Mar 6, 2020 This Week in Cardiology Podcast

John M. Mandrola, MD


March 06, 2020

Please note that the text below is not a full transcript and has not been copyedited. For more insight and commentary, subscribe to the This Week in Cardiology podcast.

Podcast Highlights

For the week ending Feb 28, 2020 John Mandrola, MD comments on the following cardiology news [and features] stories.


There are weeks when other medical stories dwarf cardiology news. Coronavirus invites us to think. And this podcast loves thinking. There are important themes to discuss. Themes that apply to everyday medical decisions. Even scarier than the chance of being the unlucky 10% to 20% of those infected who will need ICU care (and God forbid ECMO), are the effects the virus will have on society. The real test, said the prime minister of Singapore in an amazingly calm and clear 8-minute speech to his country, is to our social cohesion and psychological resilience. Fear, he said, can do more harm than the virus itself.

An infectious diseases doctor at my hospital is on an e-group of ID clinicians. One of the ID docs at a hospital in Washington State has been contributing. The summary I got was that it is a mess. Many people are sick, and there is no way to isolate all the caregivers or trace contacts.

Containment is going to be hard on a people used to the comforts of life. Fear tramples on common sense. My cath lab has to lock up masks and surgical garb. Why? Healthcare workers are hoarding them. That doesn’t bode well. Fear can do more harm than the virus.

For instance, what shall we do about medical meetings? My friend Dr. Bogdan Enache Tweeted, half in jest, half not, “If I were a virus I would ask myself how to get as many clinicians as possible from around the world in the same place for several days, mix them all together and then let them go back to their hospitals.” Ajay Kirtane Tweeted that Columbia University (not a small institution) has banned international and work-related domestic travel to meetings or conferences.

The combination of social media, preprint servers, and Twitter provide an amazing way to follow COVID-19. No, not all the info is accurate; you have to read with the assumption that info has not been vetted. But it is fast. And you can read threads from leading epidemiologists, virologists, and public health officials.

Journals have a role here, we need vetting of big interventions, but in a breaking story, peer-reviewed journals don’t stand a chance of keeping up.


Left Main PCI

Deb Cohen and Ed Brown reporting in the BMJ tell us that a spokesperson for the New England Journal of Medicine said a review process is under way regarding the controversial EXCEL trial and published findings.

Meanwhile, the European Heart Journal has published a meta-analysis of left main PCI vs CABG trials. This included five trials of varying time. It was a study level rather than a patient level meta-analysis. The bottom line was that overall death was similar although heterogeneity was moderate.

Problems with this meta-analysis are obvious. Among them: Excel was the largest contributor, but it is under review by NEJM for (potential) irregularities. It seems silly to publish a meta-analysis until that issue is sorted out.


Prescription Cascades

JAMA Internal Medicine again has published an important and useful observational study, this one from a group at the University of Toronto.

Rachel Savage and her team used a database of about 41,000 older adults from the province who were prescribed a calcium channel blocker vs those prescribed and ACE or ARB, or an unrelated medication. And even in Canada, a country known for its good sense and active participation of pharmacists, people who were newly dispensed a calcium channel blocker had a higher cumulative incidence at 90 days of being dispensed a loop diuretic than individuals in both control groups.

The longer the time period they looked at after calcium channel blocker prescription, the greater the risk of getting a diuretic. This study makes the podcast because This Week in Cardiology aims to help reduce medical harm by highlighting the danger of seemingly small decisions that start cascades.


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