterior wall and anterolateral segments.
Our plan was to treat the high Ramus/OM1 and then proceed with the LAD CTO PCI. Here is the LCX PCI. We performed Culotte.

This is the dual injection angio for CTO PCI planning.

Here are some potential options for the CTO PCI.
Antegrade contrast modulation seemed to be our best bet. Here is the sequence for this rather novel crossing technique…

Proximal cap puncture with Gaia 2

The modified Carlino injection. Note the three breakout stains. In chronological order, these are a diagonal, a septal, and the distal true lumen.

These are the three stains. Carlino has a name for this mechanism of CTO crossing. He calls it hydrodynamic contrast recanalization. Or HDR for short. This is a new term that you will be hearing about quite a bit in the future.

It can be difficult to tell if the ongoing stain is re-entry or infiltration into the extra plaque space. A retrograde injection clarifies this.

A Fielder XT without a tip bend is advanced across the channel made by the contrast under fluoroscopic guidance.

The micro catheter is an advanced over this wire. We confirm distal re-entry by means of pressure transduction and…

A distal tip injection.

Here is the final angiogram. This case highlights a new CTO crossing technique introduced by Mauro Carlino, and refined by us at UT. He calls it HDR as noted above. We have just submitted a paper describing the technique, and hopefully it will be accepted (soon!).

Arain CVI 2024 ShortDownload


For our colleagues: CTO PCI is a mature field and several strategies for crossing CTOs have been developed. Most of them use wires. This ‘new’ technique is not so new – it is modification of an older technique which uses contrast injections. It is called Carlino after the interventionalist who described it.









Career Choices for Trained Physicians: Cardiology

Michael Walter | July 12, 2024 |

Compensation keeps climbing in cardiology, electrophysiology, heart surgery

Cardiology salaries have continued to climb in 2024, according to a new survey from the American Medical Group Association (AMGA). Among general cardiologists, for example, median compensation jumped nearly 8% from $552,000 in 2023 to $596,000 in 2024.

The 2024 AMGA Medical Group Compensation and Productivity Survey includes feedback from more than 189,000 healthcare providers representing nearly 200 different specialties. In 2024, compensation for primary care providers increased 3.6% compared to 2023. Medical and surgical specialties saw compensation go up 5.1% and 5.5%, respectively, and the year-over-year increase for radiology, anesthesiology and pathology was 5.8%.

“We are seeing significant productivity increases, which, in essence, drove the compensation increases across specialties,” AMGA Consulting President Fred Horton, MHA, said in a statement.

A closer look at cardiology salaries in 2024

Diving back into cardiology, most subspecialties saw considerable growth in compensation from 2023 to 2024. Echocardiography lab and nuclear cardiology (12.4%), cardiothoracic surgery (11.2%), cardiovascular surgery (10.5%), interventional cardiology (9.7%), electrophysiology (8.2%), general cardiology (7.9%) and pediatric/adolescent cardiology (5.7%) all experienced healthy year-over-year increases, outpacing primary care providers by a significant margin.

Compensation for advanced heart failure and transplant cardiologists also increased in 2024, but only by 2.9%. Cardiothoracic surgeons focused on pediatric patients, meanwhile, saw their median compensation decrease 2%; it went from $899,000 in 2023 to $881,000 in 2024.

Out of all of cardiology’s subspecialties, the highest 2024 salary belongs to cardiovascular surgeons ($911,000). The lowest, on the other hand, belongs to pediatric/adolescent cardiologists ($356,000).

Changes in work RVUs in cardiology

The AMGA survey also explored work relative value units (RVUs), which went up in 2024 for every cardiology subspecialty. Among general cardiologists, for example, median work RVUs increased from 8,368 in 2023 to 9.010 in 2024, a difference of 7.7%. This resulted in a compensation/work RVU ratio of 2.9% for general cardiology.

Echocardiography lab and nuclear cardiology saw a large year-over-year jump in work RVUs (15.2%), explaining that group’s notable salary bump during the same time period. Even with the higher salaries in mind, however, the compensation/work RVU ratio for that group was -3.2%.

On the other hand, advanced heart failure and transplant cardiologists saw an even bigger increase in work RVUs (18.9%), but that was not associated in any way with higher salaries. This resulted in a compensation/work RVU ratio of -16.4%.

The smallest increase in work RVUs was seen in the pediatric/adolescent cardiologist group; they went up just 0.5% year over year.

Many salary figures listed above were rounded for the sake of simplicity.

Career Choices for Trained Physicians in USA. Viewpoints 1

By Amin H. Karim MD

PREFACE:
In many physician professional social media groups, physicians nearing the end of their residency or into early practice often ask senior physicians in the group about their experience in choosing their career; why did they choose private practice v/s joining a large hospital system v/e faculty teaching or research position? Many senior physicians volunteer the answer to the best of their ability and explain their choices. Some members get to read them and most miss it since the groups like WhatsApp have disappearing messages option and the views of the senior physicians are lost forever. Residents outside the groups never get the benefit of the views and this valuable ad hoc proctorship. The same happens with email and FaceBook groups.

In this section of the website, I have tried to record the views of the volunteering senior physicians and surgeons who have been kind enough to allow us to publish their views. We will do this in an orderly fashion first outlining what specialties are covered (the ones most practiced by Pakistani Descent physicians in USA and Canada) and also try to classify the various avenues of career available to the newly trained doctors at this time i.e. 2024-25 and beyond. We will try to keep the comments updated; readers are also invited to post their own comments in the comments section.

COMMON SPECIALITIES IN USA.
These 30 or so medical specialties are the ones mostly chosen by residents from Pakistan. There are many other subspecialties within these groups, which are beyond our scope for now.


These are alphabetically arranged.
Addiction Medicine
Anesthesiology
Colon and Rectal Surgery
Cardiovascular Diseases General.
Cardiovascular Disease Interventional
Critical Care Medicine
Dermatology
Endocrinology
Emergency Medicine
Family Medicine
Gastroenterology
General Surgery
Geriatric Medicine
Hematology
Hospitalist
Infectious Diseases
Internal Medicine (General In and Outpatient)
Nephrology
Neurology
Neurosurgery
Oncology
Orthopedic Surgery
Otolaryngology
Pain Management
Pathology
Pediatrics (General)
Physical Medicine and Rehabilitation
Plastic Surgery
Psychiatry
Pulmonary Diseases
Radiation Oncology
Radiology
Rheumatology
Urology
Wellness Medicine
OTHER (Please define in your comments)

CAREER PATHS AVAILABLE TO TRAIND DOCTORS AS OF 2024:

Private Practice Solo
Private Practice with Uni Specialty Group Self Managed
Private Practice with Uni Specialty Group Managed by a Company
Private Practice with Multispecialty Group Self Managed
Private Practice with Multispecialty Group Managed by a Company
Health Care Administration
Hospital Employment
Academic Employment with a Teaching Institution
Pharmacological Company Employment.
Veterans Administration Employment
Government/Armed Forces
Government/Federal/
State/County/City Employment.
Other (please define in you comments)

PROCTORING COMMENTS FROM PRACTICING AND/OR RETIRED PHYSICIANS
Here are the comments in the order received: For volunteering proctors please use the set up as below and send it to me

AMIN H. KARIM MD
CARDIOVASCULAR DISEASES INTERVENTIONAL
PRIVATE PRACTICE SOLO
I have been in Solo private practice of Cardiology since the late 1980s.
I started immediately after graduation from the fellowship program and have lived and practiced in Houston, Texas since then. Will not go into details of how we did in those years in the last century (although you can read about them on this website under My Journey. The object is to guide the younger generation onwards since the medical world has changed and is fast changing.
I will simply list the PROS AND CONS.

PROS:
1) Number one is INDEPENDENCE. You are your own boss and everyone knows what that means. The buck stops on your desk bringing its own responsibilities.
2) Brings forth all your innate faculties, innovation and resources to learn, plan, implement and see the results. Rejoice in the success and learn from failures!
3) Put your best effort and hard work with resulting satisfaction. This includes marketing, accounting, purchasing and other nitty gritty of running a business.
4) Bring forth your best in manners and behavior towards everyone including patients, employees, referral physicians, colleagues and even relatives. Each one of them are important in the success of your practice in sending referrals and in their comments to others.
5) Last but not the least, the satisfaction of knowing that what you are making is yours and the patients you are making and the name you are making in the community are your “equity” that is only going to build with time. Also you get to claim many expenses in your returns and have your own 401K retirement plan for retirement.

CONS:
As they say there are no free lunches.
1) Number one expressed by many is more time to the practice and less for family. Here you need to plan and adjust according to your needs as time goes.
2) Hassles of billing, insurance, employee retention, regulations like OSHA and HIPPA, Metric s reporting. These have solutions these days as there are companies for everything. Billing and Payroll should always be outsourced as it is not worth doing it yourself. Virtual receptionists are available and your secretary (costing much lower) will be in Pakistan or Philippines.
3) But at this stage, it is becoming increasingly difficult to establish as solo in large cities, unless you are giving an income guarantee (still legal) in outlying area by a new hospital or are willing to go to an area lacking your specialty and still live nearer to the city (eg living in Houston and practicing in Angleton or Baytown).
For the brave and adventurist nothing is impossible. It can still be done for the one who is willing to put in long hours in the beginning.

MUNIR A. SHIKAR MD
Cardiovascular Diseases General
Solo Private Practice
It’s good option if you are young – it takes a lot of time and a lot to learn with a learning curve. Once you are set it’s great. Soon you can pick juniors and make sure you know to reap the harvest of the basic set up that you do. Make sure that you always have an edge above others in any contracts that you make for or with others
Step ladder – solo and soon in couple of years at best partners of single specialty and merge a few years later with larger group with multispecialty group
Pick a specialty of your choice with office and hospital procedures coz that’s the beef of practice
Member: APCNA

ANONYMOUS
Pain Management
Solo Private Practice
I have been in the practice of Pain Management for last decade. It’s non-interventional and includes Addiction Medicine.
Pros: There is a lot of satisfaction in treating pain, even if by a simple trigger point or joint injection. Even removal of joint fluid can add to the comfort and mobility.
Cons: Patient’s tend to be difficult, especially if they have been addicted to narcotic pain medicines or years. Taking them off these can be a challenge.
Then there are professional pain medicine traders who bring in people to make up a story and get a prescription for pain meds. Regulators always watch closely.
Member: APPNA.

ANONYMOUS
Colon and Rectal Surgery
Multispeciality Group Self Managed
Very satisfying and you can do some good for patients. Patients are quite miserable with colorectal problems and they are usually appreciative.
PROS: Good lifestyle, you can work as little or as much as you want. You can do minor surgeries or very major surgeries.
CONS: I cannot think of any. But some people don’t like to deal with poop.
Would choose same again
Member of APPNA.

ABDUL MUNIS
Internal Medicine
Private Practice in Uni Speciality Group Self Managed.
Worked 20 years as hospitalist now working in post acute care for last 4 years
Pros: Less stress time flexibility more time off reasonable income
Chronic pts in nursing home poor nursing family pressure
Would choose a SPECIALTY if given a chance to start all over
Do you what likes you best adjusting for your life style

If you wish to give your views, please click on the link below to go the Google Forms and fill it out. If accepted, we will add to the above

https://forms.gle/b6NLpbUY478vbrAC6