Cardiology's workforce shortage: implications for patient care and research.

Fibrinolytic therapy has been an important means of establishing reperfusion for decades. However, limitations to the use of thrombolytic therapy include perceived or definite contraindications, intracranial bleeding, inability to establish Thrombosis In Myocardial Infarction (TIMI-3) flow in many patients, and high rates of recurrent ischemia and reocclusion. Accordingly, primary percutaneous coronary intervention (PCI) has emerged as the preferred reperfusion strategy. Nearly all acute myocardial infarction (AMI) patients are eligible for emergency catheterization. Knowledge of the coronary anatomy allows immediate triage to surgery, medical therapy, or primary PCI, when appropriate, and results in earlier hospital discharge compared to thrombolytic therapy.1 Primary PCI establishes TIMI-3 flow in >90% of patients and is associated with reduced rates of recurrent ischemia and reocclusion. With the addition of stenting, reocclusion has been further reduced to 5% at routine 6-month angiography.2,3 Small studies have suggested that pharmacological adjuncts to PCI such as abciximab may improve myocardial perfusion and limit infarct size4,5 without the risk of bleeding observed with thrombolytic therapy.6 Finally, new technologies such as coronary thrombectomy, distal projection, and systemic cooling are easily applied in the catheterization laboratory and may further improve myocardial perfusion and infarct size. Although primary PCI has been in use for more than 25 years, the first trials randomizing PCI to intravenous thrombolytics therapy were not published until 1993.7 A meta-analysis of the first 10 randomized trials demonstrated a reduction in death, reinfarction, and stroke with primary PCI in all subgroups, but the greatest absolute benefit was observed in high-risk patients.8 On the basis of these early results, many experienced interventionalists were no longer willing to randomize patients to thrombolytic therapy. Therefore, the next decade of research was focused on perfecting the primary PCI technique, with studies randomizing patients to intraaortic balloon pumps, stents, glycoprotein …

COUNTERPOINT: Should Interventional Pulmonology Be Given American Board of Internal Medicine Subspecialty Status? No

Fibrinolytic therapy (FT) and primary percutaneous coronary intervention (PCI) are both well-accepted reperfusion therapies in ST-segment elevation myocardial infarction (STEMI). The evidence of randomized clinical trials indicates a relatively modest difference in 30-day mortality (≈1%) in favor of primary PCI over fibrin-specific FT and was based on very timely primary PCI (ie, a primary PCI–related delay of 40 minutes [door-to-balloon less door-to-needle time]).1 Longer delays to primary PCI, which are far more frequent in clinical practice,2 are associated with attenuated benefit or no benefit at all, particularly when compared with fibrin-specific FT.3,4 The benefit of timely primary PCI over FT is likely to especially apply to higher-risk patients.5,6 Irrespective of the method of reperfusion, the potential for myocardial salvage and better clinical outcome is inversely proportional to ischemic time or its only available clinical surrogate, symptom duration.7–12 These considerations underpin the notion expressed in the American College of Cardiology/American Heart Association (ACC/AHA) guidelines on the treatment of STEMI that timely reperfusion therapy is likely more important in determining outcome than whether FT or primary PCI is the chosen reperfusion method.13 Response by Armstrong et al p 1310 The ACC/AHA STEMI guidelines highlight the time point of 3 hours of symptom duration in guiding the choice of reperfusion therapy. They state that if symptom duration is <3 hours, no preference exists between FT and primary PCI provided that treatment is timely (for FT, door-to-needle time <30 minutes; for primary PCI, door-to-balloon time <90 minutes and ≤60 minutes between estimated needle time and estimated balloon time). However, if symptom duration exceeds 3 hours, these guidelines favor primary PCI over FT, again provided that primary PCI can be performed in a timely fashion.13 This article reexamines the evidence that may or may not be the basis …

Risks and Benefits of Antiplatelet Therapy in Uremic Patients

Education: “The process or art of imparting knowledge, skill and judgment; Facts, skills and ideas that have been learnt, either formally or informally.” — Wikipedia 1 The term profession is applied to those persons who have specialized and technical skill or knowledge which they apply, for a fee, to certain tasks that ordinary and unqualified people cannot ordinarily undertake. The term derives from the Latin: “to swear (an oath) …” . — Wikipedia 2 Let’s consider how we as cardiovascular medicine specialists spend our days in the care of people with cardiovascular disease. In the office or making rounds in the hospital, we prescribe drugs and order diagnostic tests; in the noninvasive laboratory, we obtain and interpret images of the heart; in the electrophysiology and cardiac catheterization laboratories, we program and implant devices in patients. When antithrombotic and fibrinolytic drugs are administered, and primary percutaneous coronary intervention is done using balloon catheters and intracoronary stents, lives are saved among patients with acute myocardial infarction. Response by Avorn and Choudhry see p 2221 The mortality risk from heart failure decreases and quality of life increases from the proper and appropriate use of angiotensin-converting enzyme inhibitors and β-blockers. Lipid lowering through the use of statin drugs saves lives and reduces serious cardiovascular complications such as myocardial infarction and stroke when properly prescribed to patients with a variety of manifestations of atherosclerotic vascular diseases. According to a recent publication by Ford and colleagues,3 deaths due to coronary heart disease in the United States declined substantially from 1980 to 2000, resulting in >340 000 fewer deaths in 2000. The authors attributed approximately half of this decline to changes in cardiac risk factors and half to the application of evidence-based therapies. An underlying theme in all of this is that the pharmaceutical, biotechnology, and …

2019 AATS/ACC/ASE/SCAI/STS expert consensus systems of care document: A proposal to optimize care for patients with valvular heart disease: A joint report of the American Association for Thoracic Surgery, American College of Cardiology, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons

HRS Expert Consensus Statement on remote interrogation and monitoring for cardiovascular implantable electronic devices.

2019 ACC/AHA/ASE Advanced Training Statement on Echocardiography (Revision of the 2003 ACC/AHA Clinical Competence Statement on Echocardiography): A Report of the ACC Competency Management Committee

The Gastroenterology Core Curriculum, Third Edition

Is Nephrology Fellowship Training on the Right Track?

Physician Recruitment into Geriatrics—Further Insight into the Black Box

How many pediatricians? pitfalls in analysis and possible approaches

The Accreditation and Certification System After Next

Benefit of Long-Term Dual Anti-Platelet Therapy in Patients Treated With Drug-Eluting Stents: From the NHLBI Dynamic Registry

In this issue we publish 2 differing cardiovascular perspectives on how to manage ST-segment-elevation myocardial infarction (STEMI) during the coronavirus disease 2019 (COVID-19) pandemic.COVID-19 has disrupted many processes of care related to emergency cardiac conditions.These perspectives offer 2 opinions understanding that capacity of treating hospitals will continue to evolve and management should change based on it.Placing these side-by-side will allow readers to understand the tradeoffs inherent in such decisions. The coronavirus disease 2019 (COVID-19) pandemic has dramatically altered the delivery of reperfusion therapy for patients with ST-segment-elevation myocardial infarction (STEMI).At this crucial time, it seems prudent to reevaluate STEMI reperfusion pathways (Figure).Although primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy when available, its benefit depends on rapidly achieving firstmedical-contact-to-device times within 90 to 120 minutes.Delayed reperfusion results in larger myocardial infarct size, increased risk for heart failure and shock, and no survival advantage compared with fibrinolytic therapy.Moreover, in the STREAM trial (Strategic Reperfusion Early after Myocardial Infarction), a pharmacoinvasive strategy of early fibrinolytic therapy coupled with timely PCI compared with primary PCI provided similar 30-day clinical outcomes and 1-year mortality. 1Half-dose tenecteplase in those ≥75 years obviated major bleeding and intracranial hemorrhage rates and in a large real-world registry, this pharmacoinvasive strategy was associated with improved 1-year clinical outcomes compared with primary PCI without differences in major bleeding or intracranial hemorrhage rates. 2 STEMI rates have declined during the COVID-19 pandemic, perhaps partly because of patients unwilling to access the emergency medical system or risk hospital exposure to COVID-19.Those presenting to hospitals without PCI-capability are subject to transfer delays for primary PCI, or even transfer refusal, because of COVID-19 demands.Those presenting by ambulance directly to hospitals with PCIcapability are not receiving the benefit of prehospital cardiac catheterization laboratory activation because it has been suspended. 3Emergency department evaluations are prolonged with additional screening for COVID-19 and STEMI mimics that affect troponin release and confound ST-segment elevation interpretation.Transfer from the emergency department to the catheterization laboratory is complicated by risks of additional staff exposure and delays in preparation associated with personal protective equipment.As the frequency and duration of PCI-related delays for reperfusion therapy increase, fibrinolytic therapy and the pharmacoinvasive strategy offer a logical, effective, simple, and safe alternative for an overtaxed health system while decreasing COVID-19 exposure risk for healthcare providers.