Emil Nielsen Holck

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Emil Nielsen Holck

Emil Nielsen Holck

@EmilHolckMD

MD PhD and Trialist at Aarhus University Hospital @AUHcardio | PCI Research | Father and Ultra Runner

Aarhus University Hospital Katılım Eylül 2019
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Emil Nielsen Holck
Emil Nielsen Holck@EmilHolckMD·
Ten-year outcome in the NOBLE trial 🫀Today, we presented that there is no difference in all-cause mortality ten years after randomization to PCI or CABG in patients with unprotected LMCA disease. For more info contact @h_evald or me - always eager to interact!
Emil Nielsen Holck tweet mediaEmil Nielsen Holck tweet mediaEmil Nielsen Holck tweet mediaEmil Nielsen Holck tweet media
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MIЯVΛƬ #IC ༄ ｡°
MIЯVΛƬ #IC ༄ ｡°@mirvatalasnag·
@DFCapodanno If we’re adding 22 min, shouldn’t that mean we’re optimizing more? Passing a catheter is quick..presumably it’s the optimization yet ~ pre-imaging not done in 35% & optimization achieved in 50% (IVUS ACS 90% & DK CRUSH VIII 75%) Perhaps time to revisit NOBLE @EuroInterventio
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Davide Capodanno
Davide Capodanno@DFCapodanno·
OPTIMAL suggests that using IVUS in unprotected left main PCI may cost you 22 minutes with no clinical benefit. One might think it’s an outlier. Yet, the same day, IVUS-CHIP reports no advantage of IVUS over angiography in complex high-risk PCI. Either we have been fundamentally misinterpreting the evidence so far, or we urgently need to reconcile these data. #ACC26 nejm.org/doi/full/10.10… nejm.org/doi/full/10.10…
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Emil Nielsen Holck
Emil Nielsen Holck@EmilHolckMD·
@sbrugaletta Agree - Also looking forward to predictors of stent failure! However, the site reported LM MSA was 12.99 (appendix table 10). I am really curious about the fraction of patients with unintended stent deformations visible by IVUS. It was 18.5% in LMCA in OCTOBER.
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Salvatore Brugaletta
Salvatore Brugaletta@sbrugaletta·
what I found interesting are the criteria used for IVUS-guided stent optimization, with the famous rule of 8,7,6 and 5, which comes from asian patients, and they could be too low for an european population. I am curious to see the IVUS substudy. in the meanwhile I hope none will be switching to angio when doing LM PCI
Elad Asher@AsherElad

Two RCTs. Different populations. Same message. IVUS-guided PCI: ❌ No reduction in clinical events in complex PCI ❌ No benefit in left main disease Better imaging ≠ better outcomes. Are we overestimating the power of optimization? #CardioTwitter #PCI #IVUS nejm.org/doi/full/10.10… nejm.org/doi/full/10.10… @PCRonline @Sbrugaletta @Ortega_Paz @Anazmicalik @guilbom @hect2701 @NicolaRyanI1 @DrPascalMeier @W_jyg @ICigalini @Hragy @SABOURETCardio @mmamas1973 @djc795 @GreggWStone @toreyj01 @EAPCIPresident @CMichaelGibson @SmithElliotjs @ArielRoguin @aayshacader @twj1974 #europcr @dangiloncardio @deharo_pierre @DanieleGiacoppo @MilasinD18 @Taiebphil @plateletdoc @realarainmd

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Emil Nielsen Holck
Emil Nielsen Holck@EmilHolckMD·
@realarainmd @evandrofilhobr @asaadnakhle Depends on how you define “outcome”. The pre stenting assessment will probably prevent ISR because you will gain larger MSA etc. However, the final run is extremely important to make sure you don’t leave any unintended stent deformations that will give ST.
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Salman Arain
Salman Arain@realarainmd·
Always a good topic to discuss and/or debate Evandro. 😀 Which IVUS run has the greatest impact on the PCI outcome? List in order of importance (highest to lowest): 1 - Baseline (pre 🎈) 2 - Mid intervention (pre stent) 3 - Post stent 4 - Post stent optimization My selection: 2, 3, 1, 4. What is yours?
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Salman Arain
Salman Arain@realarainmd·
A Question Inspired By A Discussion On IVI Guided PCI In Gim et al. (doi:10.1016/j.jcin.2025.11.036), the angio-only arm had a higher proportion of acute MI pts vs the IVI-guided arm. Raises a practical question: how often is IVI actually used in acute MI? Reply and repost!
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I.H.Tanboga, MD, PhD
I.H.Tanboga, MD, PhD@ihtanboga·
IVI use being associated with such benefit in the very early period (first 3-5 days) is clinically implausible. In addition to your points, I would add the following: - Key claim: IVI-PCI ≈ CABG - But the data come from 3 very different sources, and the mixing creates serious bias concerns. 1/
Salman Arain@realarainmd

PCI vs. PCI - More reflections on the study by Gim et al The sticking point for me (and others like @aymanka, @ihtanboga, @GreggWStone) is the immediate separation of the curves bet. the PCI arms. It is difficult to see how immortal time bias alone accounts for this. doi: 10.1016/j.jcin.2025.11.036

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Emil Nielsen Holck
Emil Nielsen Holck@EmilHolckMD·
@ihtanboga And confounding by indication. Probably has a big role in angio arm of the study.
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I.H.Tanboga, MD, PhD
I.H.Tanboga, MD, PhD@ihtanboga·
This is the nature of observational studies. Biases that come to mind: • Immortal time bias (CABG wait) • Selection bias (non-shared populations) • Chronological bias (2001–2017 vs 2018–2021) • Ascertainment bias (MI definition differs) • Design heterogeneity (RCT vs registry pooled) • Unmeasured confounding (SYNTAX, DM severity,.......) 3/
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Emil Nielsen Holck
Emil Nielsen Holck@EmilHolckMD·
@realarainmd Many of our ACS patients are randomized to IVI or angio guidance. Right now we are randomizing in the OCTAVE trial. 3000 patients with signs of af culprit lesion. ISRCTN10469053
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Women As One
Women As One@WomenAs1·
🚨 Analysis of 12,000+ PCI patients challenges long-held assumptions. Younger women (40–61) had better long-term outcomes than men, including lower mortality and fewer major cardiac events. Yet women remain underrepresented in trials and practice. ahajournals.org/doi/10.1161/JA…
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Emil Nielsen Holck
Emil Nielsen Holck@EmilHolckMD·
@SarahFairley7 I disagree. We would love to design the trials - however it is very difficult to get none trialists to randomise the right patients. When the wrong patients are randomised we have poor external validity. That is the real problem.
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Sarah Fairley
Sarah Fairley@SarahFairley7·
Interventional cardiology - the leaders in designing trials that won't answer the question we really want to be answered. And when the answer we finally get isn't the answer we want to hear, we argue about it about amongst ourselves for the next 10 years. Rinse & repeat!
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Emil Nielsen Holck
Emil Nielsen Holck@EmilHolckMD·
@AlfredoERodrig2 @DFCapodanno The lower risk of spontaneous MI did not translate into a mortality benefit at ten years. We have had the ten year report accepted for publication and it will be published soon.
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Alfredo E Rodriguez
Alfredo E Rodriguez@AlfredoERodrig2·
It is interesting to analyze also numbers of spontaneous MI in the NOBLE trial which included patients with low risk LMCA stenosis .In NOBLE there was a huge differences of spontaneous MI between CABG and DES in favor to CABG. Early neoatherosclerosis and endothelial dysfunction both important limitations of DES are responsible for these findings, stent related events. We should be aware of that when we are planning PCI in MVD or LMCA.
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Davide Capodanno
Davide Capodanno@DFCapodanno·
In the EXCEL trial, the lower rate of myocardial infarction after CABG was largely driven by fewer events related to graft failure and fewer infarctions arising from untreated vessels, compared with the higher burden of stent failure–related events and infarctions in non-stented vessels after PCI. In contrast, there was no evidence to support the traditional theory that CABG reduces MI by protecting against new events occurring proximal to the graft insertion site. ahajournals.org/doi/full/10.11…
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Emil Nielsen Holck
Emil Nielsen Holck@EmilHolckMD·
@DavidLBrownMD Honestly, it is not about the science. It is about trust. Patients/citizens trust the system and are therefore almost always willing to contribute to clinical trials. Another benefit of universal health care.
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Emil Nielsen Holck retweetledi
Mamas A. Mamas
Mamas A. Mamas@mmamas1973·
If there are companies / industry that wishes to support our @HeartAEthiopia mission on 3-18th July 2026- please contact me so i can put you in touch with the charity, or directly contact @TTelila one of the founders of the charity we already have firm commitments from @BrosMedMedical and @BiosensorsLtd we especially need pacemakers as charitable donations - @Medtronic @AbbottNews @BostonSciWDD are you able to help?
Mamas A. Mamas@mmamas1973

Congratulations to the team at TASH in Ethiopia for undertaking their 100th primary PCI - it's been a privilege to be a small part of this milestone, The highlight of my career was working in Ethiopia for 2 weeks and supporting them virtually and watching them grow a primary PCI service in Ethiopia Congratulations to @TTelila and @drmerid - they have worked tirelessly in creating @HeartAEthiopia to make this happen. They have changed many people's lives in their country despite living in the USA. Congratulations to @adane_petros8 @ChalaFekadu12 sister kono and all the team for doing this without payment and dedicated funds often Thank you to our industry partners such as @BiosensorsLtd @terumoisuk @cordis and others who supported my mission to Ethiopia with charitable donations of kit. Thank you to @flyethiopian for supporting the transfer of volunteers and kit I can't wait for the next mission in July 2026. Happy New Year everyone @mirvatalasnag @TCTMD @alaide_chief @parthaskar @DrAsifQasim

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Sripal Bangalore
Sripal Bangalore@SripalBangalore·
10/ Case resolution. To summarize, 67 y/o w chest pain, EKG changes, low level troponin elevation. "Negative" NHPR, cFFR 0.88. Adenosine FFR 0.79. OCT images below. MLA 1.54 w large lipidic plaque w TCFA. No rupture.
Sripal Bangalore tweet media
Sripal Bangalore@SripalBangalore

7/ Based on the cFFR of 0.88, what is the next step? @AntoniousAttall @Ajar_Kochar @DrDamluji @adityadoc1 @abadkhan2002 @mirvatalasnag @mmamas1973 @sbrugaletta @nyalborgesmd @PinakShahMD @Laserrman @TWilsonMD @HollandTamis @pooneh_nabavi @DrRajeshG1 @SandeepNathanMD

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josep
josep@josepgomezlara·
Recta final para la inclusion del @VulnerableTrial con el paciente 500 del RCT aleatorizado. Ya quedan 100 para llegar a los 600 objetivo. Esta vez nos ha tocado en Bellvitge. Caso muy claro de una CF con ALM 2,5 mm2, carga placa 80%, arco lipido >300^ y capa fibrosa de 50 micras
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Emil Nielsen Holck
Emil Nielsen Holck@EmilHolckMD·
@drjohnm To say that 10 year mortality is a highly curated endpoint isn’t fair. To acquire funding for a ten-year FU on MACCE is not a simple task. At the moment we are in the process 🙏. When the NOBLE paper becomes available you’ll see that we discuss many of the points raised by Faisal
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Emil Nielsen Holck
Emil Nielsen Holck@EmilHolckMD·
@SrineilV @adnanalkhouli I agree, conclusions must be drawn on all available evidence. When the paper is published you will see that this is also the case when we discuss the findings.
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Srineil Vuthaluru
Srineil Vuthaluru@SrineilV·
@EmilHolckMD @adnanalkhouli I’d argue to draw conclusions from the 10 year follow-up without mentioning the original primary outcome of the study is cherry-picking. As you astutely pointed out, for the appropriately powered 5 year MACE outcome, CABG > PCI. Cannot change practice based on false equivalence.
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Mohamad Alkhouli
Mohamad Alkhouli@adnanalkhouli·
The 10-year outcome of Noble trial may be the most impactful data presented at #TCT2025 PCI=CABG for isolated left main disease regardless of Syntax score Which isolated LM patients (suitable for PCI) will you refer to CABG?
MIЯVΛƬ #IC ༄ ｡°@mirvatalasnag

#TCT2025 @TCTConference @crfheart 10 year results of Noble Trial 🧨PCI vs. CABG: similar all-cause mortality 🧨No difference at 0-5 and 5-10 years 🧨In ACS: PCI associated with lower mortality 🧨SYNTAX score: no association with mortality

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Carlos Collet MD PhD
Carlos Collet MD PhD@ColletCarlos·
🔥 Physiology has evolved. From a diagnostic method to a prognostic tool. 💡 What if we could predict outcomes before we stent? The Pullback Pressure Gradient (PPG)—a metric describing how disease is distributed along the coronary artery—may hold that key. Our latest study, now published, explores this idea.👇
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Emil Nielsen Holck
Emil Nielsen Holck@EmilHolckMD·
Ten-year outcome in the NOBLE trial 🫀Today, we presented that there is no difference in all-cause mortality ten years after randomization to PCI or CABG in patients with unprotected LMCA disease. For more info contact @h_evald or me - always eager to interact!
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Keşfet

@mirvatalasnag @DFCapodanno @EuroInterventio @sbrugaletta @realarainmd @evandrofilhobr @asaadnakhle @ihtanboga