Dr. Jeffrey W. Moses

@Nasser_Ghattar 1) first ivus to made sure is not in the coronary system as a stent in the guide or embolized systemically is generally benign in this care you might have seen it on the guide tip or it would not pass 2) looks like no stent ? there is no stent 3) outside of the inside ???

4 A.M. STEMI call. 45-year-old male with acute anterior STEMI activated through the STEMI pathway. Coronary angiography showed complete thrombotic occlusion of the LAD. Initial ballooning restored flow, and a drug-eluting stent was deployed successfully… or so we thought. Seconds later came one of the true nightmares in interventional cardiology: The stent was physically delivered. Deployment was confirmed. But fluoroscopy showed… no stent in the lesion. The LAD still looked unstented. Immediate full fluoroscopic search of the patient’s body was performed. No lost stent was seen anywhere. The table? Negative. The sheath? Negative. The guiding system inside the body? Negative. Unfortunately, stent boost was unavailable at that moment, and IVUS was not accessible. Multiple vigorous flushes of the guiding catheter failed to reveal the missing stent. At that point, the concern escalated dramatically — embolized stent? Lost in the system? Somewhere unseen? Decision was made to retrieve the entire system and physically inspect everything outside the patient. Still nothing. Finally, as a last attempt, the guiding catheter was carefully cut in small external segments. And there it was. The entire undeployed stent was trapped inside the OUTSIDE portion of the guiding catheter — beyond the fluoroscopy field — firmly stuck despite repeated flushing attempts. The relief in the cath lab at that moment was indescribable. A new stent was then successfully deployed with excellent final angiographic result. Lessons from the night: • Never trust assumptions in the cath lab • Lost stents can hide in unexpected places • Systematic troubleshooting saves lives — and saves operators from panic • Sometimes the solution is not high-tech… but persistence and careful thinking Interventional cardiology continues to humble us. #Cardiology #InterventionalCardiology #STEMI #PCI #CathLab #CoronaryIntervention #LAD #CardioTwitter #MedTwitter #STEMIPathway

@Z_XSophie ironic cause he actually subscribes to many nazi doctrines

Remember how they lost their shit when Elon did this? Now it’s suddenly “my heart goes out to you” and everyone’s totally fine 😂 The rules change depending on who’s waving. Classic selective outrage.

@GreggWStone @SVRaoMD important study for safety but also makes practical sense .

Complete revasc (CR) in pts with non-shock STEMI and multivessel ds. reduces MACE. But is the best timing for non-culprit lsn PCI immediate (during primary PCI) or staged? Our new meta-analysis publ in Circ CV Interv suggests immediate CR may increase mortality, same as in shock.

@realarainmd @Hragy @ziadalinyc one must remember context .after the first Orbita there were world wide headlines pronouncing PCI in CCS placebo.It was disingenuous but impactful. These studies demolished that contention and level set the discussion in a realistic framework to discuss its place

Hany, I enjoyed reading @ziadalinyc's editorial just as much as the study. His measured and even-keeled analysis resonated with me, and I think you will enjoy it too (link below). The rational here was the same as that of ORBITA-2 → to isolate the impact of #CTOPCI and to show that it is not a placebo. No one actually discontinues anti-anginals before #CTOPCI - nor should they. 😳 Most CTO operators understand that the trial setting does not match everyday practice. Or at least I hope. jacc.org/doi/10.1016/j.…

I look at ORBITA-CTO concept as a bit of an insult! The degree of uncertainty about the value of CTO PCI single most claimed benefit-relief of Angina-was so high such that the most hard core CTO operators are jubilant that it was proved to be better than Placebo without pills!

@AmmousMD i have to confess this is the silliest ,most childish set of assertions running counter to all scientific evidence i've ever seen have fun

Lower your LDL enough and you won’t die of heart disease. You’ll die of something else sooner.

@SShadman1 @SyedYNaqvi1 look at the areas in the appendix : excellent.Dave you are on to something Remember Illumium 4 ?

My cynical read: IVUS works when you actually USE the information it gives you. A probe in the artery operated by someone who ignores it is just an expensive catheter. The question was never “IVUS vs angiography.” It was always “good operator vs bad operator.” Uncomfortable? 😳

🧵So OPTIMAL just dropped at ACC.26, and I’ll be honest — it’s going to make a lot of interventionalists very UNCOMFORTABLE. 806 patients 😮. Unprotected left main PCI. Randomized to IVUS vs angiography guidance. Result? No difference.🤯

@jbspadoni Wouldn't be so skeptical .As a long term advocate for IVI one must accept this important dataset(s) .If you look at the stent areas in the appendix , they are excellent , as good as any I've seen . We have had similar outcomes in Illumium 4 .The challenge is to focus on the why

No difference in IVUS-guided vs. angio for LM PCI? It is ESCAPE trial all over again. Like pulmonary artery catheters, IVUS is a diagnostic tool. The catheter, per se, doesn’t have a magic power to change the outcome of a procedure. We should move away from doing trials that only compare IVUS vs angio. Trials that successfully advanced the field, such as ULTIMATE and DKcrush VIII(presented at ACC as well) had strict criteria for “real IVUS-guided PCI”. Here, only 65% of the IVUS guided group had a pre IVUS to “guide the PCI”. Prior trials showed that IVUS-guided PCI leads to statistically significantly larger balloons and stents, and more post-dilation. Here we see less POT in the IVUS group. Also, despite most patients receiving less than 2 stents (provisional), the cardiac mortality at 2 years was exceptionally high at 9.5% (Syntax II was 2.8%, DKCRUSH 1.3%, PRECOMBAT 2.7%, all at 5 years). I hope this does not make us lose the recent improvement in imaging uptake. It took us years to convince people that a PA catheter is important in cardiogenic shock because of ESCAPE. I hope the field moves to design better trials with different strategies for imaging-guided PCI, rather than reverting to angio, where you have to guess the calcium arch, a nodule, or even whether the stent is indeed expanded.

@Hragy 1)There was an abundance of preclinical work 2) there was a pilot trial indicating no increase in infarct sixe3) there wasNO increase with the delay : ( if anything slightly lower)The impella stopped the clock just didn't reverse it

Now the million (or much more) dollar question, can the patients who were led to consent getting an Impella for non CS STEMI, who suffered delay in reperfusion, or worse : a major bleeding -sue for harm? And if suing after RCT,who should they sue? The doctors or the industry?

@BenBikmanPhD may have something to do with half a century of research in vascular biology delineating disease origins just a guess

I wonder how much of medicine is driven by drugs. For example, why did they decide that LDL cholesterol is the main marker for heart disease, rather than triglycerides or insulin? After all, triglycerides and insulin are better markers of heart disease risk. The reason? Probably because LDL cholesterol is "targetable"--there's a drug (statins) that will lower it. So it matters less that LDL is a good marker, and more that it's a number we can change with a drug. And of course, make money in the process. If there were a drug that lowered triglycerides really well, I suspect mainstream medicine would focus more on triglycerides. (Incidentally, the best way to lower triglycerides and insulin is to control consumption of refined carbohydrates.)

@DrBPHealth This conversation is pretty funny a large part of the inflammation can be resolved by the. starin the lipid penetration into the arterial wall sets off the cascade there are many other sources. of inflammation as well but you have the basic vascular biology backwards

Your doctor says your cholesterol is too high. But did they check your inflammatory markers? My guess is "no" they didn't. But they really should if they want to address the true cause. Simply put, high cholesterol isn't the problem—it's your body's adaptive response to chronic inflammation. The cholesterol is there to help repair the damaged inner linings of you blood vessels. Fix the inflammation first. The cholesterol levels naturally normalize in 98%+ of cases. If you want to learn more, I share more details in this article: drbrandonpettke.substack.com/p/high-cholest…

@MdOsler @LDLSkeptic thanks for the lesson on reading scientific papers

@JWMoses @LDLSkeptic Please do read those stories yourself. The entire studies not just an abstract. Also who conducts them.

Elegantly stated Richard. The hypothesis that high LDL in a healthy person is atherogenic is unsupported, and that lowering LDL is beneficial has been propped up by the financial gain of statins and successor drugs. Ultimately, insulin resistance (chronically high glucose and insulin) is a core feature of modern day diseases.

@Mr_Husky1 20-25% ( before tax) is more than enough the waiter is a fool

My husby and I went out to dinner last night, and the bill came out to $200. I left a $50 tip on the table, thinking that was pretty reasonable. But the waiter looked at it and flat-out refused to take it. ​He told us that if we weren’t willing to leave at least $85, we shouldn’t be eating out in the first place. ​I was honestly caught off guard. I felt embarrassed sitting there, like we’d done something wrong. We weren’t trying to be cheap or disrespectful — I genuinely thought $50 was a fair tip for that bill. Now I keep replaying the whole thing in my head, wondering if I misjudged it and questioning whether $50 really wasn’t enough.😱 By Angela mcnutt

@ElieJarrougeMD yeah and with smallpox too !!!

Cardiologists have set an LDL target the human body can’t reach on its own without a pill. So either nature got it wrong OR the guidelines did. I know where I’m putting my money.

@CaptMarkKelly you are clearly an idiot

Trump ripped up the Iran nuclear deal and created this mess. Now, he's putting servicemembers in harm's way with no clear plan and no Congressional approval. The American people deserve answers — and Congress needs to do its job.

@NYCMayor well Zo your iranian citizens are dancing in the street sorry you lost the plot

Today’s military strikes on Iran — carried out by the United States and Israel — mark a catastrophic escalation in an illegal war of aggression. Bombing cities. Killing civilians. Opening a new theater of war.  Americans do not want this. They do not want another war in pursuit of regime change. They want relief from the affordability crisis. They want peace. I am focused on making sure that every New Yorker is safe. I have been in contact with our Police Commissioner and emergency management officials. We are taking proactive steps, including increasing coordination across agencies and enhancing patrols of sensitive locations out of an abundance of caution. Additionally, I want to speak directly to Iranian New Yorkers: you are part of the fabric of this city — you are our neighbors, small business owners, students, artists, workers, and community leaders. You will be safe here.

@thehealthb0t liar was a over 80% reductions in infections and hospitalization the number he states are single digit differences with nothing close to statistical significance covid deaths reduced what a reprehensible liar

RFK Jr: "If you look at the studies of the Pfizer vaccine…the people who got the vaccine had a 23% higher death rate from all causes." Bill Maher: "But that could be the disease itself." RFK Jr: "Then the vaccine doesn’t work, does it?"

@redpillb0t placebo controlled evidence with all components of mmr zoster pneumococcal HPV rita flu many subsequent trials are with historic controls as you can't deprive a child of a known effective treatment just saying

RFK JR: "They're not doing vaccinated versus unvaccinated studies because they're frightened of the results." "If you did a vaccinated versus unvaccinated study... the entire vaccine program would come into question."

@redpillb0t of course they did all initial covid vaccine trials were with placebo just an inveterate liar

@Bitcoin_Teddy pediatric patients on medicare ??? hmmmm

RFK JR: “Doctors are being paid to vaccine … We've recently uncovered that more than 36,000 doctors had their Medicare reimbursements altered based upon childhood vaccination rates. That's not medicine. That's coercion.”