Exploring Pericarditis: Diagnosis, Challenges, and Clinical Insights

On episode 42 of Inside the Studio, Dr. Joseph Rogers, THI President and CEO, sits down with Grand Rounds guest Dr. Allan L. Klein from Cleveland Clinic to discuss pericarditis, a disease often overlooked. Dr. Klein shares his expertise on diagnosing subtle presentations, the importance of clinical examination, and the latest advancements in treatment, including biologics and the role of exercise.

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Transcript

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Thanks so much, uh, for the kind introduction

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and also for, you know, inviting me

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to a pretty historic place.

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I was actually just reflecting

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after having come down here that um,

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when you're at a place steeped in history,

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it's not common a lot of times for people to recognize that.

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And many times it's taken for granted.

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And one of the things that I've been struck is that, that

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that preservation of the history

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and understanding of what it meant to the field

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of cardiovascular disease, uh, lives strong.

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Not only within um, the faculty here, but also the staff

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and people who set this up.

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And so, um, that's a remarkable thing.

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You should be really proud of it and it's kind of inspiring,

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uh, for folks like me from New York

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where literally people don't remember

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who the last division chief was.

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So, um, super important and,

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and really an honor for me to be here today.

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You know, I grew up in an era

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where I think grand Rounds was one of those things

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where you talked about patients, you talked about data,

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and you tried to put them together to figure out

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how best to take care of your patients.

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And so for me, the best grand rounds were not just data,

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it was very patient oriented.

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And what I've tried to do with this talk, um,

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hopefully I'll succeed, is to take you through my journey

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after fellowship, being a practicing clinician,

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also a researcher, um,

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and teacher of how I like to think about coronary disease.

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What's nice about coronary disease is very prevalent, uh,

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and hopefully many of you don't have family members

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who have it, but as you get older,

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it's an inevitable part of life.

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And the way I like to think about it really draws upon data

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but draws upon clinical experience that's not only um,

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e experiential, but it evolves over time.

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And so that's how I've put this together.

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All my disclosures are in the CME materials.

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This is kind of everything. It mainly goes to Columbia

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and the Cardiovascular Research Foundation

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for trials that we conduct.

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So I'll start off with a case,

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'cause that's how I always

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historically thought about grand rounds.

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And this is a woman that I took care of

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who several years ago, you know, had risk factors,

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had a known ischemic cardiomyopathy

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with a chronic total occlusion, um,

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had near Sinkable episode and an ICD was placed,

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but she had worsening dyspnea on exertion

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and medical therapy was escalated.

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And ultimately the outside referring hospital in the state

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of Pennsylvania called one of our heart failure doctors

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and said, look, I think

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that she might need enrollment in a stem cell trial

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or for advanced heart failure therapies

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like LVAD or transplant.

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And the heart failure doctor called me

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as the interventionalist and said, you know,

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before we do any of that, uh,

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I think she might need a cath again

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to figure out what's going on with the coronary anatomy.

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And it struck me at the time,

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and it still strikes me today,

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that there are many patients like this out there

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who have heart failure and people think about other things

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but they don't necessarily think

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about going to the cath lab.

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And there's this been feeling that, that that's developed.

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And I graduated in 2006, the courage trial came out soon

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after that that maybe the way to think about procedures,

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cath lab and otherwise was that less is more.

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And there's this from Newsweek at the time it was a

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different jour different magazine than it is now, um,

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where the patient's saying no

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and the entire healthcare system is predatory on the patient

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because they wanna do procedures and make money

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and bill for it, et cetera.

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And this blows the healthcare budget

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and also puts the patient at risk.

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And that was kind of the paradigm that that came out right

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after I finished fellowship.

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And you can imagine if your fellowship is done,

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you're excited to go out

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and practice, you're excited to help people

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and that at the same time there are all these newspaper

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articles saying you're not helping anybody

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and you're doing unnecessary procedures.

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So why did that come about? Why was this paradigm espoused?

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And I think one of the reasons for it is we had to recognize

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that there were disparities in the way people

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were getting PCI.

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So this is just a map obviously of the United States

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and you can see the different penetrance of PCI

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or revascularization procedures

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based upon where people live.

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Some people don't have any access to care,

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but other people just get a ton of procedures.

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New York, um, we get a lot of snowbirds to Florida.

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You can see how many procedures are being done down there

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and we always tell our patients, please give me a call

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before someone does a cath or does some procedure on you

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because I wanna make sure it's

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legit and for the right reason.

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And if you recognize that there are definitely cases that

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where this is going on, what ends up happening is societies

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came together and they came up

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with what's called appropriate use criteria

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for coronary revascularization.

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In the beginning of my fellowship

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or as I started practicing, this was like a bad thing.

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We thought that this was not gonna be good

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because outside societies were gonna tell

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us how to practice medicine.

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But in reality what they did

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by doing this is they did drive more appropriate care in the

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sense that at the patient level, the folks

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that were then coming to the cath lab typically had more

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severe symptoms, were on more meds.

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And at the hospital level, the rate

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of unnecessarily rated procedures went down.

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So I evolved. Initially I thought this was not a good thing

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and in in retrospect what you had to realize,

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and especially for me practicing in New York,

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is there was a fair amount of

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what I would call shamila plasty going on.

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There were cases where the patient would come in,

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someone would stent the OM three

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and tell the patient they saved their life when the patient

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didn't have any angen or any acute coronary syndrome.

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That's not likely a, a true assessment of the situation.

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And so if we eliminate those procedures

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and focus instead on the ones

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where we can really help patients,

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that's probably a better way to practice.

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And so that's how I evolved in my thinking.

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One of the things that was interesting is as I started

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to study this, the earliest efforts that appropriate use not

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designed to identify overuse of procedures,

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they actually were designed to try

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to figure out are there patients

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who should get revascularization who are somehow not?

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And if they don't, how do those patients do?

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And so this was the first paper on it published in in

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JAMA back in the nineties.

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And they looked at patients, they looked at the charts

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and they said, look, this guy has got multi-vessel disease

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and symptoms and yet he didn't go for cabbage, didn't go

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for any revascularization.

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If you didn't do that, the mortality was a lot higher than

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if you happen to go for a revascularization procedure.

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This is obviously association, not necessarily causation,

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but the point is, is that there are patients out there

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that don't get revascularization procedures

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that could benefit from them.

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This is another example from the get

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with the guidelines registry.

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These are folks who come into the hospital with a non stemi.

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They have three vessel disease or left main on cath

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and on the right of the slide there's certain hospitals

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that are medically managing that over 30% of the time.

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Now perhaps some of those patients are 92 years old,

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maybe demented don't want to go for revascularization,

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but should that really happen 30% of the time

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or is it that they're so high risk that nobody wants

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to take on the case despite the indications clearly in

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favor of revascularization.

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We had one of our fellows look at an insurance company

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database and look at patients who came into the hospital

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for the first time with heart failure.

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So first diagnosis of heart failure, hospitalized,

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obviously treated with diuretics and that kind of thing.

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But does anybody go

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and try to diagnose why the patient had heart failure

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by looking at the coronary arteries, not just

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with a cath but with stress testing?

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And it turned out within 90 days, only 27%

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of patients had any assessment to look for coronary disease,

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despite the fact that we're in the northern hemisphere

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and coronary disease is the most likely

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cause of the heart failure.

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So some people have said, wow, this is claims data,

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it's probably under-reported.

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Well double that number, make it 60%.

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That's still too few patients who are getting diagnosed

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with coronary disease when

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that could actually change their management.

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And it doesn't just change their management.

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In terms of revascularization,

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if you actually look at the use

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of guideline directed medical therapy in patients

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with heart failure that are have a diagnosis of CAD,

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there's greater adherence

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and use of all the guideline directed medical

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therapy drugs out there.

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So it's not just about revascularization,

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it's making a diagnosis.

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Just think about a patient comes into

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the hospital, they have heart failure.

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What's the goal of target LDL for that patient?

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Well it's gonna be different if you diagnose

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coronary disease and if you don't.

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And so you really need to make the diagnosis irrespective

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of the revascularization point.

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So when we talk about revascularization,

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I think it's important to consider, you know,

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we wanna do it in the right patients.

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We don't wanna do the shamila plasty of OM three

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that I talked about before.

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But we also don't wanna miss true ischemic heart disease

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that patients could benefit from revascularization of

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and we wanna do it for the right reason.

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And so if we do that,

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I think we can optimize outcomes and costs.

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So the framework that I'd present to you that the way I like

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to think about coronary disease is I try

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to answer two questions for my patients.

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The first is what are their symptoms and quality of life

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and can I improve them with medicines or revascularization?

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And the second is their prognosis.

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Is there a way to reduce their subsequent rate

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of adverse events like heart attacks

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and death and that sort of thing?

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What's kind of funny is

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that in the literature the former is referred to

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as soft endpoints and the latter is referred

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to as heart endpoints.

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Even though we know that the troponins

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with high sensitivity troponins right now,

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these are like minor, minor infarcts

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and for many patients their symptoms matter more

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to them than those inlets of troponin.

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So it's just somewhat of a way of thinking.

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But I'll talk about the data in terms of both of those

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and talk about how I like

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to apply the data in a patient-centric approach.

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So let's first start with symptoms.

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This is kind of an interesting way to start.

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This was in 2018, again through my practice, I,

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by this time I had started to treat a lot of patients.

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I felt pretty good 'cause I

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thought I was doing it for the right reason.

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And then something like this comes out

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with this interesting like smiley frowny face.

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Um, heart stents are useless for most stable patients.

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They're still widely used.

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And why are people agreeing to an expensive procedure

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and putting themselves at risk for a placebo effect?

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So where does this come from?

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Because I think most people now agree

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00:09:23.645 --> 00:09:26.805
that we can reduce anginal symptoms with a stent procedure.

256
00:09:27.315 --> 00:09:29.445
Well the way it came about is there was a trial

257
00:09:29.445 --> 00:09:33.445
that was done in um, and it was published in 2017, uh,

258
00:09:33.505 --> 00:09:35.965
and then subsequent multiple publications from it

259
00:09:36.065 --> 00:09:37.245
called the Orbital Trial.

260
00:09:37.245 --> 00:09:39.765
And what the investigators actually asked the question

261
00:09:39.865 --> 00:09:42.485
of was whether if you did A PCI

262
00:09:43.305 --> 00:09:46.605
and if you did a fake PCI could patients exercise

263
00:09:46.605 --> 00:09:48.445
differently with one versus the other.

264
00:09:48.945 --> 00:09:50.085
And what they showed is that

265
00:09:50.135 --> 00:09:53.085
after you did the real PCI patients did exercise

266
00:09:53.085 --> 00:09:54.365
more than they did at baseline.

267
00:09:54.625 --> 00:09:56.365
It just wasn't appreciably different

268
00:09:56.595 --> 00:09:57.685
from the fake procedure.

269
00:09:58.185 --> 00:10:00.525
If this procedure, if this study was twice as big,

270
00:10:00.525 --> 00:10:02.125
this would've been statistically significant.

271
00:10:02.385 --> 00:10:03.485
But that doesn't really matter.

272
00:10:03.515 --> 00:10:04.965
What matters is that the difference

273
00:10:04.965 --> 00:10:07.325
between the two arms was not as great

274
00:10:07.505 --> 00:10:08.965
as people previously thought.

275
00:10:09.585 --> 00:10:12.245
So one of the first things that many people do, um,

276
00:10:12.245 --> 00:10:13.925
when they look at data that they don't believe,

277
00:10:13.925 --> 00:10:15.565
and this is true not just within medicine

278
00:10:15.565 --> 00:10:18.845
but in society, is they have a preexisting belief

279
00:10:19.105 --> 00:10:20.725
and they see data and they either say,

280
00:10:20.725 --> 00:10:22.005
that matches my belief

281
00:10:22.225 --> 00:10:24.325
or that's completely against my belief.

282
00:10:24.325 --> 00:10:26.365
So that's just garbage. I'm not gonna believe it.

283
00:10:26.865 --> 00:10:29.205
And that's not the way we should practice anything.

284
00:10:29.225 --> 00:10:30.885
We should basically assess something

285
00:10:31.065 --> 00:10:33.165
and then try to figure out what happened in the trial

286
00:10:33.225 --> 00:10:35.885
and then understand that within the context of

287
00:10:35.885 --> 00:10:37.365
what we already knew and then

288
00:10:37.365 --> 00:10:38.605
how we can apply it to patients.

289
00:10:38.625 --> 00:10:40.965
And so what's kind of interesting though is

290
00:10:40.965 --> 00:10:44.085
that the newspapers even back then responded this way.

291
00:10:44.545 --> 00:10:47.405
So unbelievable heart stents failed to ease chest pain.

292
00:10:47.995 --> 00:10:50.285
They don't actually help treat chest pain like the guy

293
00:10:50.285 --> 00:10:51.405
who's having an acute mi.

294
00:10:51.465 --> 00:10:53.285
So this was a problem after the study came out,

295
00:10:53.285 --> 00:10:55.405
I don't know if you remember this, but we had patients in

296
00:10:55.405 --> 00:10:57.645
the ER who were having STEMIs saying,

297
00:10:57.655 --> 00:10:58.645
don't put a stent in me

298
00:10:58.645 --> 00:10:59.885
because I heard that that doesn't help.

299
00:11:00.345 --> 00:11:02.165
Um, this is another one thousands

300
00:11:02.165 --> 00:11:03.325
of heart patients get stents

301
00:11:03.325 --> 00:11:05.125
that they may do more harm than good.

302
00:11:05.385 --> 00:11:08.085
And finally the more existential placebo effects

303
00:11:08.085 --> 00:11:10.525
of the heart with this like sort of interesting thing,

304
00:11:10.825 --> 00:11:12.005
um, that you can think about.

305
00:11:12.545 --> 00:11:14.725
So what you wanna really do is look into the data

306
00:11:14.745 --> 00:11:16.005
and try to understand this within

307
00:11:16.025 --> 00:11:17.085
the context of everything else.

308
00:11:17.265 --> 00:11:20.485
So few facets of this trial, it's a super important trial.

309
00:11:20.885 --> 00:11:22.525
I actually know the investigator really well.

310
00:11:22.905 --> 00:11:24.805
She did an amazing job with this trial

311
00:11:24.805 --> 00:11:26.005
as well as subsequent trials.

312
00:11:26.345 --> 00:11:27.685
But there's certain attributes

313
00:11:27.705 --> 00:11:28.845
of the trial that are important.

314
00:11:28.865 --> 00:11:30.925
And the first is that it enrolled patients

315
00:11:30.925 --> 00:11:32.205
that had single vessel disease.

316
00:11:32.625 --> 00:11:35.445
30% of them did not have positive physiology

317
00:11:35.465 --> 00:11:36.925
or ischemia in that distribution

318
00:11:36.925 --> 00:11:37.965
as assessed in the cath lab.

319
00:11:38.265 --> 00:11:39.965
And many people said, well this is ridiculous.

320
00:11:39.965 --> 00:11:41.205
How could you stent that? Well,

321
00:11:41.205 --> 00:11:43.725
because in clinical practice there are a lot of people

322
00:11:43.745 --> 00:11:45.485
who stent lesions just by looking at them

323
00:11:45.485 --> 00:11:46.565
and saying it needs a stent.

324
00:11:46.945 --> 00:11:48.325
So that's kind of one of the things

325
00:11:48.325 --> 00:11:50.085
that they showed you probably shouldn't do.

326
00:11:50.865 --> 00:11:52.805
The other thing is that patients were on an average

327
00:11:52.825 --> 00:11:54.405
of three antigens

328
00:11:54.785 --> 00:11:56.965
before they even were in the, in the study.

329
00:11:57.145 --> 00:11:59.725
And they were treated for an average duration

330
00:11:59.725 --> 00:12:01.365
of about eight months beforehand

331
00:12:01.365 --> 00:12:03.805
because in the uk, which is where this trial was done,

332
00:12:04.265 --> 00:12:06.165
it takes a while to get to the cath lab.

333
00:12:06.195 --> 00:12:07.845
It's not like here in New York

334
00:12:07.845 --> 00:12:08.965
where someone's having chest pain

335
00:12:08.965 --> 00:12:11.285
and you can get 'em a ca, you can book them a case that week

336
00:12:11.405 --> 00:12:12.605
or the next week there.

337
00:12:12.605 --> 00:12:15.205
It takes a long time. And they really tried

338
00:12:15.205 --> 00:12:16.565
to manage the angina well.

339
00:12:16.825 --> 00:12:19.565
And as a result, by the time the patients were in the study,

340
00:12:19.875 --> 00:12:22.005
they only had angina about once a month.

341
00:12:22.625 --> 00:12:23.765
That's really rare.

342
00:12:24.345 --> 00:12:25.845
So if you take patients like that

343
00:12:25.865 --> 00:12:27.365
and really optimize them that way,

344
00:12:27.905 --> 00:12:30.045
of course it's gonna be harder to show a benefit

345
00:12:30.465 --> 00:12:33.085
of an effective therapy versus a placebo.

346
00:12:33.395 --> 00:12:35.085
They also had good exercise tolerance

347
00:12:35.085 --> 00:12:37.765
and minimal ischemia on uh, dobutamine stress testing.

348
00:12:38.705 --> 00:12:42.365
What's interesting is the investigators have studied this

349
00:12:42.365 --> 00:12:43.965
further because they wanted to understand this.

350
00:12:43.965 --> 00:12:45.325
They're all interventional cardiologists.

351
00:12:45.325 --> 00:12:47.525
They, they know that we can help people with stents

352
00:12:47.525 --> 00:12:49.325
and so they want to try to figure some of this out.

353
00:12:49.785 --> 00:12:51.925
So one experiment that they did is they took people

354
00:12:51.925 --> 00:12:55.565
to the cath lab and they exercised them

355
00:12:55.665 --> 00:12:57.605
before opening up their physiologically

356
00:12:57.605 --> 00:12:58.645
significant stenosis.

357
00:12:58.955 --> 00:13:00.125
They then stented it

358
00:13:00.305 --> 00:13:02.645
and told the patient, we just opened up your

359
00:13:02.965 --> 00:13:04.605
stenosis exercise again.

360
00:13:05.805 --> 00:13:08.445
Interestingly, the exercise increment was now a minute.

361
00:13:08.545 --> 00:13:10.525
In the other study it was about 20 something seconds.

362
00:13:10.745 --> 00:13:12.565
So why do they do so much better now

363
00:13:12.875 --> 00:13:13.885
than they did in the study?

364
00:13:14.395 --> 00:13:16.645
Well maybe it's because the patient knew

365
00:13:16.915 --> 00:13:18.765
that their artery had been opened

366
00:13:19.225 --> 00:13:21.085
and it was truly a significant lesion

367
00:13:21.145 --> 00:13:23.925
and so they could then be exercising in a more unfettered

368
00:13:23.925 --> 00:13:25.325
way than if you're in a study

369
00:13:25.575 --> 00:13:27.765
where you don't know if you're in the placebo group

370
00:13:27.765 --> 00:13:29.565
or the stent group and you might be a little bit

371
00:13:29.565 --> 00:13:30.805
worried to exercise more.

372
00:13:30.865 --> 00:13:32.445
So that's one possible explanation.

373
00:13:33.145 --> 00:13:34.725
In addition, within this study

374
00:13:35.305 --> 00:13:37.685
in the beginning everybody stopped due to chest pain.

375
00:13:37.685 --> 00:13:39.365
Almost everybody stopped due to chest pain

376
00:13:39.375 --> 00:13:41.645
after they relieved the obstruction of the stenosis.

377
00:13:42.275 --> 00:13:44.925
Virtually all of them stopped due to exhaustion

378
00:13:44.925 --> 00:13:46.965
and that was associated with an increased lactate.

379
00:13:47.385 --> 00:13:50.925
So these investigators on the, on the heels of orbita

380
00:13:51.445 --> 00:13:54.525
actually showed that there was a physiologic effect of PCI.

381
00:13:55.025 --> 00:13:56.125
So let's take that further

382
00:13:56.145 --> 00:13:57.365
and let's try to look at symptoms.

383
00:13:57.365 --> 00:13:59.805
So they went back and reanalyzed their data from the trial

384
00:13:59.985 --> 00:14:01.445
and what they showed is remember,

385
00:14:01.445 --> 00:14:03.685
most patients only had angina once a month,

386
00:14:04.105 --> 00:14:05.965
but let's take those patients

387
00:14:05.965 --> 00:14:08.405
and see how many of them we could make free of angina.

388
00:14:08.405 --> 00:14:10.205
And when they and analyze the data that way

389
00:14:10.465 --> 00:14:12.765
and they publish this in circulation, they showed

390
00:14:12.765 --> 00:14:15.445
that there was definitely a clear benefit of PCI compared

391
00:14:15.445 --> 00:14:16.685
to the, to the uh, placebo.

392
00:14:17.105 --> 00:14:19.405
So that's new data from this trial.

393
00:14:19.985 --> 00:14:22.445
And finally to really sort of, you know,

394
00:14:22.795 --> 00:14:24.925
make it make it clear they did another study

395
00:14:24.925 --> 00:14:26.245
and this was published last year.

396
00:14:26.555 --> 00:14:29.525
They took patients off anti medications

397
00:14:29.525 --> 00:14:31.965
because the medicines can confound the effect of the therapy

398
00:14:32.625 --> 00:14:35.765
and they then randomized patients to PCI or a sham procedure

399
00:14:35.985 --> 00:14:38.405
and clearly show that PCI improved angina.

400
00:14:38.705 --> 00:14:41.125
So I think there should be no question

401
00:14:41.125 --> 00:14:42.725
that PCI improves angina.

402
00:14:42.985 --> 00:14:45.845
The real question is how do we identify those patients

403
00:14:46.075 --> 00:14:48.725
that are gonna benefit from our revascularization procedure,

404
00:14:48.725 --> 00:14:50.165
whether it's PCI or surgery.

405
00:14:51.065 --> 00:14:54.165
Within these studies they've done another few studies

406
00:14:54.185 --> 00:14:56.245
and what they've shown kind of interestingly is

407
00:14:56.245 --> 00:14:59.405
that if you can reproduce the patient's symptoms on the

408
00:14:59.405 --> 00:15:00.725
table by blowing up the balloon

409
00:15:00.985 --> 00:15:02.485
and that symptom is correlated

410
00:15:02.485 --> 00:15:05.045
with the way they felt beforehand, then

411
00:15:05.045 --> 00:15:08.405
that's also a predictive of their ability to free

412
00:15:08.405 --> 00:15:10.565
that patient from those symptoms that follow up.

413
00:15:10.865 --> 00:15:12.205
So we have to be good clinicians.

414
00:15:12.225 --> 00:15:14.685
We really need to ask our patients a detailed history

415
00:15:14.685 --> 00:15:17.085
because some people will say I have chest pain.

416
00:15:17.395 --> 00:15:19.085
Some people will say they have shortness of breath,

417
00:15:19.105 --> 00:15:21.605
but they might have COPD, they could have a variety

418
00:15:21.625 --> 00:15:23.125
of other reasons, they could be, you know,

419
00:15:23.355 --> 00:15:25.165
well overweight and just out of breath.

420
00:15:25.165 --> 00:15:27.245
Because of that we have to do better.

421
00:15:27.545 --> 00:15:31.205
And one of the advantages of being a specialist I think is

422
00:15:31.205 --> 00:15:33.685
that those office visits that I used to hate

423
00:15:33.685 --> 00:15:36.365
as an internal medicine clinic, uh, resident,

424
00:15:36.735 --> 00:15:38.645
where I would have to do healthcare maintenance

425
00:15:38.645 --> 00:15:41.165
and everything else with the patient all within the 15

426
00:15:41.165 --> 00:15:44.285
minute confine, those things are much better as a specialist

427
00:15:44.285 --> 00:15:46.325
because we're really just focusing on cardiovascular.

428
00:15:46.785 --> 00:15:48.325
And so I can take the time

429
00:15:48.545 --> 00:15:51.805
and effort to identify exactly why patients are

430
00:15:51.805 --> 00:15:52.885
there or or not.

431
00:15:53.065 --> 00:15:55.085
So just an audience question to make sure,

432
00:15:55.125 --> 00:15:56.125
I know you've had lunch

433
00:15:56.145 --> 00:15:57.685
so it gets postprandial a little bit.

434
00:15:58.185 --> 00:16:00.245
So the orbital results are most consistent

435
00:16:00.245 --> 00:16:01.245
with the following statement.

436
00:16:01.545 --> 00:16:04.645
Number one, there's no role for PCI for patients

437
00:16:04.645 --> 00:16:05.965
with stable ischemic heart disease

438
00:16:05.965 --> 00:16:07.405
and it should be class three in the guidelines.

439
00:16:07.635 --> 00:16:09.005
This may sound ridiculous,

440
00:16:09.265 --> 00:16:12.765
but this was exactly what the editorial in the Lancet wrote,

441
00:16:13.625 --> 00:16:15.085
no role, it should be class three.

442
00:16:16.065 --> 00:16:17.925
Number two, the symptomatic benefits

443
00:16:17.925 --> 00:16:20.765
of PCI over maximum medical therapy are modest for patients

444
00:16:20.765 --> 00:16:22.845
with single vessel stable ischemic heart disease.

445
00:16:23.265 --> 00:16:26.165
And number three, the shamila plasty argument.

446
00:16:26.285 --> 00:16:28.685
PCI should be the default therapy for all patients

447
00:16:28.685 --> 00:16:30.325
with angiographically severe lesions.

448
00:16:30.925 --> 00:16:32.645
I think you can probably already tell that I'm kind

449
00:16:32.645 --> 00:16:34.085
of a middle of the road kind of guy

450
00:16:34.085 --> 00:16:35.365
and so the answer's gonna be two.

451
00:16:35.625 --> 00:16:37.205
But what's also important is

452
00:16:37.205 --> 00:16:39.285
that the symptom improvement is gonna correlate

453
00:16:39.285 --> 00:16:41.205
with the nature of the prior symptoms.

454
00:16:41.545 --> 00:16:44.845
So if somebody has kind of wishy-washy symptoms at baseline,

455
00:16:45.795 --> 00:16:49.125
it's not gonna do them a benefit to open up their artery

456
00:16:49.265 --> 00:16:52.325
and you know, expect them to be completely rid

457
00:16:52.325 --> 00:16:53.525
of those wishy-washy symptoms.

458
00:16:53.785 --> 00:16:55.845
On the other hand, if somebody tells you every time I walk

459
00:16:56.085 --> 00:16:58.525
upstairs I get this, you know, discomfort in my chest

460
00:16:58.625 --> 00:17:00.125
and if I stop it goes away.

461
00:17:00.455 --> 00:17:03.725
Those are the types of patients in whom honestly you're

462
00:17:03.725 --> 00:17:07.165
gonna have the best um, efficacy with um, with some sort

463
00:17:07.165 --> 00:17:08.365
of revascularization procedure.

464
00:17:09.145 --> 00:17:11.445
What's interesting is if you look at our guidelines,

465
00:17:11.505 --> 00:17:14.005
our guidelines often say this is a prior iteration

466
00:17:14.005 --> 00:17:15.925
of the guidelines, but most people in medical school are

467
00:17:15.925 --> 00:17:18.565
taught this, that if somebody comes in with stable disease,

468
00:17:18.565 --> 00:17:20.485
what we try doing first is we give them

469
00:17:20.595 --> 00:17:22.085
guideline directed medical therapy.

470
00:17:22.225 --> 00:17:24.125
So sublingual, nitro beta blocker,

471
00:17:24.125 --> 00:17:26.125
calcium channel blocker, maybe olaine.

472
00:17:26.385 --> 00:17:29.285
And only if those things fail do we then consider

473
00:17:29.525 --> 00:17:31.085
revascularization to improve symptoms.

474
00:17:31.705 --> 00:17:32.805
And as a clinician,

475
00:17:33.525 --> 00:17:35.405
I understand why the guidelines say this, it's

476
00:17:35.405 --> 00:17:37.405
because they don't want to revascularize everybody.

477
00:17:37.905 --> 00:17:41.045
And if people are doing a lot of these bogus ish procedures,

478
00:17:41.195 --> 00:17:42.285
then you want to prevent them

479
00:17:42.285 --> 00:17:43.365
from having to come to the lab.

480
00:17:43.945 --> 00:17:45.605
But if you have severe symptoms

481
00:17:46.225 --> 00:17:48.565
and you already have to take a lot of other medicines

482
00:17:48.565 --> 00:17:50.725
to prevent the disease from getting worse,

483
00:17:51.265 --> 00:17:53.165
do you really wanna have to fail all

484
00:17:53.165 --> 00:17:56.805
of these therapies when we know that by revascularizing you,

485
00:17:57.145 --> 00:18:00.245
you can avoid this and actually take patients off of this.

486
00:18:00.745 --> 00:18:04.285
So an alternate perspective on antis I think is

487
00:18:04.285 --> 00:18:07.125
that we don't really talk about, there are certain types

488
00:18:07.245 --> 00:18:08.765
of guideline directed medical therapy

489
00:18:08.915 --> 00:18:11.765
that are prognostically important things like aspirin,

490
00:18:12.375 --> 00:18:14.765
lipid lowering medications and lifestyle modification.

491
00:18:15.225 --> 00:18:20.165
But we don't separate out those things from anti als, none

492
00:18:20.165 --> 00:18:21.565
of which alter prognosis.

493
00:18:21.905 --> 00:18:23.445
So every clinic fellow is like,

494
00:18:23.445 --> 00:18:25.165
we gotta start this patient on a beta blocker.

495
00:18:25.985 --> 00:18:28.165
Why? There's no mortality benefit,

496
00:18:28.165 --> 00:18:29.885
there's no MI benefit in the patient

497
00:18:29.885 --> 00:18:33.445
with a normal ef if the patient really has severe symptoms,

498
00:18:34.065 --> 00:18:35.405
why don't we define the anatomy

499
00:18:35.625 --> 00:18:38.525
and then offer the therapy that would be most aligned

500
00:18:38.525 --> 00:18:40.445
with the patient's interest, which are typically gonna be

501
00:18:40.445 --> 00:18:41.925
getting rid of my severe symptoms.

502
00:18:42.265 --> 00:18:45.645
If the symptoms are mild, then of course it makes sense

503
00:18:45.645 --> 00:18:48.205
to try medical therapy because why would you take someone

504
00:18:48.205 --> 00:18:50.725
with minimal symptoms and rush 'em to the cath lab?

505
00:18:50.985 --> 00:18:52.365
So that's kind of the way I like

506
00:18:52.365 --> 00:18:53.365
to think about it in clinic.

507
00:18:53.465 --> 00:18:54.765
But recognizing the fact

508
00:18:55.035 --> 00:18:58.045
that these other agents don't really alter prognosis.

509
00:18:58.185 --> 00:19:00.925
And when you talk to a patient in the office, you're,

510
00:19:00.925 --> 00:19:03.245
you can't like hit them with five new medications

511
00:19:03.475 --> 00:19:05.045
because there's data out there.

512
00:19:05.065 --> 00:19:07.125
If I write a prescription, actually I take that back.

513
00:19:07.145 --> 00:19:09.325
I'm a very good doctor so the number is better for me.

514
00:19:09.465 --> 00:19:11.685
But if anybody generically writes a prescription,

515
00:19:11.745 --> 00:19:13.685
how often does the patient fill that prescription?

516
00:19:13.795 --> 00:19:18.635
Anybody know? It's two

517
00:19:18.635 --> 00:19:22.595
outta three of those patients that fill the prescription,

518
00:19:23.295 --> 00:19:26.315
how often do they take the medicine as prescribed?

519
00:19:27.855 --> 00:19:31.225
Anybody know that one? It's also about two outta three.

520
00:19:31.645 --> 00:19:34.145
So if you multiply those two probabilities together,

521
00:19:34.565 --> 00:19:36.505
you're basically 50 50

522
00:19:37.085 --> 00:19:38.585
if you write a prescription in the office

523
00:19:38.615 --> 00:19:39.865
that the patient's actually gonna take

524
00:19:39.865 --> 00:19:41.185
the medicine the way you describe it.

525
00:19:41.565 --> 00:19:44.625
So for me, I would much rather they do,

526
00:19:44.655 --> 00:19:47.505
they take the medicines that matter, the aspirin,

527
00:19:47.565 --> 00:19:50.105
the statin, the diabetic meds, things like

528
00:19:50.105 --> 00:19:53.065
that than the anti ols which they actually sometimes

529
00:19:53.065 --> 00:19:54.105
have side effects from.

530
00:19:54.205 --> 00:19:56.105
So it's a different way of looking at it,

531
00:19:56.105 --> 00:19:57.665
but I actually think in medicine you'd have

532
00:19:57.665 --> 00:19:59.385
to recognize these basic human facts

533
00:19:59.765 --> 00:20:01.745
and then sort of negotiate

534
00:20:01.905 --> 00:20:03.385
or horse trade with your patients

535
00:20:03.685 --> 00:20:05.545
to really emphasize what matters to them.

536
00:20:06.245 --> 00:20:07.625
The reason this is important is

537
00:20:07.625 --> 00:20:10.225
because if you revascularize, most studies have shown,

538
00:20:10.625 --> 00:20:11.625
actually every study has shown

539
00:20:11.975 --> 00:20:13.985
that you can get the same symptom benefit

540
00:20:14.125 --> 00:20:16.945
or greater symptom benefit with less antianginal.

541
00:20:16.945 --> 00:20:19.505
So you don't encourage, use as much nitrates

542
00:20:19.505 --> 00:20:20.785
or calcium channel blockers.

543
00:20:21.165 --> 00:20:23.865
And in the ischemia trial, which is a more recent trial,

544
00:20:23.865 --> 00:20:27.385
looking at cathing patients versus medical therapy alone,

545
00:20:27.485 --> 00:20:28.985
if you have a high risk stress test,

546
00:20:29.295 --> 00:20:31.985
they looked very carefully at symptoms and quality of life.

547
00:20:32.455 --> 00:20:34.865
What they did is they asked this question according

548
00:20:34.865 --> 00:20:36.705
to what's called the Seattle angina questionnaire,

549
00:20:36.885 --> 00:20:38.345
how often are you having angina?

550
00:20:38.345 --> 00:20:39.865
And so these are the numbers.

551
00:20:39.925 --> 00:20:41.585
If you have no angina at all,

552
00:20:41.605 --> 00:20:42.745
the rate the number is a hundred.

553
00:20:43.045 --> 00:20:44.665
If you have it three times a week, it's 40.

554
00:20:45.125 --> 00:20:47.105
So in the trial, the mean number

555
00:20:47.505 --> 00:20:49.645
or the mean number was 80, which meant

556
00:20:49.645 --> 00:20:52.765
that patients had angina about once a month in that trial.

557
00:20:52.865 --> 00:20:53.885
The reason for that is

558
00:20:54.045 --> 00:20:56.325
'cause they didn't wanna take really symptomatic patients.

559
00:20:56.565 --> 00:20:58.605
'cause if you randomize 'em to medical therapy,

560
00:20:58.605 --> 00:21:00.965
they're all gonna cross over and have a calf.

561
00:21:01.225 --> 00:21:03.365
So they took minimally symptomatic patients.

562
00:21:03.825 --> 00:21:05.565
But what they showed within the trial,

563
00:21:05.565 --> 00:21:07.485
which is really interesting, is

564
00:21:07.485 --> 00:21:10.765
that your improvement was directly proportional to

565
00:21:10.785 --> 00:21:12.765
how severe your angina was at baseline.

566
00:21:13.305 --> 00:21:15.605
So if you had somebody with daily angina

567
00:21:15.605 --> 00:21:17.405
or weekly angina, you only needed

568
00:21:17.405 --> 00:21:20.125
to treat three patients in order to render one

569
00:21:20.125 --> 00:21:22.405
of them angina free by going to the cath lab.

570
00:21:23.105 --> 00:21:24.525
If you had no symptoms

571
00:21:24.545 --> 00:21:27.245
or minimal symptoms, there was no difference

572
00:21:27.245 --> 00:21:28.325
between the two groups.

573
00:21:29.265 --> 00:21:30.965
Why? Because if you have no symptoms,

574
00:21:30.985 --> 00:21:33.085
how am I gonna make you feel any better by cathing?

575
00:21:33.085 --> 00:21:35.685
You, on the other hand, if you have severe symptoms,

576
00:21:36.055 --> 00:21:37.405
those are the people we can benefit.

577
00:21:37.545 --> 00:21:40.045
And by the way, that effect was durable at, at uh,

578
00:21:40.045 --> 00:21:42.685
both 12 months and 36 months within the trial.

579
00:21:43.745 --> 00:21:45.125
If you look within the trial,

580
00:21:45.585 --> 00:21:48.725
the the conservative managed patients, which are the ones

581
00:21:48.725 --> 00:21:51.085
that, that then came to the cath lab early,

582
00:21:51.625 --> 00:21:54.445
the strongest predictor was the severity of symptoms.

583
00:21:54.745 --> 00:21:57.285
If you had a lot of angina, you'd failed medical therapy

584
00:21:57.305 --> 00:21:58.325
and went to the cath lab.

585
00:21:58.745 --> 00:22:00.365
So this is like common sense.

586
00:22:00.465 --> 00:22:02.285
If you're seeing somebody in the, in the clinic

587
00:22:02.705 --> 00:22:04.445
and they come to you and they tell you, you know,

588
00:22:04.565 --> 00:22:06.325
I get a twinge of chest pain, you know,

589
00:22:06.325 --> 00:22:08.405
once every other week, fine.

590
00:22:08.435 --> 00:22:10.045
Make sure they don't have left main disease.

591
00:22:10.045 --> 00:22:11.525
Define the anatomy, but you're gonna

592
00:22:11.525 --> 00:22:12.605
treat that patient medically.

593
00:22:13.065 --> 00:22:14.565
If someone comes to you and says, you know,

594
00:22:14.565 --> 00:22:16.485
every time I walk up the stairs I have chest pain,

595
00:22:16.785 --> 00:22:18.245
of course you're gonna cap that patient.

596
00:22:18.305 --> 00:22:20.005
You're not gonna push beta blockers

597
00:22:20.005 --> 00:22:21.205
and all that other stuff on them.

598
00:22:21.425 --> 00:22:24.085
And so this is nicely shown within the trials as well.

599
00:22:25.085 --> 00:22:26.925
I will emphasize we have to be better doctors

600
00:22:27.025 --> 00:22:28.365
and we have to take better histories.

601
00:22:28.395 --> 00:22:31.205
This was a really, really interesting paper that um, uh,

602
00:22:31.205 --> 00:22:33.805
Suzanne Arnold published where each one

603
00:22:33.805 --> 00:22:36.125
of these bars is a individual clinician.

604
00:22:37.155 --> 00:22:39.895
And what they did is they asked the patients

605
00:22:39.895 --> 00:22:41.455
with the Seattle angina questionnaire,

606
00:22:41.875 --> 00:22:42.935
are you having angina?

607
00:22:42.935 --> 00:22:45.335
Yes or no? And then they asked the doctor

608
00:22:45.435 --> 00:22:47.255
or the clinician taking care of the patient,

609
00:22:47.915 --> 00:22:49.375
is your patient having angina?

610
00:22:49.375 --> 00:22:51.495
Yes or no? And then they correlated it.

611
00:22:51.955 --> 00:22:54.215
It turns out that each of these physicians

612
00:22:54.835 --> 00:22:56.535
had a pretty significant rate

613
00:22:56.635 --> 00:22:58.695
of underreporting their patient's angina.

614
00:22:58.825 --> 00:23:01.535
These docs over here under purported

615
00:23:01.535 --> 00:23:03.935
or under recognize their angina 60% of the time.

616
00:23:04.435 --> 00:23:05.855
So why is that? The reason is,

617
00:23:05.875 --> 00:23:07.015
is that we're all really busy.

618
00:23:07.315 --> 00:23:09.335
We have to deal with epic, we have to deal

619
00:23:09.335 --> 00:23:11.575
with administrators like taking us from room to room.

620
00:23:11.575 --> 00:23:12.815
And so we don't take the time

621
00:23:13.155 --> 00:23:14.815
to ask the questions that matter.

622
00:23:15.035 --> 00:23:17.655
So let me give you an example. So patient comes to see me.

623
00:23:17.655 --> 00:23:19.375
Are you having any chest discomfort? No.

624
00:23:19.795 --> 00:23:21.295
Do you have any shortness of breath? No.

625
00:23:21.915 --> 00:23:23.735
So many people would stop and move on

626
00:23:23.735 --> 00:23:25.495
and say no chest pain, no shortness of breath.

627
00:23:25.995 --> 00:23:28.055
But what you can do as a specialist,

628
00:23:28.055 --> 00:23:30.695
because you literally are specializing in cardiovascular

629
00:23:30.695 --> 00:23:32.615
disease, is you can say, well, tell me what you like to do.

630
00:23:33.315 --> 00:23:35.975
Um, they say, well, I'd like, like to hang out with my dog.

631
00:23:36.365 --> 00:23:38.695
Okay, so my next question is, does the dog walk you

632
00:23:38.695 --> 00:23:39.695
or do you walk the dog?

633
00:23:39.755 --> 00:23:41.935
How big is the dog? It matters

634
00:23:41.935 --> 00:23:45.015
because if they're walking a, you know, big doberman,

635
00:23:45.385 --> 00:23:48.405
that's a very, very different type of walk than the little,

636
00:23:48.665 --> 00:23:50.685
you know, rescue shihtzu that I have at home

637
00:23:51.015 --> 00:23:52.725
where it's pretty easy to walk around.

638
00:23:52.825 --> 00:23:54.725
You, you, you say them well. So how does that go?

639
00:23:54.985 --> 00:23:56.045
You know, it was actually great,

640
00:23:56.105 --> 00:23:57.445
but then when I walked to the end

641
00:23:57.445 --> 00:23:59.125
of my driveway, I started getting out of breath.

642
00:24:00.245 --> 00:24:01.565
Hmm, that's interesting. So what do you do?

643
00:24:01.725 --> 00:24:03.765
I don't really do that anymore. I just sit on the couch.

644
00:24:04.145 --> 00:24:07.565
That's a very different history than do you have chest pain

645
00:24:07.565 --> 00:24:08.565
or do you have shortness of breath?

646
00:24:08.705 --> 00:24:11.925
And you can ask these questions in a precise way really

647
00:24:11.925 --> 00:24:14.085
quickly and ascertain what's going on.

648
00:24:14.545 --> 00:24:16.165
But you also kind of have to be savvy.

649
00:24:16.235 --> 00:24:18.125
Like you can't tell patients to exercise.

650
00:24:18.125 --> 00:24:19.685
Like if you don't yourself exercise,

651
00:24:19.685 --> 00:24:20.925
you just look disingenuous.

652
00:24:21.185 --> 00:24:23.685
So when I ask a patient like, what do you do for exercise?

653
00:24:23.765 --> 00:24:27.445
I like to go for walks. I get a lot of, of, um, of, uh,

654
00:24:27.445 --> 00:24:29.805
Indian patients or South Asian patients 'cause I'm Indian.

655
00:24:30.025 --> 00:24:32.725
And so I say, well do you do like the Indian auntie walk?

656
00:24:32.725 --> 00:24:33.645
Which is this?

657
00:24:37.855 --> 00:24:40.475
Or do you like go for a walk like a lot

658
00:24:40.475 --> 00:24:42.835
of American people do, which is like, you know, you go

659
00:24:42.835 --> 00:24:44.195
for a walk and it really matters.

660
00:24:44.295 --> 00:24:46.275
Do you sweat when you walk? How is this going?

661
00:24:46.785 --> 00:24:48.155
This allows you to determine

662
00:24:48.155 --> 00:24:51.075
with more precision if a patient is truly having symptoms,

663
00:24:51.075 --> 00:24:53.435
and it might not be angen that might be COPD or otherwise,

664
00:24:53.655 --> 00:24:54.955
but we have to be better doctors.

665
00:24:55.695 --> 00:24:56.795
So this is just an example

666
00:24:56.795 --> 00:24:58.355
of somebody we helped symptomatically.

667
00:24:58.355 --> 00:25:00.035
This is a gentleman who had, um,

668
00:25:00.815 --> 00:25:05.195
low EF PVD prior cabage had inferior ischemia on the stress

669
00:25:05.195 --> 00:25:08.195
test medicines were escalated, um, to no avail.

670
00:25:08.195 --> 00:25:09.355
And he really came to see me

671
00:25:09.355 --> 00:25:11.675
because he had progressive angina, was told that, you know,

672
00:25:11.675 --> 00:25:12.875
not much could be done for him.

673
00:25:13.255 --> 00:25:14.875
And so we took him to the cath lab.

674
00:25:14.875 --> 00:25:16.435
This is what his right coronary artery looks like,

675
00:25:16.865 --> 00:25:18.475
says CTO of the RCA.

676
00:25:18.815 --> 00:25:21.675
And he had rema to this right, which was open,

677
00:25:22.215 --> 00:25:23.355
but there's something funny

678
00:25:23.375 --> 00:25:25.355
and hazy going on at the anastomosis.

679
00:25:25.425 --> 00:25:26.675
It's a pretty big RCA.

680
00:25:27.015 --> 00:25:28.995
So I wasn't sure if that was significant or not.

681
00:25:28.995 --> 00:25:30.195
And I, you know, back I was younger,

682
00:25:30.355 --> 00:25:33.275
I said maybe I'll do imaging on this and, and look at it.

683
00:25:33.435 --> 00:25:34.795
I don't think imaging is the right thing

684
00:25:34.795 --> 00:25:35.835
for this intravascular

685
00:25:35.835 --> 00:25:37.155
because you're gonna straighten the

686
00:25:37.155 --> 00:25:38.355
artery out when you wire it.

687
00:25:38.375 --> 00:25:39.995
And so it's gonna give you something strange.

688
00:25:40.415 --> 00:25:42.555
But even just during the wiring,

689
00:25:42.915 --> 00:25:44.675
I couldn't wire into the RCA

690
00:25:44.675 --> 00:25:45.875
because there was a lesion there.

691
00:25:46.215 --> 00:25:47.955
And so ultimately I was able to,

692
00:25:47.955 --> 00:25:51.515
with a hydrophilic wire come up back off the CTO occlusion

693
00:25:51.535 --> 00:25:54.435
and down the vessel and then I decided to treat it.

694
00:25:54.435 --> 00:25:58.275
So what I did is I stented the anastomosis looks pretty good

695
00:25:58.855 --> 00:26:00.635
and he went on his way.

696
00:26:00.895 --> 00:26:02.755
Now he's gonna come back and I'll show you a little bit

697
00:26:02.755 --> 00:26:03.835
later what he came back with.

698
00:26:04.215 --> 00:26:05.315
But how did he feel?

699
00:26:05.315 --> 00:26:08.275
Because he had was a real patient with a real lesion.

700
00:26:08.575 --> 00:26:10.115
He had ischemia in that territory

701
00:26:10.335 --> 00:26:12.755
and we revascularized him, he thanks me

702
00:26:12.755 --> 00:26:14.075
for all of his of my help.

703
00:26:14.185 --> 00:26:15.995
It's a great feeling to be angina free.

704
00:26:15.995 --> 00:26:19.395
You're grateful patient and this is a much nicer thing than,

705
00:26:19.455 --> 00:26:21.035
you know, a social media message

706
00:26:21.175 --> 00:26:23.075
or like a thumbs up or something like that.

707
00:26:23.415 --> 00:26:24.915
And, and um, and by the way,

708
00:26:25.385 --> 00:26:28.275
that was also on less medication because

709
00:26:28.325 --> 00:26:31.515
after I did this, I could stop his beta blocker.

710
00:26:32.195 --> 00:26:34.075
I could back off on his nitrate

711
00:26:34.075 --> 00:26:35.835
because neither of those, uh,

712
00:26:35.835 --> 00:26:37.395
well actually in his case I backed

713
00:26:37.395 --> 00:26:38.435
off on the beta blocker a little bit.

714
00:26:38.435 --> 00:26:40.715
His EF was down, but the nitrate I stopped.

715
00:26:41.015 --> 00:26:43.500
And because neither of those really changed prognosis

716
00:26:43.500 --> 00:26:46.205
that much for many patients, I'm just gonna be honest,

717
00:26:46.215 --> 00:26:48.445
there are many patients in whom I revascularized

718
00:26:48.445 --> 00:26:50.725
and I stop the beta blocker where their EF is fine

719
00:26:51.265 --> 00:26:54.565
and they actually tell me they have as much benefit in terms

720
00:26:54.565 --> 00:26:56.885
of their symptoms from stopping the beta blocker than

721
00:26:56.885 --> 00:26:57.925
from the PCI itself.

722
00:26:57.975 --> 00:27:00.205
Especially younger patients who get sluggish

723
00:27:00.205 --> 00:27:01.925
and have other issues, they can't work out

724
00:27:01.985 --> 00:27:03.405
to a good heart rate, et cetera.

725
00:27:03.955 --> 00:27:06.685
This is supported by the guidelines, uh, it's class one A

726
00:27:06.685 --> 00:27:07.965
to revascularize patients

727
00:27:07.965 --> 00:27:10.045
with refractory angina despite medical therapy

728
00:27:10.185 --> 00:27:11.445
and significant stenosis.

729
00:27:11.535 --> 00:27:13.645
Personally, I think it should be a little bit

730
00:27:13.645 --> 00:27:14.805
less prescriptive than that.

731
00:27:14.805 --> 00:27:16.645
It really ought to offer this to patients

732
00:27:16.745 --> 00:27:19.485
who are symptomatic and want additional options.

733
00:27:19.885 --> 00:27:22.125
I think this will change on the heels of orbita two.

734
00:27:22.545 --> 00:27:24.885
But it's also important to recognize we don't have

735
00:27:24.885 --> 00:27:27.005
to revascularize everybody forgetting the

736
00:27:27.005 --> 00:27:28.365
shamila plasty procedures.

737
00:27:28.455 --> 00:27:30.045
There are people with real disease

738
00:27:30.275 --> 00:27:32.445
that don't necessarily need to be revascularized.

739
00:27:32.715 --> 00:27:35.125
This is a letter I got from a patient who came to see me

740
00:27:35.125 --> 00:27:36.405
with a chronic total occlusion.

741
00:27:36.625 --> 00:27:37.965
He was totally asymptomatic.

742
00:27:38.465 --> 00:27:40.645
He thanked me for taking the time to meet with him.

743
00:27:40.795 --> 00:27:41.885
Everybody was friendly.

744
00:27:42.145 --> 00:27:43.405
It was a great visit, one

745
00:27:43.405 --> 00:27:45.005
that was important to him and his family.

746
00:27:45.585 --> 00:27:48.445
So why was it important to him and his family to meet me?

747
00:27:48.905 --> 00:27:50.845
For me to tell him, you don't need a PCI.

748
00:27:51.275 --> 00:27:52.365
Well the reason is, is

749
00:27:52.445 --> 00:27:54.045
'cause he was deathly afraid that

750
00:27:54.045 --> 00:27:56.845
with his a hundred percent occlusion that he was gonna die

751
00:27:56.845 --> 00:27:59.165
or have a heart attack or something was gonna happen to him.

752
00:27:59.625 --> 00:28:02.165
And I talked to him, he was totally asymptomatic,

753
00:28:02.165 --> 00:28:03.605
he had normal ventricular function.

754
00:28:03.825 --> 00:28:05.325
And I said, look, you know, there's not a lot

755
00:28:05.325 --> 00:28:06.405
of data that we can prevent this.

756
00:28:06.405 --> 00:28:08.245
And by the way, the artery's already closed

757
00:28:08.545 --> 00:28:10.005
so it's not gonna close again.

758
00:28:10.505 --> 00:28:13.445
And he was relieved by that and sent me a note like this.

759
00:28:14.185 --> 00:28:16.205
So that's the part about symptoms.

760
00:28:16.305 --> 00:28:18.605
Be a good doctor ascertain the history well

761
00:28:18.665 --> 00:28:19.845
and treat the right patients.

762
00:28:20.345 --> 00:28:21.605
But what about prognosis?

763
00:28:21.945 --> 00:28:24.925
Can we change people's outcomes in terms of heart attacks,

764
00:28:25.145 --> 00:28:28.765
cardiovascular death or otherwise with revascularization?

765
00:28:29.805 --> 00:28:32.245
I would dare say that most people in medical school right

766
00:28:32.245 --> 00:28:35.245
now are taught that for stable ischemic heart disease,

767
00:28:35.375 --> 00:28:37.005
there is no prognostic benefit

768
00:28:37.065 --> 00:28:38.365
to coronary revascularization.

769
00:28:38.925 --> 00:28:40.125
I think that's a true statement.

770
00:28:40.125 --> 00:28:41.325
Most people are being taught that.

771
00:28:41.745 --> 00:28:44.125
But I'd like to show you some data that shows you

772
00:28:44.125 --> 00:28:45.325
that maybe that's not really true.

773
00:28:46.185 --> 00:28:48.245
Before I show you that on revascularization.

774
00:28:48.245 --> 00:28:50.685
When it comes to prognosis, the most important things

775
00:28:50.685 --> 00:28:54.685
that we can do relate to guideline directed medical therapy.

776
00:28:55.185 --> 00:28:57.045
So I'm not arguing revascularization,

777
00:28:57.065 --> 00:28:58.805
no revascularization without talking about

778
00:28:58.805 --> 00:29:00.085
guideline directed medical therapy.

779
00:29:00.145 --> 00:29:02.965
And it includes diet, weight loss, smoking cessation,

780
00:29:03.075 --> 00:29:05.525
aspirin, statins, blood pressure medications,

781
00:29:05.585 --> 00:29:07.165
and diabetes medications as well.

782
00:29:07.785 --> 00:29:09.445
The reason that this is important is

783
00:29:09.445 --> 00:29:12.725
because if you get more of these things under control,

784
00:29:12.995 --> 00:29:14.805
there's a much better prognosis when it

785
00:29:14.805 --> 00:29:15.965
looks, when it comes to mortality.

786
00:29:16.625 --> 00:29:18.965
One of the nicest things about being an interventional

787
00:29:18.965 --> 00:29:20.125
cardiologist is

788
00:29:20.125 --> 00:29:22.485
that I can see patients just like everybody else

789
00:29:22.985 --> 00:29:24.565
and I like interventions that work.

790
00:29:25.145 --> 00:29:27.485
So it doesn't just have to be interventions in the cath lab.

791
00:29:27.865 --> 00:29:30.365
As a physician, when I see people for follow up,

792
00:29:30.365 --> 00:29:31.525
because I follow my patients,

793
00:29:32.025 --> 00:29:34.965
we spend the entire visit talking about this type

794
00:29:34.965 --> 00:29:37.525
of stuff like why you gotta get exercising,

795
00:29:37.545 --> 00:29:39.845
why you gotta get moving around, why you have to, you know,

796
00:29:39.845 --> 00:29:42.165
take your diabetes medicines, all this other stuff.

797
00:29:42.665 --> 00:29:44.285
Um, the reason it's important is

798
00:29:44.285 --> 00:29:45.565
because we don't do very well at it.

799
00:29:45.565 --> 00:29:48.165
These are patients with self-reported coronary disease

800
00:29:48.545 --> 00:29:51.765
and there's great, you know, with legislation, um,

801
00:29:52.085 --> 00:29:54.005
benefits in terms of smoking cessation, et cetera.

802
00:29:54.185 --> 00:29:56.325
But things like physical activity, BMI control,

803
00:29:56.415 --> 00:29:57.525
lipid control, we're terrible.

804
00:29:57.585 --> 00:30:01.165
At maybe a show of hands from all of you, how many

805
00:30:01.165 --> 00:30:02.765
of you have your plan for

806
00:30:02.765 --> 00:30:04.245
what your workout is gonna be today?

807
00:30:07.105 --> 00:30:10.955
Nobody, somebody worked out today already? No.

808
00:30:11.785 --> 00:30:13.195
Okay, well a couple people. Do you

809
00:30:13.215 --> 00:30:14.675
and other other folks, do you have a plan

810
00:30:14.675 --> 00:30:15.755
for what your workout's gonna be?

811
00:30:16.735 --> 00:30:20.035
So if we can't do this, how hard is it

812
00:30:20.035 --> 00:30:21.115
for our patients to do it?

813
00:30:21.175 --> 00:30:23.835
We really have to emphasize this for, for them

814
00:30:24.175 --> 00:30:25.755
and frankly for ourselves as well.

815
00:30:25.755 --> 00:30:27.515
We know we take care of ourselves terribly,

816
00:30:27.935 --> 00:30:29.755
but you need to have plans for these things

817
00:30:29.815 --> 00:30:32.035
and you need to spend the office visit explaining

818
00:30:32.095 --> 00:30:33.235
why this is so important.

819
00:30:33.575 --> 00:30:36.035
Yes, we fixed the total block, we fixed the blockage,

820
00:30:36.215 --> 00:30:37.915
but the house is still on fire.

821
00:30:38.255 --> 00:30:40.275
We gotta put that fire out somehow.

822
00:30:40.375 --> 00:30:41.435
And how are we gonna do that?

823
00:30:41.895 --> 00:30:44.275
Now why am I so enthusiastic about this stuff

824
00:30:44.275 --> 00:30:45.595
as an interventional cardiologist?

825
00:30:45.825 --> 00:30:48.475
It's because I like any intervention that works,

826
00:30:49.055 --> 00:30:50.315
not just those in the cath lab.

827
00:30:50.335 --> 00:30:52.515
And so part of what we do in the cath lab has

828
00:30:52.515 --> 00:30:53.675
to be tied to this as well.

829
00:30:54.055 --> 00:30:56.675
The reason for it is we're terrible at it.

830
00:30:56.705 --> 00:31:00.355
This is under use of high intensity statins in US patients

831
00:31:00.355 --> 00:31:01.355
with A-S-C-V-D.

832
00:31:01.625 --> 00:31:02.755
Look at this slide here.

833
00:31:02.755 --> 00:31:04.955
These are people with established A-S-C-V-D

834
00:31:05.375 --> 00:31:08.195
and 50% of them are not on any statin at all.

835
00:31:08.835 --> 00:31:11.195
I mean, that's crazy. Now some of it is because of Dr.

836
00:31:11.195 --> 00:31:13.115
Google and all the bad stuff about statins,

837
00:31:13.115 --> 00:31:15.795
but this is also true with any lipid lowering therapy

838
00:31:15.815 --> 00:31:17.755
that's out there and that is awful.

839
00:31:17.975 --> 00:31:20.795
So when we're talking about prognosis, we have

840
00:31:20.795 --> 00:31:21.875
to get this right first

841
00:31:22.295 --> 00:31:24.475
and then we can talk about revascularization as well.

842
00:31:25.215 --> 00:31:28.595
So what did the colloquial newspapers say about coronary

843
00:31:28.755 --> 00:31:30.875
revascularization says that stents

844
00:31:30.875 --> 00:31:32.955
for stable patients prevent zero heart attacks

845
00:31:32.975 --> 00:31:34.515
and extend the lives of patients.

846
00:31:34.555 --> 00:31:37.315
A grand total, if not at all, this is from the Atlantic.

847
00:31:37.555 --> 00:31:38.755
I actually love the Atlantic.

848
00:31:38.935 --> 00:31:41.555
Um, David Epstein has written some pretty interesting books.

849
00:31:41.595 --> 00:31:43.995
I, I dunno if you've read many ways, read the Sports Gene,

850
00:31:44.295 --> 00:31:45.395
um, and stuff like that.

851
00:31:45.575 --> 00:31:47.995
But so I saw this and I was so upset

852
00:31:47.995 --> 00:31:49.755
because I've been giving this talk for a while

853
00:31:49.755 --> 00:31:51.275
and I like to think about these things.

854
00:31:51.755 --> 00:31:53.515
I actually wrote 'em, I emailed him

855
00:31:53.515 --> 00:31:54.515
and I was like, what is going,

856
00:31:54.545 --> 00:31:55.795
like, where are you getting this from?

857
00:31:55.895 --> 00:31:58.275
Why is this like this? It's actually far more nuanced.

858
00:31:58.615 --> 00:32:01.235
Um, I actually sent him, we had a nice conversation back

859
00:32:01.235 --> 00:32:03.355
and forth and I even sent him a version of this talk

860
00:32:03.565 --> 00:32:05.915
where I explained to him, yes, that's true for the patient

861
00:32:05.915 --> 00:32:07.075
with the OM three lesion,

862
00:32:07.455 --> 00:32:09.635
but that's most certainly not true if you have a

863
00:32:09.635 --> 00:32:10.755
left main disease.

864
00:32:11.625 --> 00:32:14.125
How can you say that in somebody that has left main disease?

865
00:32:14.305 --> 00:32:16.245
So let me talk about the data.

866
00:32:16.345 --> 00:32:17.565
So the reason he said it is

867
00:32:17.565 --> 00:32:18.925
because there's a trial called courage

868
00:32:19.275 --> 00:32:20.645
that randomized patients

869
00:32:20.645 --> 00:32:24.045
to medical therapy versus PCI versus medical therapy alone.

870
00:32:24.385 --> 00:32:26.965
And the overall results of the trial were negative.

871
00:32:26.965 --> 00:32:28.445
There was no real difference in death

872
00:32:28.585 --> 00:32:31.765
or infarction for me, this was not a surprise.

873
00:32:31.765 --> 00:32:34.125
When I trained in fellowship, I never told somebody

874
00:32:34.125 --> 00:32:35.645
that I was doing, there was a stable patient

875
00:32:35.645 --> 00:32:36.845
that I was gonna save their life

876
00:32:36.865 --> 00:32:38.605
or prevent heart attacks by putting in stents.

877
00:32:38.745 --> 00:32:40.885
In fact, I told them there's probably an upfront risk

878
00:32:40.885 --> 00:32:44.005
of the procedure that during the PCI that we were gonna try

879
00:32:44.005 --> 00:32:45.325
to minimize by doing it safely.

880
00:32:45.705 --> 00:32:47.325
But the main reason was for symptoms.

881
00:32:48.105 --> 00:32:51.325
But it turns out that that's for all comers disease

882
00:32:51.545 --> 00:32:53.765
and it excludes patients with the most severe anatomy.

883
00:32:54.145 --> 00:32:56.205
If you have severe coronary artery disease,

884
00:32:56.275 --> 00:32:58.565
it's actually prognostically important for you.

885
00:32:59.185 --> 00:33:01.925
And one of the challenges of trials, like the courage

886
00:33:01.945 --> 00:33:05.125
or any trial that you read, just the, the headline of is

887
00:33:05.125 --> 00:33:07.925
that you're basically taking the treatment effect across all

888
00:33:07.925 --> 00:33:10.525
the patients in the trial and homogenizing it.

889
00:33:10.525 --> 00:33:11.845
So if I see 20 people in the clinic,

890
00:33:12.105 --> 00:33:13.365
I'm saying every single one

891
00:33:13.365 --> 00:33:16.165
of 'em is gonna have the same exact treatment irrespective

892
00:33:16.165 --> 00:33:17.965
of what their anatomy is or what I do.

893
00:33:18.435 --> 00:33:21.245
What we really want to do is we wanna separate out patients

894
00:33:21.245 --> 00:33:24.445
that are gonna have benefit from our procedures, offer it

895
00:33:24.445 --> 00:33:26.645
to them, not offer it to those

896
00:33:26.645 --> 00:33:27.845
that are gonna have complications

897
00:33:27.865 --> 00:33:29.125
and have a good discussion about

898
00:33:29.125 --> 00:33:30.245
those in whom we're less certain.

899
00:33:30.865 --> 00:33:33.205
So anatomy is really important.

900
00:33:33.875 --> 00:33:36.565
This is from an earlier, uh, version of the guidelines

901
00:33:36.565 --> 00:33:38.965
where it shows you that if you're a 55-year-old woman

902
00:33:39.705 --> 00:33:42.205
and you're sitting in my clinic next

903
00:33:42.205 --> 00:33:43.645
to another 55-year-old woman,

904
00:33:44.395 --> 00:33:46.445
they're not gonna have the same prognosis

905
00:33:46.635 --> 00:33:47.845
independent of everything else.

906
00:33:48.145 --> 00:33:50.205
It really depends what they're there with in terms

907
00:33:50.205 --> 00:33:51.205
of their coronary anatomy.

908
00:33:51.305 --> 00:33:53.885
So if you, if one of them has single vessel disease

909
00:33:53.885 --> 00:33:58.245
with a 75% lesion that they have a 93% chance of surviving

910
00:33:58.585 --> 00:33:59.885
to their 60th birthday,

911
00:34:00.465 --> 00:34:02.485
if the other one has three vessel disease

912
00:34:02.485 --> 00:34:06.445
with a 95% proximal LLAD, they have a

913
00:34:07.055 --> 00:34:10.045
60% chance of surviving to their 60th birthday.

914
00:34:10.545 --> 00:34:13.485
So the the same two patients, they may look the same.

915
00:34:13.545 --> 00:34:16.925
The anatomy completely differentiates the two of them.

916
00:34:17.625 --> 00:34:20.285
Um, this has also been shown in CT based studies.

917
00:34:20.345 --> 00:34:22.725
If you do a large series of patients in Denmark

918
00:34:22.835 --> 00:34:25.445
that had CTAs performed, it wasn't just the plaque burden,

919
00:34:25.465 --> 00:34:28.525
it was also how severely obstructive the disease was that

920
00:34:29.045 --> 00:34:31.645
ultimately was uh, tied to their prognosis.

921
00:34:32.065 --> 00:34:34.245
And in fact, if you look at other CTA studies,

922
00:34:34.245 --> 00:34:36.125
this was just published last year in the European Heart

923
00:34:36.125 --> 00:34:37.645
Journal, that there are all these things

924
00:34:37.645 --> 00:34:39.565
that increase the risk of adverse events.

925
00:34:39.945 --> 00:34:42.285
But the things that really, really increase your risk

926
00:34:42.285 --> 00:34:44.605
of adverse events is three vessel left main disease

927
00:34:44.825 --> 00:34:46.925
or severe stenosis seen on the CTA.

928
00:34:47.545 --> 00:34:51.005
So the anatomy really, really can arbitrate prognosis.

929
00:34:51.545 --> 00:34:55.565
The question is, is you know, why are our guidelines saying

930
00:34:55.665 --> 00:34:56.765
and why are we being taught

931
00:34:56.995 --> 00:34:59.005
that there's no difference in terms of these outcomes?

932
00:34:59.065 --> 00:35:01.685
And the reason is is I think in the United States

933
00:35:01.975 --> 00:35:03.285
we've been over ing people.

934
00:35:03.465 --> 00:35:06.165
We c too many people who have executive stress tests

935
00:35:06.855 --> 00:35:10.205
borderline inferior ischemia likely from the diaphragm or

936
00:35:10.225 --> 00:35:11.605
or anterior from the breast.

937
00:35:11.865 --> 00:35:13.045
We bring 'em to the cath lab

938
00:35:13.265 --> 00:35:15.045
and we don't need to bring 'em to the cath lab.

939
00:35:15.505 --> 00:35:17.325
So where is my evidence for this?

940
00:35:17.355 --> 00:35:19.085
This is a really interesting study, um,

941
00:35:19.085 --> 00:35:20.845
from about 10 years ago in JAMA

942
00:35:21.095 --> 00:35:23.365
where they looked at people in Ontario.

943
00:35:23.585 --> 00:35:26.525
So Canadian healthcare system where it takes a lot more

944
00:35:26.525 --> 00:35:28.885
to come to the cath lab versus New York

945
00:35:29.135 --> 00:35:30.845
where you have executive physicals

946
00:35:30.845 --> 00:35:32.365
and people coming to cath lab all the time.

947
00:35:32.825 --> 00:35:35.405
And at the very bottom of this slide, the incidence

948
00:35:35.425 --> 00:35:38.165
of left main or three vessel disease is basically double

949
00:35:39.225 --> 00:35:41.485
in Ontario as it is in New York

950
00:35:41.795 --> 00:35:44.565
because it takes a lot more to get you to the cath lab.

951
00:35:44.565 --> 00:35:46.485
They're starting to see an enriched population

952
00:35:46.485 --> 00:35:47.565
of more severe disease.

953
00:35:48.365 --> 00:35:50.725
'cause here in the US we're just randomly cathing people.

954
00:35:50.755 --> 00:35:52.325
It's not really that bad but you know what I mean.

955
00:35:52.625 --> 00:35:56.845
Um, basically you end up, you know, doing too many cats

956
00:35:56.865 --> 00:35:58.365
and not finding not enough disease.

957
00:35:59.225 --> 00:36:01.165
So if you have severe disease though

958
00:36:01.195 --> 00:36:02.445
there's clearly benefits.

959
00:36:02.445 --> 00:36:05.165
So this is left main disease, two studies, minimal number

960
00:36:05.165 --> 00:36:06.565
of patients mortality benefit

961
00:36:06.595 --> 00:36:08.085
from surgical revascularization.

962
00:36:08.555 --> 00:36:09.885
This is multivessel disease

963
00:36:09.935 --> 00:36:11.845
where you have a mortality benefit from

964
00:36:12.165 --> 00:36:13.205
surgical revascularization.

965
00:36:13.665 --> 00:36:15.845
The first thing people say when they see these data,

966
00:36:15.845 --> 00:36:18.085
they say, man, that looks like a really old slide.

967
00:36:18.085 --> 00:36:19.125
Look at the way it looks

968
00:36:19.125 --> 00:36:21.205
because this trial, these trials are old.

969
00:36:21.545 --> 00:36:24.165
So of course that's true with more medical therapy.

970
00:36:24.305 --> 00:36:25.405
Now aspirin, statins

971
00:36:25.405 --> 00:36:26.965
and things like that, our outcomes are better.

972
00:36:27.225 --> 00:36:28.725
But that doesn't mean that vascular

973
00:36:29.605 --> 00:36:31.565
revascularizing high risk anatomy is not important.

974
00:36:32.345 --> 00:36:34.445
So where is the more recent data on this?

975
00:36:34.535 --> 00:36:36.205
We're gonna draw upon the ischemia trial.

976
00:36:36.265 --> 00:36:39.925
So this was a trial that an aim to enroll 8,800 patients

977
00:36:40.265 --> 00:36:42.685
to show that by doing a cath

978
00:36:42.985 --> 00:36:44.605
and diagnosing severe disease,

979
00:36:44.955 --> 00:36:48.125
typically you could improve cardiovascular death

980
00:36:48.125 --> 00:36:50.645
and myocardial infarction compared to not doing a,

981
00:36:51.625 --> 00:36:53.445
the study actually did not enroll fully.

982
00:36:53.465 --> 00:36:57.125
It enrolled too slowly. So it randomized 51 79 patients, um,

983
00:36:57.265 --> 00:36:59.965
and followed people for an average of 3.3 years.

984
00:37:00.745 --> 00:37:03.725
And interestingly, not many people know this.

985
00:37:03.955 --> 00:37:06.005
They did blinded CTAs upfront

986
00:37:06.385 --> 00:37:09.285
to make sure they were not randomizing left main disease

987
00:37:09.285 --> 00:37:11.165
because that would be dangerous to patients.

988
00:37:11.505 --> 00:37:13.845
And they found left main disease in about 8%.

989
00:37:13.845 --> 00:37:15.165
It's actually more like 10%

990
00:37:15.165 --> 00:37:17.685
because they didn't do the CTAs in people with CKD.

991
00:37:18.305 --> 00:37:20.165
So if you're gonna take a patient

992
00:37:20.165 --> 00:37:21.285
with a high risk stress test

993
00:37:21.305 --> 00:37:23.005
and apply the results of the ischemia trial

994
00:37:23.005 --> 00:37:25.405
and just medically manage them, I would besiege you

995
00:37:25.405 --> 00:37:27.085
to at least do a CTA

996
00:37:27.085 --> 00:37:29.285
to make sure they don't have a one in 10 chance

997
00:37:29.465 --> 00:37:30.885
of a left main lesion 'cause

998
00:37:30.885 --> 00:37:32.445
that would not be good for the patient.

999
00:37:33.265 --> 00:37:36.125
Now most people know that the primary endpoint was negative

1000
00:37:36.125 --> 00:37:37.645
and this is an expanded endpoint

1001
00:37:37.645 --> 00:37:39.525
because they didn't enroll the full sample size

1002
00:37:39.695 --> 00:37:41.045
where there was really no difference

1003
00:37:41.045 --> 00:37:43.205
between the two arms even though there was upfront risk

1004
00:37:43.205 --> 00:37:45.605
with going to the cath lab, which we expect

1005
00:37:45.605 --> 00:37:48.205
because we're doing procedures, there was a late benefit

1006
00:37:48.305 --> 00:37:50.205
but the net net was equivalent.

1007
00:37:50.875 --> 00:37:52.205
What people don't know

1008
00:37:52.465 --> 00:37:55.165
and most people don't even realize from the ischemia trial

1009
00:37:55.305 --> 00:37:57.805
is that the original endpoint, cardiovascular death

1010
00:37:57.805 --> 00:38:00.525
and mi, when you look at the data from this trial,

1011
00:38:00.525 --> 00:38:02.845
there's an upfront risk with going to the cath lab.

1012
00:38:03.465 --> 00:38:06.565
But at four years there's a statistically significant

1013
00:38:07.045 --> 00:38:08.965
reduction in cardiovascular death

1014
00:38:08.965 --> 00:38:12.165
or MI with the invasive arm of the trial.

1015
00:38:13.385 --> 00:38:14.715
Most people have no idea,

1016
00:38:14.825 --> 00:38:16.235
they just know ischemia is negative.

1017
00:38:16.345 --> 00:38:19.155
It's actually not negative At four years, there's a benefit

1018
00:38:19.615 --> 00:38:20.875
to doing the cath

1019
00:38:20.875 --> 00:38:24.115
and defining the anatomy despite the upfront risk

1020
00:38:24.195 --> 00:38:25.595
that's incurred within the trial.

1021
00:38:26.335 --> 00:38:28.355
So you may ask, well why are they benefiting?

1022
00:38:28.435 --> 00:38:30.195
I thought you told me that you know, there's no evidence

1023
00:38:30.195 --> 00:38:31.715
that we can reduce e events.

1024
00:38:31.785 --> 00:38:34.635
Well it turns out that if you look at studies of PCI,

1025
00:38:34.655 --> 00:38:35.925
and this is also true with surgery,

1026
00:38:36.535 --> 00:38:39.365
there is a reduction in spontaneous MI

1027
00:38:39.575 --> 00:38:42.765
after the procedure with a revascularization strategy.

1028
00:38:42.795 --> 00:38:45.085
This was published in circulation in 2013.

1029
00:38:45.665 --> 00:38:48.005
That's often offset by the procedural risk.

1030
00:38:48.025 --> 00:38:49.645
But there is a late reduction in events

1031
00:38:49.665 --> 00:38:51.445
and within ischemia they've assessed this

1032
00:38:51.445 --> 00:38:54.165
and analyzed what type of mis are prevented.

1033
00:38:54.515 --> 00:38:55.805
It's not type two mi,

1034
00:38:56.115 --> 00:39:00.925
it's actually a reduction in type one MI by being randomized

1035
00:39:00.925 --> 00:39:02.285
to the invasive arm of the trial.

1036
00:39:02.665 --> 00:39:04.605
And that doesn't matter whether you get cabbage,

1037
00:39:04.605 --> 00:39:05.685
whether you get PCI

1038
00:39:05.945 --> 00:39:08.085
or in the invasive arm if you get medical therapy.

1039
00:39:08.705 --> 00:39:10.445
So you might ask the question, well

1040
00:39:10.465 --> 00:39:11.805
how do you in the invasive arm

1041
00:39:11.965 --> 00:39:13.245
of the trial you're getting medical therapy,

1042
00:39:13.505 --> 00:39:17.125
why is your event rate lower than just the conservative arm?

1043
00:39:17.125 --> 00:39:18.445
Anyway, they're getting the same therapy.

1044
00:39:19.065 --> 00:39:20.845
The reason is, is because those folks

1045
00:39:20.845 --> 00:39:23.085
that had conservative therapy in the invasive arm

1046
00:39:23.085 --> 00:39:24.405
didn't need a revascularization.

1047
00:39:24.425 --> 00:39:27.005
So there were lower risk than the just generic,

1048
00:39:27.005 --> 00:39:28.605
conservatively managed patients.

1049
00:39:29.265 --> 00:39:31.445
If you actually look within the original New England Journal

1050
00:39:31.445 --> 00:39:34.605
publication and the supplement, there's a Bayesian analysis

1051
00:39:34.605 --> 00:39:36.005
of the difference in event rates,

1052
00:39:36.005 --> 00:39:37.725
cardiovascular death and MI in a year.

1053
00:39:38.105 --> 00:39:40.245
It actually favors the conservative arm at a year

1054
00:39:40.245 --> 00:39:41.405
because of the risk upfront.

1055
00:39:41.985 --> 00:39:43.045
But at three years

1056
00:39:43.705 --> 00:39:47.165
and five years almost the entire distribution is in favor

1057
00:39:47.505 --> 00:39:50.125
of defining the anatomy and going to the cath lab.

1058
00:39:51.085 --> 00:39:53.955
Again, not commonly known from the ischemia trial,

1059
00:39:54.565 --> 00:39:56.835
there have been follow on studies looking at, uh,

1060
00:39:56.835 --> 00:39:57.835
longer term data.

1061
00:39:58.015 --> 00:40:00.995
And in fact if you look at extended follow up from the

1062
00:40:00.995 --> 00:40:03.275
trial, there's a statistically significant reduction in

1063
00:40:03.275 --> 00:40:05.875
cardiovascular death in the ischemia trial.

1064
00:40:05.895 --> 00:40:07.955
But that's predominantly observed in patients

1065
00:40:07.955 --> 00:40:09.115
with multivessel disease.

1066
00:40:09.425 --> 00:40:10.515
Totally makes sense.

1067
00:40:10.775 --> 00:40:13.235
You're never gonna save someone's life with the PDA

1068
00:40:13.235 --> 00:40:15.355
or the OM or even the distal LAD.

1069
00:40:15.655 --> 00:40:17.435
If you have multivessel disease though,

1070
00:40:17.435 --> 00:40:20.395
and you define the anatomy that is prognostically important.

1071
00:40:20.895 --> 00:40:23.155
Now it's offset by an increase in non-cardiovascular

1072
00:40:23.475 --> 00:40:24.995
mortality that is not well understood.

1073
00:40:24.995 --> 00:40:27.955
It might be fluke, it might be real, it might be the some

1074
00:40:27.955 --> 00:40:30.795
of the, the, the, uh, antiplatelet therapy that we use.

1075
00:40:31.055 --> 00:40:33.435
But nonetheless, there's a reduction in cardiovascular death

1076
00:40:34.015 --> 00:40:35.835
and the authors have gone further.

1077
00:40:35.935 --> 00:40:38.275
And this was published last year in your, your intervention

1078
00:40:38.745 --> 00:40:41.635
that if you on CTA had three vessel disease

1079
00:40:42.215 --> 00:40:45.235
and you were randomized within the invasive arm

1080
00:40:45.235 --> 00:40:47.275
of the trial, not the non cath arm

1081
00:40:47.275 --> 00:40:49.875
and the invasive arm, there is a benefit in terms

1082
00:40:49.875 --> 00:40:52.275
of cardiovascular death and MI irrespective

1083
00:40:52.335 --> 00:40:54.395
of whatever subsequent treatment you receive.

1084
00:40:54.895 --> 00:40:56.915
So the second question I'll ask all of you

1085
00:40:56.915 --> 00:40:59.595
before ending to the the, the conclusion part of the talk is

1086
00:40:59.595 --> 00:41:02.355
with regards to the prognostic benefit of revascularization.

1087
00:41:02.975 --> 00:41:04.715
Number one, there are no patients

1088
00:41:04.735 --> 00:41:06.595
for which coronary revascularization has been shown

1089
00:41:06.595 --> 00:41:08.595
to have a prognostic benefit over medical therapy.

1090
00:41:08.705 --> 00:41:10.475
This is the medical school, school teaching.

1091
00:41:10.855 --> 00:41:12.675
Number two, the prognostic benefits

1092
00:41:12.675 --> 00:41:15.355
of revascularization are manifest in higher risk patients

1093
00:41:15.695 --> 00:41:18.595
but they take time to offset the procedural risk.

1094
00:41:19.095 --> 00:41:22.075
And number three, you know, I'm gonna save your life

1095
00:41:22.095 --> 00:41:24.875
by any revascularization I do irrespective of your risk.

1096
00:41:25.425 --> 00:41:27.235
Once again, it's in the middle and,

1097
00:41:27.255 --> 00:41:29.275
but it's important that there actually is a benefit.

1098
00:41:30.215 --> 00:41:31.875
Now I'm not telling you you need

1099
00:41:31.875 --> 00:41:32.955
to revascularize every patient.

1100
00:41:33.145 --> 00:41:35.525
In fact, there are many patients I see who are asymptomatic

1101
00:41:35.545 --> 00:41:37.045
and I say, look, you need medical therapy.

1102
00:41:37.665 --> 00:41:39.205
You all have epic. We have epic.

1103
00:41:39.645 --> 00:41:42.845
I have a phrase the A JK, my initials ischemia,

1104
00:41:43.125 --> 00:41:44.965
I type ajk ischemia.

1105
00:41:45.185 --> 00:41:46.325
And this is what comes out.

1106
00:41:46.705 --> 00:41:48.805
And that is we had an extensive discussion on

1107
00:41:48.805 --> 00:41:49.965
the basis of this trial.

1108
00:41:50.085 --> 00:41:52.085
I don't see any prognostic benefit to going

1109
00:41:52.085 --> 00:41:53.605
to the cath lab and figuring this out.

1110
00:41:54.005 --> 00:41:55.205
I would therefore recommend medical

1111
00:41:55.205 --> 00:41:56.365
therapy for the time being.

1112
00:41:56.785 --> 00:41:58.965
It would change if something changed with the patient.

1113
00:41:59.425 --> 00:42:01.485
We discussed the risks and benefits of this approach.

1114
00:42:01.685 --> 00:42:03.645
I do have, in the disclaimer I did mention,

1115
00:42:03.705 --> 00:42:04.845
we can never predict the future.

1116
00:42:04.875 --> 00:42:06.925
It's certainly possible that an adverse event could occur,

1117
00:42:07.345 --> 00:42:10.165
but the important statement is I'm not confident

1118
00:42:10.245 --> 00:42:12.285
that I could prevent that event from occurring

1119
00:42:12.435 --> 00:42:13.605
with an invasive approach,

1120
00:42:13.605 --> 00:42:15.765
especially based upon prior randomized data.

1121
00:42:16.265 --> 00:42:18.165
So I don't cath everybody.

1122
00:42:18.445 --> 00:42:20.125
I try to make a rational decision,

1123
00:42:20.495 --> 00:42:22.645
especially if they have a CTA or something upfront

1124
00:42:22.645 --> 00:42:23.645
and then figure out what to do.

1125
00:42:24.025 --> 00:42:26.365
And this is entirely supported in the guidelines.

1126
00:42:26.365 --> 00:42:28.485
While many people you know think

1127
00:42:28.565 --> 00:42:30.205
that the ischemia trial was a negative trial,

1128
00:42:30.575 --> 00:42:33.805
there is actually a class two a recommendation on the basis

1129
00:42:33.985 --> 00:42:37.605
of the ischemia trial that says if you have stable disease

1130
00:42:37.625 --> 00:42:39.925
and multi-vessel coronary artery disease, it's appropriate

1131
00:42:39.925 --> 00:42:41.365
for either CABG or PCI.

1132
00:42:41.885 --> 00:42:43.885
Revascularization is reasonable to lower the risk

1133
00:42:43.885 --> 00:42:46.565
of cardiovascular events such as spontaneous mi,

1134
00:42:46.765 --> 00:42:49.085
unplanned revascularizations or cardiac death.

1135
00:42:49.755 --> 00:42:51.645
This needs to find its way back into

1136
00:42:51.645 --> 00:42:52.725
the medical school curriculum.

1137
00:42:53.385 --> 00:42:54.485
So to sort of conclude

1138
00:42:54.485 --> 00:42:57.085
and where I've taken this in in terms of my approach

1139
00:42:57.085 --> 00:43:00.325
to cardiovascular care in the, in the uh, cath lab is,

1140
00:43:00.345 --> 00:43:02.045
you know, we really didn't wanna focus on the

1141
00:43:02.075 --> 00:43:03.205
sham lipoplasty anymore.

1142
00:43:03.205 --> 00:43:04.405
We wanted to look at patients

1143
00:43:04.515 --> 00:43:05.885
that could benefit from the

1144
00:43:06.005 --> 00:43:07.525
revascularization procedures we did.

1145
00:43:07.905 --> 00:43:10.445
And so we wanted to focus on the highest risk patients,

1146
00:43:10.445 --> 00:43:11.845
those that have the most symptoms

1147
00:43:11.845 --> 00:43:13.005
or the most severe anatomy.

1148
00:43:13.305 --> 00:43:14.485
And we wrote this sort of white,

1149
00:43:14.485 --> 00:43:16.645
white paper on the evolution within our field,

1150
00:43:17.105 --> 00:43:18.965
not focusing on the sham lipoplasty

1151
00:43:18.965 --> 00:43:19.965
but focusing on other things.

1152
00:43:20.655 --> 00:43:23.845
First and foremost, I wanna emphasize you gotta do

1153
00:43:23.845 --> 00:43:24.965
the medical therapy, right?

1154
00:43:25.025 --> 00:43:26.485
So we looked at our own cath lab

1155
00:43:26.585 --> 00:43:29.485
and for 400 of these patients that had PCI

1156
00:43:29.485 --> 00:43:31.325
for CTL left mannar calcific coronary

1157
00:43:31.325 --> 00:43:32.365
disease with atherectomy.

1158
00:43:32.825 --> 00:43:36.725
It was sad but true that we recognized that only 43%

1159
00:43:36.725 --> 00:43:38.325
of them had their LDL less than 70.

1160
00:43:38.865 --> 00:43:41.005
That's horrible. So what did we do?

1161
00:43:41.265 --> 00:43:44.245
We actually said that when you draw pre cath labs along

1162
00:43:44.245 --> 00:43:48.405
with pure PT and your INR and your CBC and your, and your

1163
00:43:48.405 --> 00:43:51.085
and your creatinine, we're gonna draw a lipid panel.

1164
00:43:51.545 --> 00:43:53.085
And we've wrote written about this

1165
00:43:53.085 --> 00:43:55.285
and basically said we should state what should be obvious.

1166
00:43:55.345 --> 00:43:58.005
And that is that when we see the anatomy in the cath lab

1167
00:43:58.005 --> 00:44:01.045
or do an intervention, we tell the patient we fixed

1168
00:44:01.045 --> 00:44:04.445
what we needed to fix but the house is on fire and you

1169
00:44:04.445 --> 00:44:06.365
therefore need to do this right now

1170
00:44:06.365 --> 00:44:08.565
with your lipid-lowering therapy so as

1171
00:44:08.565 --> 00:44:10.005
to achieve the best outcomes.

1172
00:44:10.345 --> 00:44:12.045
So medical therapy is super important,

1173
00:44:12.545 --> 00:44:14.485
but beyond medical therapy, you also need

1174
00:44:14.485 --> 00:44:16.005
to learn specialized skills to be able

1175
00:44:16.005 --> 00:44:17.045
to treat these high risk patients.

1176
00:44:17.065 --> 00:44:18.605
And so I'm not gonna go through this,

1177
00:44:18.625 --> 00:44:20.525
but there are a lot of skills you need to learn.

1178
00:44:20.985 --> 00:44:24.845
So back to my guy, he came back, he had recurrent angina

1179
00:44:25.145 --> 00:44:28.085
and now you see he's got a tight lesion within the stent on

1180
00:44:28.085 --> 00:44:29.925
that bend, uh, of the remu.

1181
00:44:30.345 --> 00:44:32.485
So it becomes challenging. What do you do with this?

1182
00:44:32.485 --> 00:44:33.525
Because it's on a bend,

1183
00:44:33.585 --> 00:44:35.005
you know evac, he's a drug coated balloon.

1184
00:44:35.045 --> 00:44:37.485
I could use a lot of things, but what I actually wanted

1185
00:44:37.485 --> 00:44:39.725
to do is just open the native coronary at that time.

1186
00:44:40.145 --> 00:44:42.005
For many people, this is not approachable,

1187
00:44:42.005 --> 00:44:43.285
you can't do these cases, but

1188
00:44:43.285 --> 00:44:45.445
with dual injections you can actually figure out

1189
00:44:45.445 --> 00:44:48.365
where the RCA should be and with specialized techniques

1190
00:44:48.365 --> 00:44:51.085
and anchoring balloon in the conus a DR.

1191
00:44:51.185 --> 00:44:54.925
So you come down, uh, subtly in the vessel we reenter in, in

1192
00:44:54.925 --> 00:44:57.445
that stented area, you can basically do the case

1193
00:44:57.505 --> 00:44:59.205
and open up the native coronary artery.

1194
00:44:59.565 --> 00:45:01.565
I still follow him years later and he's great.

1195
00:45:01.635 --> 00:45:03.485
He's doing way, way better as angina got better

1196
00:45:03.625 --> 00:45:05.725
and he still remains off the anginal.

1197
00:45:06.265 --> 00:45:09.925
The problem is not everybody can do these cases in the us If

1198
00:45:09.925 --> 00:45:11.565
you look at the average interventionalists,

1199
00:45:11.565 --> 00:45:13.845
they do less than one PCIA week.

1200
00:45:14.385 --> 00:45:16.165
That's the problem. You need specialized

1201
00:45:16.165 --> 00:45:17.285
centers to be able to do this.

1202
00:45:17.515 --> 00:45:18.885
What we do at Columbia is

1203
00:45:18.885 --> 00:45:20.245
because we're on a salary type

1204
00:45:20.245 --> 00:45:22.005
of model is we have specific operators

1205
00:45:22.145 --> 00:45:23.205
who do high risk cases

1206
00:45:23.425 --> 00:45:25.885
and we double scrub with other operators so

1207
00:45:25.885 --> 00:45:27.445
that when you come to the Columbia cath lab,

1208
00:45:27.545 --> 00:45:29.485
you're getting essentially the same level

1209
00:45:29.505 --> 00:45:32.045
of care irrespective of who your primary operator is.

1210
00:45:32.545 --> 00:45:34.885
The reason we think that's important is there's data like

1211
00:45:34.885 --> 00:45:36.605
this from the busiest cath lab in the world.

1212
00:45:36.605 --> 00:45:38.085
This is fu y hospital in China

1213
00:45:38.415 --> 00:45:42.205
where left main disease based upon your operator volume.

1214
00:45:42.355 --> 00:45:45.005
High volume operators have a lower cardiac mortality than

1215
00:45:45.005 --> 00:45:46.045
those are low volume

1216
00:45:46.345 --> 00:45:47.725
and the high volume ones are probably

1217
00:45:47.725 --> 00:45:48.765
doing more complex cases.

1218
00:45:49.265 --> 00:45:51.405
So for simple cases it probably doesn't matter

1219
00:45:51.665 --> 00:45:53.005
for the really complex stuff,

1220
00:45:53.075 --> 00:45:54.445
this type of stuff does matter.

1221
00:45:54.875 --> 00:45:57.645
There's also institutional stuff that matters.

1222
00:45:57.785 --> 00:46:00.805
So this is a very interesting study of cabbage versus PCI.

1223
00:46:01.315 --> 00:46:04.605
Each of these balloons is an individual site At this site.

1224
00:46:04.605 --> 00:46:06.525
In the trial, the rate of adverse events

1225
00:46:06.525 --> 00:46:10.285
with cabbage was 40%, but with PCI it was minimal 10%.

1226
00:46:10.835 --> 00:46:13.965
This site, it was 50% adverse events with PCI,

1227
00:46:14.275 --> 00:46:15.525
0% with cabbage.

1228
00:46:16.105 --> 00:46:18.005
If you're a patient, you don't know which

1229
00:46:18.005 --> 00:46:19.205
of these bubbles you're going to.

1230
00:46:19.305 --> 00:46:21.445
But if you're the physician at one of the bubbles

1231
00:46:22.025 --> 00:46:24.605
at this place, you really don't want to have bypass surgery.

1232
00:46:24.705 --> 00:46:26.885
And at this place you really don't wanna have PCI.

1233
00:46:27.465 --> 00:46:29.965
So we need to be better about conveying these things

1234
00:46:29.965 --> 00:46:31.245
to ourselves and understanding

1235
00:46:31.265 --> 00:46:32.525
our strengths and limitations.

1236
00:46:32.785 --> 00:46:34.245
In fact, that's in the guidelines

1237
00:46:34.245 --> 00:46:36.525
where the guidelines talk about spending time to engage

1238
00:46:36.525 --> 00:46:38.725
with the patient, allow for a second opinion,

1239
00:46:39.195 --> 00:46:42.125
discuss the specific risks and benefits with procedural

1240
00:46:42.225 --> 00:46:44.805
and outcomes on the operator level so

1241
00:46:44.805 --> 00:46:45.805
that we're giving the patient

1242
00:46:46.195 --> 00:46:48.165
what they best deserve as a patient.

1243
00:46:48.665 --> 00:46:50.565
Not what I feel comfortable providing

1244
00:46:50.565 --> 00:46:52.165
because I'm limited in terms of what I do.

1245
00:46:52.825 --> 00:46:55.365
So to conclude, I'll just point out the way I like

1246
00:46:55.365 --> 00:46:57.125
to think about medicine is, you know, through, through,

1247
00:46:57.125 --> 00:46:59.445
through these personal examples, informed by data,

1248
00:46:59.785 --> 00:47:01.765
and this was an interesting one, you all know who this is?

1249
00:47:01.785 --> 00:47:05.565
I'm down in Houston of course. So this, he had a PCI done.

1250
00:47:05.665 --> 00:47:07.085
And at the time this was done.

1251
00:47:07.635 --> 00:47:09.125
This is really American medicine.

1252
00:47:09.125 --> 00:47:10.605
In his worst, he's a poster child

1253
00:47:10.605 --> 00:47:12.165
for the inappropriate use of stenting.

1254
00:47:12.425 --> 00:47:14.405
Now unfortunately, I don't think either of these folks

1255
00:47:15.445 --> 00:47:18.525
reviewed the chart, saw the patient or anything like that.

1256
00:47:18.525 --> 00:47:20.445
They're just like opining off the cuff.

1257
00:47:20.445 --> 00:47:21.885
And as, and I think one of my

1258
00:47:22.485 --> 00:47:24.125
residents once told me when I was an intern,

1259
00:47:24.375 --> 00:47:26.485
don't ever opine on a case definitively

1260
00:47:26.485 --> 00:47:27.765
unless you've actually seen the patient.

1261
00:47:28.475 --> 00:47:30.245
Nonetheless, this was said this way.

1262
00:47:30.265 --> 00:47:33.005
And so what was interesting is he was asked at a subsequent

1263
00:47:33.005 --> 00:47:34.605
meeting, you know, what did you think

1264
00:47:34.605 --> 00:47:36.405
of people saying all this stuff about you?

1265
00:47:37.265 --> 00:47:39.085
Now you remember, if you remember him,

1266
00:47:39.425 --> 00:47:41.325
he basically has a lot of one-liners

1267
00:47:41.325 --> 00:47:42.725
and they're often self-deprecating.

1268
00:47:42.725 --> 00:47:43.805
They're often inadvertent

1269
00:47:43.805 --> 00:47:44.645
and they're always, you know,

1270
00:47:44.785 --> 00:47:46.005
it made him look funny at times.

1271
00:47:46.545 --> 00:47:48.525
But in this case, the best one-liner ever,

1272
00:47:50.125 --> 00:47:51.265
it wasn't their LED.

1273
00:47:52.255 --> 00:47:53.825
They could say whatever the heck they want,

1274
00:47:54.005 --> 00:47:55.345
but it wasn't their LED.

1275
00:47:55.885 --> 00:47:58.985
So he had a subtotal, occluded LEDs, an avid cyclist,

1276
00:47:59.205 --> 00:48:01.545
and he wants to bike in the woods and do all this stuff.

1277
00:48:01.855 --> 00:48:04.025
It's his decision as to whether he wants to do it or not.

1278
00:48:04.445 --> 00:48:06.785
And so ultimately it has to be patient centered.

1279
00:48:06.925 --> 00:48:09.665
So to conclude, what did I attempt to convey today?

1280
00:48:09.695 --> 00:48:11.505
Well, first coronary disease

1281
00:48:11.505 --> 00:48:13.025
and the clinical syndromes associated

1282
00:48:13.025 --> 00:48:14.025
with it really should be treated

1283
00:48:14.025 --> 00:48:15.745
with therapies aimed at symptom relief

1284
00:48:16.005 --> 00:48:19.305
and prognostic benefit, the location of the disease,

1285
00:48:19.565 --> 00:48:21.225
the type and severity of the symptoms

1286
00:48:21.365 --> 00:48:24.825
and the patient risk will most often dictate the benefits

1287
00:48:24.825 --> 00:48:26.345
of revascularization informed

1288
00:48:26.345 --> 00:48:27.945
by a healthy dose of common sense.

1289
00:48:28.475 --> 00:48:30.785
Don't do procedures because you're gonna bill more for them.

1290
00:48:31.525 --> 00:48:33.505
Do to the patient what you would want for one

1291
00:48:33.505 --> 00:48:35.305
of your family members and really try to be honest.

1292
00:48:35.445 --> 00:48:37.785
Are the symptoms real? What does the anatomy look like?

1293
00:48:39.465 --> 00:48:40.665
Interventional cardiology can be

1294
00:48:40.665 --> 00:48:42.305
as cerebral as its technical.

1295
00:48:42.305 --> 00:48:44.505
We always talk about the in lab stuff,

1296
00:48:44.525 --> 00:48:45.665
but it's not just that.

1297
00:48:45.775 --> 00:48:49.665
It's interventions that work that we are most happy about,

1298
00:48:49.965 --> 00:48:51.585
not just those occurring in the cath lab.

1299
00:48:52.165 --> 00:48:53.585
And I really think it feels great

1300
00:48:53.585 --> 00:48:55.465
to think when practicing clinical medicine,

1301
00:48:55.465 --> 00:48:56.985
we don't often have enough time to do it,

1302
00:48:56.985 --> 00:48:58.025
but when we can actually think

1303
00:48:58.405 --> 00:49:01.785
and then use that data to apply it

1304
00:49:01.785 --> 00:49:04.825
to our patients thoughtfully communicating that judgment

1305
00:49:04.885 --> 00:49:07.065
to our patients, that's our fundamental

1306
00:49:07.065 --> 00:49:08.265
responsibility as physicians.

1307
00:49:08.265 --> 00:49:09.265
It's actually a privilege

1308
00:49:09.265 --> 00:49:10.745
to practice under those environments

1309
00:49:10.965 --> 00:49:12.865
and it's what's fulfilled me in my career.

1310
00:49:13.365 --> 00:49:15.545
Um, and hopefully you can get some inspiration out of it.

1311
00:49:15.565 --> 00:49:16.705
So thanks so much for listening.