FJB

@willyhfrick @ECGEPSCADEVICE @RobertHermanMD @PendellM @smithECGBlog @EM_RESUS @The_Nanashi_O @DidlakeDW @AmmarNasirMD @ecgandrhythmRoe @ecgrhythms @EcgsOnly I do not think these can be Wellens waves if they are having active chest pain.

@ECGEPSCADEVICE @RobertHermanMD @PendellM @smithECGBlog @EM_RESUS @The_Nanashi_O @DidlakeDW @AmmarNasirMD @ecgandrhythmRoe @ecgrhythms @EcgsOnly That is the question! I was on the fence about this one.

I have been fooled by a few biphasic T waves lately. What do you think? OMI or no? Culprit?

@willyhfrick @RobertHermanMD @PendellM @smithECGBlog @EM_RESUS @The_Nanashi_O @DidlakeDW @AmmarNasirMD @ecgandrhythmRoe @ecgrhythms @EcgsOnly I vote not OMI. Lots of R-wave (I don’t know if that is should alter my probability). Also V4 makes me think of a benign variant of TWI. I am also frequently wrong.

@PulmCrit I think nicardipine also has the advantage of pulmonary vasodilation (over nicardipine or clevedipine). Maybe nicardipine/clevedipine over nitroprusside if you know they have unrevascularized territory and are worried about coronary steal?

what thoughts do people have on using nitroprusside to reduce afterload in severe heart failure / borderline cardiogenic shock patients?

@TropeLeak @JeffLittle76 Pamela, I am not attracted to you anymore!

@JeffLittle76 I would call that “Severe”

@IDstewardship Does it work? ncbi.nlm.nih.gov/pmc/articles/P…

💊💊 Brand name: Tamiflu Class: Neuraminidase inhibitor Treats: Influenza, start promptly Dose adjustment: for renal function Beware: GI side effects, potentially neuropsychiatric events IV counterpart: peramivir (Rapivab) Have any fun facts? My fav ref: cdc.gov/flu/pdf/profes…

@BigCoachF Does it cause more diabetes?

FDA approves inclisiran, a twice-yearly injection that lowers cholesterol cardiovascularbusiness.com/topics/prevent…

@BigCoachF Coach, does it save lives? Does it prevent STEMIs?

@NickJohnsonMD I think that’s a great statement by you and the authors. I was not able to watch the presentation but did not initially see a similar statement in their JAMA article. I was a little worried by the large effect on ROSC and the “trend” of harm. I look forward to the larger trial.

@FredMedic As the authors stated when they presented the trial, they (and I) do not think this trial should change clinical practice or guidelines. But it, along with the Greek trials, sets stage for a large, multicenter RCT (they estimated 2000-8000 depending on effect size).

Seeing lots of folks dismiss the VAM-IHCA trial based on no survival benefit. Trial was not powered to detect survival difference; primary outcome was ROSC. Not all trials, esp cardiac arrest, can enroll 5000+ pts. Walk, then run. Definitely supports a larger trial.

@jelevenson @HanCardiomd Still gets used quite a bit at Barnes.

Honest Question to #medtwitter #cardiotwitter: who is still able to use nitroprusside ? Most healthcare systems have reported cost-ineffective. I haven’t had opportunity to use it in years. I do miss my old friend nipride dearly, however, and this is great work @HanCardiomd!

@BCM_InternalMed @rabihmgeha Right sided failure (tricuspid regurgitation) causing elevated central venous pressure causing cardio renal syndrome.

Hey, #MedTwitter! What is the overlap between "Infective Endocarditis" and "Acute Kidney Injury." Let's get a broad differential diagnosis running!

@EdwardP60483089 @MKIttlesonMD I completely admit that my lipidology game is weak. I think we don’t have medical therapies that increase HDL AND improve hard outcomes but I was under the assumption that the higher your HDL (genetics/diet/exercise) the more likely to avoid CVD and sequela?

@FredMedic @MKIttlesonMD No data that hdl of 100 will protect you!

53F with no prior cardiac history. BP 110/70, no meds. Cholesterol 305, HDL 89, LDL 192, triglycerides 119. No family history CAD, smoking, or diabetes. Requests coronary calcium scan as she does not want to start statin therapy: CAC zero. Do you recommend statin therapy?

@kaptinMD @MKIttlesonMD So true. But with the prior information that she could be a premenopausal woman and clinical trials are designed to enrich for events, I’d guess the NNT people similar to her is a higher than 92?

@jholtzman3 Is it possible the control arm wasn’t truly a placebo?

Ok, so what's the data -- In 2018, REDUCE-IT showed a 26% ⬇️ in ischemic events (CV death, nonfatal MI, or stroke) with pure EPA vs placebo when TGs >135mg/dL despite statin therapy.

Have you ever had a patient hop on a video visit, proudly hold up the bottle of a new 💊 and ask “Hey doc, I heard fish oil 🐟🐠🐡 is good for my heart so I went out and bought this. What do you think?” Check out this #tweetorial for my approach!

@EM_RESUS Sodium channel blockade due to elevated potassium.

Here’s a fantastic #ECG that was paged out as a prehospital STEMI alert. Can you guess the culprit?

@smithECGBlog @yadersandoval @adnanalkhouli @BrooksWalsh Though not part of Sgarbossa, do you have any opinions on what looks like T-wave inversions in the inferior leads?

@yadersandoval @adnanalkhouli @BrooksWalsh Tough one! Irreg irreg, so Atrial fib RVR. Intraventricular conduction delay that is nearly LBBB. Concordant STD in V2-V4: probably posterior OMI. One caveat: sometimes A fib RVR can cause demand ischemia with STD. If new, cardiovert and see if STD resolves in 15 min.

If you are skeptical about new LBBB as a reason for STEMI activation, see 👇

@AvrahamCooperMD Thank you for posting this. But I think there is also a bit of literature on the use of IV furosemide causing acute vasoconstriction (pubmed.ncbi.nlm.nih.gov/2860833/). When I worked as a paramedic we used a lot of IV nitroglycerin. It was fast acting and more titratable.

14/ 💡Furosemide rapidly⬇️LV filling pressures in acute heart failure, via venodilation and independent of diuresis 💡Purported mechanism =⬆️endothelial cell prostaglandin production 💡Furosemide also is a bronchodilator, likely via ⬆️prostaglandins in a similar fashion

1/ Why can furosemide improve dyspnea/pulmonary edema from acute congestive heart failure within minutes of administration? The answer does not involve diuresis. #medtwitter #tweetorial

@DSpeerbrecher @Toaster_Pastry I think he referring to the chronic management of patients with CHF as opposed to the acute treatment we see when patients call 911 with acute SOB.

@Toaster_Pastry Our field treatment of CHF has de- emphasized lasix. Focuses on preload reduction with high dose NTG and PPV via CPAP. Thoughts ?

Heart failure treatment is like fixing a sinking boat. Diuretics are a cup used to bail out water. You can either get a bigger cup (more diuretics) or fix the leak directly.

@christifulli88 @adamdavidthomas @critconcepts @khaycock2 Do you have a link to the randomized controller trial? The link you posted appears to be a retrospective cohort study?

Recent RCT showing mortality benefit for ACS patients who get admitted to ICU. Question for the twitter intensivists out there. When caring for a post PCI ACS. what blood pressure goals are you using (S/D)? bmj.com/content/365/bm… @adamdavidthomas @critconcepts @khaycock2