Luke Joseph, MD @LukeJosephMD

@RitikaTuliMD Congratulations! That is a very tough exam. Probably the toughest I have taken at least

Med students may hate learning PV loops of the heart, but no one hates them more than the dogs of Baltimore in the 1970s. These graphs were originally created using data from canine hearts at Johns Hopkins in the early 70s. Dogs were anesthetized, the RV was bypassed, and preload and afterload were manipulated. In later experiments, researchers actually removed the heart and kept it functioning with blood supplied by another dog! So if you live in Maryland, be extra careful walking your dog in East Baltimore.

Breaking and MASSIVE: Lowering Lp(a) with #pelacarsen in patients with elevated Lp(a) and heart disease does NOT improve cardiovascular outcomes in Phase 3 trial globenewswire.com/news-release/2…

For all of us waiting on HORIZON results, sadly they are negative 🫀Lp(a)HORIZON trial did not meet its primary endpoint of ⤵️the risk of cardiovascular events (composite of CV death, non-fatal MI, non-fatal stroke, & urgent coronary revascularization requiring hospitalization) 🆚 placebo despite ⤵️ Lp(a) #CVPrev #Lpa @Novartis @ASPCardio globenewswire.com/news-release/2…

HFrEF Quadruple therapy - in☝️post #meded 1️⃣ Beta blockade (COPERNICUS, MERIT-HF, CIBIS II) 2️⃣ Renin-angiotensin inhibition (CONSENSUS, SOLVD, PARADIGM-HF) 3️⃣ Mineralocorticoid receptor antagonism (RALES, EPHESUS, EMPHASIS-HF) 4️⃣ SGLT-2 Inhibition (DAPA-HF, EMPEROR-Reduced)

Trials to date have shown clear benefit for those with elevated CHADSVASC, leading to a class I indication for anticoagulation with scores of 2 in men and 3 in women. However intermediate scores have been left with a class IIa indication, with limited data – until this trial👇

Cardiac Trials @CardiacTrials

2 months ago

#2026 Anticoagulation for afib patients with intermediate CHADSVASC (1 in men, 2 in women)? This trial presented just days ago at #ESCCongress showed benefit without increased bleeding – guiding our longterm stroke prevention in atrial fibrillation. SINGLE-AF Trial, NEJM 2026 ♥️

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How a Heart Attack Begins: Plaque Rupture in Seconds

You're fresh out of fellowship on the cusp of making the big bucks. Here are 9 ways you could it screw up and what to do instead:

🫀 CardioNugget™ | Best Phase for Coronary CTA For CCTA, diastole is usually preferred — but not always! 🔹 Low HR (<65 bpm) → Diastole ~70–80% R-R → Longer, quieter phase = less coronary motion 🔹 High HR (>65–70 bpm) → Systole ~30–40% R-R → Diastole shortens as HR rises, while end-systole remains relatively motion-free 🔹 RCA → often has the most coronary motion and may be better visualized in a systolic phase, especially at higher HR. 💡 Remember: Slow HR → Diastole Fast HR / moving RCA → Systole #CardioNugget #CardiacCT #CCTA #Cardiology #CardioTwitter #MedEd

CardioNugget™ 💔 Anthracycline Cardiotoxicity: Know the Numbers ❤️ Doxorubicin dose: • 60–75 mg/m² q3 weeks (single agent) • 40–75 mg/m² q3–4 weeks (combination regimens) ⚠️ High cumulative dose = ≥250 mg/m² doxorubicin-equivalent → Threshold for enhanced cardiac surveillance (NCCN/ESC/HFSA) 📈 Heart failure risk rises with cumulative dose: 300 mg/m²: ~1–2% 400 mg/m²: ~3–5% 450 mg/m²: ~5–8% 500 mg/m²: ~6–20% ❗ No truly "safe" dose—LV dysfunction can occur even <300 mg/m², especially with trastuzumab, mediastinal radiation, or cyclophosphamide. 💊 If CTRCD develops (↓LVEF): ✅ Start GDMT early β-blocker ACEi/ARB (or ARNI when appropriate) Add MRA and SGLT2 inhibitor for HFrEF as tolerated. 💡 Early initiation of HF therapy = greater chance of LVEF recovery. #CardioNugget™ #CardioOncology #CardioTwitter #Cardiology #Anthracyclines #HeartFailure #MedEd

How to measure Mitral Valve regurgitation velocity and time curve ?? Here’s a short breakdown 👇🏻

🫀 CardioNugget™ | Photon-Counting CT — Explained Simply 🔬 It detects each individual X-ray photon and its energy, so it knows not only how much signal arrived, but more about what that signal represents. 👉 That extra information gives us sharper images + information about what different tissues/materials are made of. Regular CT asks: “How much X-ray energy arrived?” Photon-counting CT asks: “How many photons arrived AND what energy was each one?” More information per photon → sharper, smarter CT. 🧠 Why do cardiologists care? 🦴 Lots of coronary calcium? → Less calcium “blooming” → better look at the true lumen 🫀 Coronary stent? → Higher resolution → better look inside the stent 🎯 Coronary plaque? → Better plaque visualization/characterization #CardioNugget #CardiacCT #CCTA #PhotonCountingCT #Cardiology #CardioTwitter #MedEd

# Cardiac CT Is No Longer a Niche Test. It's Becoming Everyday Cardiology. For years, Cardiac CT has been viewed primarily as a test for ruling out obstructive coronary artery disease. Yes it has been focused on the triage of obstructive CAD. This new EACVI Clinical Consensus tells a very different story. Cardiac CT is now presented as a comprehensive imaging platform, extending well beyond coronary stenosis to include valvular disease, cardiomyopathies, cardiac masses, congenital heart disease, pericardial disease, and large-vessel pathology. The message is clear: **Cardiac CT has moved from a specialized examination to an integral part of routine cardiovascular care.** ## The Critical Point Perhaps the most important shift is conceptual. The document no longer frames CCTA as a tool that simply detects stenosis. It emphasizes plaque characterization, plaque burden, high-risk plaque features, calcium scoring, functional assessment, and patient-specific clinical pathways. This reflects the broader evolution of cardiovascular imaging: **from identifying anatomical narrowing...** to **understanding cardiovascular disease biology.** ## My Take The question is no longer *"Can Cardiac CT do this?"* It is: **"How do we integrate Cardiac CT into everyday clinical decision-making?"** That is exactly where the field needs to go. Technology only changes medicine when it changes clinical pathways. And there is where the document is weak IMHO. I believe the weak point of this document is that it does not actually provide sufficient insight into the Anatomical (and Functional and soon Tissue) imaging standard in Cardiology which is Photon Counting CT. ## Where PCCT Fits The consensus already recognizes **Photon-Counting CT** as the next technological step, highlighting its **0.2 mm spatial resolution** and its potential in challenging scenarios such as heavily calcified plaques, in-stent restenosis, and myocardial injury—while correctly acknowledging that randomized clinical evidence is still limited. However, there are already 600+ Photon Counting CT scanners installed in the world... and the technology is available since 2021. To me, as I said several times many years ago, the key message is: - PCCT is not simply another scanner. - it represents a NEW imaging modality. If conventional CCT has now entered everyday practice, the next challenge is ensuring that **Photon-Counting CT translates its technical advantages into measurable improvements in diagnosis, clinical decision-making, and ultimately patient outcomes.** That—not higher resolution alone—will define its success. #CardiacCT #PhotonCountingCT #PCCT #CardiovascularImaging #CCTA #PreventiveCardiology #PrecisionMedicine #Radiology

CardioNugget™ 🫀 PRA (Panel Reactive Antibody) Made Simple 🎯 Think of PRA as your transplant "compatibility score." It answers one question: "What percentage of potential donor hearts would this patient's immune system reject?" 📊 PRA at a glance 🟢 0% PRA → Compatible with almost every donor 🟡 20% PRA → Would likely react against ~20% of donors 🟠 80% PRA → Compatible with only ~20% of donors 🔴 100% PRA → Highly sensitized → Very difficult to find a compatible donor 📈 What increases PRA? ❤️ Previous transplant 🩸 Blood transfusions 🤰 Pregnancy 🫀 LVAD/mechanical circulatory support 🚨 Why do we care? A high PRA means: ⏳ Longer wait for a donor ❤️ Fewer compatible hearts ⚠️ Higher risk of antibody-mediated rejection 💉 May require desensitization before transplant 🧠 Board Pearl PRA = population screening test (How many donors might be incompatible?) Crossmatch = donor-specific test (Is this donor compatible?) 💡 Memory trick: Higher PRA = Harder to find a heart. #CardioNugget™ 🫀 #CardioX #CardioTwitter #HeartTransplant #TransplantCardiology #Cardiology #MedEd #FOAMed #CardiologyFellow #BoardPrep

Paradoxical septal motion helps distinguish right ventricular volume overload from pressure overload on echocardiography. In the parasternal short-axis view: 🟦RV volume overload (e.g., severe tricuspid regurgitation): - The RV is dilated. - The interventricular septum appears flattened during diastole. - During systole, the septum returns to a normal contour, and the LV appears round. ⬛ RV pressure overload (e.g., pulmonary hypertension): - The RV is also dilated. - The septum remains flattened during both diastole and systole. - This creates the classic D-shaped left ventricle, a hallmark of increased RV pressure. A simple way to remember it: 🔻Diastolic septal flattening = RV volume overload 🔻Persistent systolic + diastolic septal flattening (D-sign) = RV pressure overload

The trial is now in large part responsible for FDA approval (just this week!) of this drug in the US. Note: although this trial showed LDLc reduction, outcomes (eg CV event reduction) specific to the oral form are not yet shown (awaiting CORALreef Outcomes Trial, ongoing)☝️

Cardiac Trials @CardiacTrials

3 months ago

PCSK9 inhibition without the injections?💉 PCSK9 inhibitors dramatically ⬇️ LDLc and improve outcomes (cc FOURIER, ODYSSEY). This trial showed enlicitide, the 1st oral PCSK9 inhibitor 💊, to have similar LDLc 🔽 as its injectable cousins. CORALreef Lipids Trial, NEJM 2026 ♥️

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A woman has repeated vomiting. The ECG now shows flattened T waves and U waves. Which electrolyte abnormality is responsible?

@RitikaTuliMD Congratulations! Definitely a nice year to craft how you like it based on your personal interests.

Great post on AF and the decision to pursue rate vs rhythm control from @skepcard 👇🏻 open.substack.com/pub/theskeptic…

At what diameter is the abdominal aorta considered aneurysmal? A. > 2.0 cm B. > 2.5 cm C. > 3.0 cm D. > 4.0 cm