Gregg W. Stone MD @GreggWStone
Interventional cardiologist, trialist, innovator, educator, husband, father, loyal friend New York and the world Joined December 2016-
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Latest poll: With 800 responses from cardiologists, it appears ~2/3 would be willing to randomize into a trial like RECOVER-IV testing an Impella strategy vs control in STEMI with cardiogenic shock.
General cardiologists and interventional cardiologists only: Following Danger-Shock, would you enroll in a second trial of STEMI with cardiogenic shock in patients without anoxic encephalopathy, randomizing to Impella versus control (pressors +|- balloon pump +|- ECMO)?
Final poll results: with 277 responses, after ULTIMATE -DAPT, 67% are ready for shorter DAPT regimens after PCI in ACS, with most of those ready for 1 month only. 33% still say 1-year DAPT! Not sure why. No one bleeds until they bleed.
Final poll results: with 677 responses, after PREVENT, 35% are ready to treat non-flow-limiting asymptomatic vulnerable plaques with preventive PCI to improve prognosis. 65% are not yet believers. 4 other trials are ongoing and more are being designed.
Final poll results - with 440 responses 44% are “sold” after Danger-Shock that Impella use should be routine in appropriate pts with AMI-CS. But 56% of cardiologists are not there yet. Is a 2nd trial possible?
This is always a great course with complex cases and excellent talks.
After all the recent IVUS and OCT guidance trials of PCI, how will your use of intravascular imaging guidance change? Percent of all PCIs (choose best answer):
After ULTIMATE-DAPT, what anti-platelet regimen will you use beginning at 1 month in most pts who remain stable on DAPT after PCI in ACS for 1 month? A=aspirin, P=P2Y12 inhibitor
After the SMART trial, what type of TAVR valve will you most likely use in small aortic annuli?
After the PREVENT trial, regarding PCI of vulnerable plaque, will you:
After DANGER SHOCK, in most pts with STEMI and cardiogenic shock w/o likely anoxic brain injury, will you use:
Our publication today in JACC describing the outcomes of MitraClip in atrial compared with ventricular FMR from 5 studies (4 with outcomes data). MR reduction to <=2+ was comparable in aFMR and vFMR (RR: 0.99; 95% CI: 0.96-1.02; P=0.53) as was 1-yr death or HFH (fig).
Following the excellent LIFE-BTK results, it’s time to bring the new and improved BVS (ESPRIT) back to the cors! Very late outcomes will be improved by leaving nothing behind.
Following the excellent LIFE-BTK results, it’s time to bring the new and improved BVS (ESPRIT) back to the cors! Very late outcomes will be improved by leaving nothing behind.
Just publ in JSCAI our first-in-human study with a new integrated AI-enabled OCT-NIRS imaging catheter that has enhanced resolution and IVUS-like depth penetration (even better in calcium). Angio co-reg w/ automated EEM, lipid and Ca detection. Free link: authors.elsevier.com/sd/article/S27…
2/4 OCT/IVUS vs angio PCI guidance also reduced cardiac death by 45%, def/prob ST by 48%, def ST by 61%, TLR by 28% and TLF by 29% at a weighted mean FU of 24.7 months. All results were similar with OCT and IVUS. Free to download: authors.elsevier.com/a/1ie90V-4XL6EY
For those feeling content with their life’s work….
Mamas A. Mamas @mmamas1973
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161 Followers 118 Following@dukwoo_park with a superb presentation at #TCTAP around LMS PCI- that factors that drive pci vs surgery, use of intravascular imaging and phydiology, and newer medical therapies such as psk9i. Awate data around ffr in lms from FATE-MAIN trial @mirvatalasnag @SVRaoMD
The 💡 findings by @SophieZGU @GreggWStone @CardioCharis @DiaaHakim may inform targeted revascularisation vs. conservative management strategies 🔗atherosclerosis-journal.com/article/S0021-… @society_eas @ELS_Cardiology #CvPrev
@kriswachtell @GreggWStone @CHassager @benhibbertMDPhD @seanvandiepen Thanks so much for sharing. Very helpful for adding context and perspective to some of the results!
@GreggWStone @sado_dan @vinvizzi @DavidLBrownMD @CardioIAN @webmd11 @stefan_harb @DocSavageTJU @mmamas1973 @AjayKirtane @purviparwani @DrMarthaGulati @SVRaoMD @rwyeh @djc795 @DLBHATTMD @Drroxmehran @fischman_david @angioplastyorg @cardiojaydoc02 @DavidWienerMD @lamelaspablo @SABOURETCardio @Vilavaite @sbrugaletta @rahatheart1 @hvanspall Maybe placebo is more likely to make you say “my pain is a bit better” but for you to say “my pain has gone away entirely” there needs to have been a genuine physical effect?
How are patients in conservative are of ISCHEMIA trial doing at 6 months. < 10% require repeat angiography. Well-controlled LDL-C associated with lower need for angiography #cardiotwiitter #AHAJournals @GreggWStone @webmd11 @JDNewmanMDMPH @sripalbangalor ahajournals.org/doi/10.1161/CI…
@AndrewJSauer @GreggWStone @Abiomed I think that should be studied. The 5.5 has even less evidence than CP. The placement risks are higher if the pt is truly unstable. I have concerns about surgical bleeding, DAPT mgt, and vascular injury. I agree outcomes I see are better w/5.5 but don’t know if that’s selection
@Ben_Kelemen @GreggWStone @Abiomed I hear you. But we are doing what’s convenient at many centers (you are not alone) rather than what is probably best. It’s a challenge. The CP, and all its complications, might not be the answer for many patients with CS.
@AndrewJSauer @GreggWStone @Abiomed Agree @AndrewJSauer one of the first thing I look at when seeing post AMI-CS pt on a CP is the color of the foley bag…
@GreggWStone I definitely want another trial. Carefully phenotyped for those with post MI CS with PA catheter, and I would request Impella 5.5 if I could order from the menu. @Abiomed folks claiming hemolysis and groin / extremity complications don’t exist with groin CP is becoming…
@adityadoc1 @GreggWStone @DmitryAbramovMD Yeah my pt was on bipap EDP 35. SCAI C. EKG nasty global pattern. But warm.
@adityadoc1 @GreggWStone @DmitryAbramovMD Didn’t mean to offend just like the occasional GIF. I apologize. I knew it wasn’t your words. Most CHIP European/Asian operators do high risk LM cases w no MCS. I think we need to use caution in allowing one trial to transform practice. I’m not anti pLVAD at all.
@GreggWStone Now we get to find out how many people lie on the internet (even in an anonymous poll). :)
@GreggWStone Can you explain why you specifically excluded cardiologists who are boarded in AHFTC and how that might bias your X poll? I’m seriously curious.
@adityadoc1 @jl35wilsonMD @GreggWStone @DmitryAbramovMD Most simple question asked by my mentor to me: Would you randomize ur father? Then be apart of the trial—if not u don’t have equipoise
@thiele_holger @GreggWStone @JasonKatzMD @seanvandiepen @CHassager @benhibbertMDPhD Finally, it is not obvious to me that patients with potential neurological ischemia during cardiac arrest would benefit greatly from the high dose heparin infusion needed for Impella placement which potentially could mask the benefit shown in cardiogenic shock patients w/o CA
@thiele_holger @benhibbertMDPhD @GreggWStone @JasonKatzMD @seanvandiepen @CHassager So clearly the inclusion/exclusion of cardiac arrest makes a world of difference. In addition, incl. patients with cardiac arrest reduces study power bc of very high neurologic and MOF mortality in both groups rendering fewer patients to contribute to the statistical difference.
@thiele_holger @benhibbertMDPhD @GreggWStone @JasonKatzMD @seanvandiepen @CHassager Another explanation for short ICU stays is the exclusion of patients with cardiac arrest. Danish registry data show that the median time to death in refractory cardiogenic shock w/o CA is only 13 hours. However, in CS with CA time to death is 140 hours from the initial 911 call.
@GreggWStone @JasonKatzMD @seanvandiepen @CHassager @benhibbertMDPhD just to let you think. Any explanation for the shortest ICU time ever in a #AMICS RCT in Control? Preemptive decision for end of life???
Fully agree. I still do not understand the 60% mortality in control. This is the highest ever reported mortality rate in contemporary PCI era. We did this analysis for all our RCTs and mortality is <50% for the DanGer eligible cohort!