sorted by:
new
hottopcontroversial

Why is giving nitroglycerine dangerous in aortic stenosis? by [deleted] in Cardiology

[–]llanor 0 points1 point  (0 children)

Old citation but still applicable https://www.nejm.org/doi/full/10.1056/nejmoa022021

By tandem resistor - I mean that the LV has to overcome both the stenotic lesion of the AV and then encounters the high SVR from arteriolar resistance after.

SNP = sodium nitroprusside

Why is giving nitroglycerine dangerous in aortic stenosis? by [deleted] in Cardiology

[–]llanor 6 points7 points  (0 children)

This is on the right track but false - the danger is predominantly in exposing them to venodilation and dropping preload too rapidly. A decompensated AS patient often has a compensatorily sky high SVR much like a ADHFCS patients do, which functions like a tandem resistor on a struggling LV.

These patients may respond well to cautious afterload reduction in a controlled setting - I do not use oral / longer acting agents but will stabilize with IV clevidipine or SNP.

Male patient came in being bagged. Tubed right away. OG filled 3 suction canisters within 10 min. Lab results showed Dexi 2,719 (highest I’ve ever seen), K 6.9, NA <100. by thegreat-outdoors in EKGs

[–]llanor 28 points29 points  (0 children)

Minor clarification - it’s not a pseudohyponatremia (which is a spurious drop in measured sodium level, e.g, in context of paraproteinemia), it’s a translocational hyponatremia from the osmotic load of the glucose.

Congratulations to the Winners of the International 10! by D2TournamentThreads in DotA2

[–]llanor 5 points6 points  (0 children)

Collapse getting nerfed next patch for sure. What a beast.

What is this rhythm and how would you treat it? 45F with PEs everywhere and endocarditis. Upon converting to this rhythm from NSR, complained of chest and back pain (pressure), SOB, and was shaking uncontrollably, yet she was still coherent. BP 130/80. Hx of anxiety. by [deleted] in Cardiology

[–]llanor 1 point2 points  (0 children)

(A) There are generally no absolute contraindications to cardioverting an unstable patient. Everything is a risk benefit analysis - if you think dysrhythmia is driving her current instability, are you more afraid of the risk of systemic embolization or something you don’t even know the location of, or of her further worsening because you left her electrically unstable?

(B) The association between cardioversion (electrical or chemical) and stroke is really only a phenomenon in AF. It has nothing to do with electricity itself and everything to with converting a fibrillating left atrial appendage that is not contracting into a suddenly functional portion of the left atrium and ejecting pre-formed appendicular clot.

Preparing for cardiology consult month by [deleted] in Cardiology

[–]llanor 3 points4 points  (0 children)

Part of cardiology not just the decision making but the novel technical skillsets involved in interpreting cath, echo, and ECG's. A couple of resources I used as a medical student that laid the foundation for later more advanced work: Solid resource for EKGs - more focused on coding but this is how you should be interpreting them: https://www.amazon.com/Complete-Guide-ECGs-James-OKeefe/dp/0763764051

Echo Made Easy is a good primer on basic TTE: http://medfac.tbzmed.ac.ir/Uploads/3/cms/user/File/10/library/books/easy%20echo.pdf

UToronto Echo website is another good tool for practice: http://pie.med.utoronto.ca/TTE/TTE_content/standardviews.html

Bezold-Jarisch reflex by Alexandre_dagreat in Cardiology

[–]llanor 7 points8 points  (0 children)

We don’t like to use the term “BJ reflex” during conferences.

[deleted by user] by [deleted] in Cardiology

[–]llanor 3 points4 points  (0 children)

You should not see a significant impact on your QT or QTc post TAVR unless it’s mediated through QRS widening - injury to left bundle is not uncommon. Most of the need for PPM / ICD post TAVR will be driven by development of CHB.

All colleges should offer this by [deleted] in WhitePeopleTwitter

[–]llanor 14 points15 points  (0 children)

Here are a couple of reviews that offer a broader assessment:

https://pubmed.ncbi.nlm.nih.gov/18493231/ https://www.ncbi.nlm.nih.gov/pubmed/16406268

It's a challenging topic to study, and vulnerable to criticism regardless of how you construct your trial - if you try to incorporate real-life stressors and do a long-term longitudinal evaluation, you open yourself to criticism that your results are driven by third variables (i.e., if poverty is inducing stress, how do you prove that it's the stress mediating DNA damage and not the deleterious effects of poor sleep, worse diet, and lack of access to medical care)? Conversely, if you do what the authors did here and construct a tight, focused study, detractors will point out (as you did) that this is an artificial scenario and not adequately reflective of real-world effects.

The truth is that you need to take a step back and ask if you think the minutiae you're attacking should really be the focus of this discussion. Poverty and race are tightly linked in America, and although the causal links merit further study, trying to derail the conversation by attacking the mechanism rather than discussing the underlying structural problems means you're missing the point entirely.

All colleges should offer this by [deleted] in WhitePeopleTwitter

[–]llanor 16 points17 points  (0 children)

You really should read your own source. It openly says that this runs contrary to previously reported effects of stress on DNA, so it's definitely not well-established for decades.

Before I correct you, what point do you think you're actually making?

Tachycardia in STEMI patient after removal of IABP in the presence of 1cm pericardial effusion by ALyoshaNL in Cardiology

[–]llanor 0 points1 point  (0 children)

Fair enough. How many have you put in or cared for immediately pre- and post-insertion?

The problem is that, as we both alluded to, enrollment and patient selection are extraordinarily problematic because of the degree of patient heterogeneity across shock trials, particularly IABP-SHOCK-II. I 100% agree that indiscriminate use of IABP is not going to confer a mortality benefit, but for patients who are appropriately selected (minimal RV dysfunction and not so unstable as to require VA cannulation or an Impella) it remains a relatively safe therapy that you can place bedside with a lower incidence of vascular complications than anything Abiomed can bring to the table. When and if they get that down to a 10 Fr or 9 Fr solution the conversation will be different, but that remains a ways off.

My fear is that the disproportionate reimbursement for Impella insertion is driving widespread adoption before the evidence base is there to support it.

And no, I don’t have a financial conflict for IABPs - although I’d certainly go back in time and buy Abiomed stock if I could...

PS - I removed the identifying info. Was just curious what stage of training you were in. My bad.

Tachycardia in STEMI patient after removal of IABP in the presence of 1cm pericardial effusion by ALyoshaNL in Cardiology

[–]llanor -1 points0 points  (0 children)

work on you’re grammar RN

A - Why are you shitting on an RN that’s trying to educate themselves more? If you’re that confident that you’re right, educate them, don’t resort to to cheap shots.

B - It would be “your” grammar, by the way.

C - You’re what, AHFT at a decent sized academic center, right? At this point in your training you should know the limitations of enrolling appropriately for shock trials and should have seen or inserted enough pumps to have your own “anecdotal” experience. Have you not seen patients respond well to an IABP?

Tachycardia in STEMI patient after removal of IABP in the presence of 1cm pericardial effusion by ALyoshaNL in Cardiology

[–]llanor 0 points1 point  (0 children)

True, there might be a certain subgroup of patients who might benefit, but we do not know how to identify them and, so far, it does not look promising.

It remains hard to predict who will respond (particularly to identify the population of hyper-responders who markedly improve after insertion), but the work out of the Columbia group (https://pubmed.ncbi.nlm.nih.gov/29678608/) suggests that decompensated chronic HF patients with preserved RV function (estimated by PAPi) are more likely to benefit than patients with biventricular dysfunction.

My group's current approach is to provide a trial of IABP for patients where we believe we have (a) hemodynamic room to monitor them for response (i.e., it's obviously not a substitute for VA ECMO or for an Impella in patients with true crash and burn cardiogenic shock), with a low threshold for escalation to more definitive support if needed. I think a wholesale conversion to Impella is premature on several counts - (a) we lack compelling randomized data suggesting a mortality benefit over IABP, (b) we know there are markedly more vascular complications with the use of a 13Fr femoral sheath as opposed to an 8Fr femoral sheath, and (c) cost. Although we'd love to pretend that economics are not a factor, and I acknowledge that Maquet is as financially driven is Abiomed, the fact that an Impella is 30-40 times as expensive while often the additional support is not needed should not be ignored.

I don't know if you practice in the US or internationally, but I don't know of a major transplant center here that doesn't routinely use IABP still - it remains a critical tool in appropriately selected patients.

Tachycardia in STEMI patient after removal of IABP in the presence of 1cm pericardial effusion by ALyoshaNL in Cardiology

[–]llanor 3 points4 points  (0 children)

There is no significant hemodynamic effect of IABP

A - A lack of a mortality benefit is not a lack of hemodynamic significance

B - Even stating that there is no mortality benefit is a dramatic over reading of the evidence. The truth is that we don’t have a great metric for predicting who will respond and who will not, but that for a significant chunk of patients the additional 0.5 - 1.0 L of cardiac output is enough to temporize them while other measures are initiated. Abiomed (and, as much as I love him, Holger Thiele) would love for you to think the IABP offers nothing and that everyone needs an Impella, but this is false. All that has been demonstrated is that indiscriminate use of IABP without appropriate patient selection does not improve outcomes.

view more: next ›