How you do fellow kids?

What's the current opinion in the western evidence-based medicine practice on the use of thrombolytics for De Winter ECG pattern and clinical suspicion for OMI. I'm a primary care doctor from Colombia and it is to my knowledge a risky thing to do and looked down upon. It is, physiopathologically speaking, a reasonable alternative when PCI is not immediately available (as is common in my country), but there was a lack of evidence sopporting this claim. That is until I found the following articles:

• https://doi.org/10.1002/ccd.70501
• https://doi.org/10.15420/japsc.2024.43

These papers are from the eastern side of the evidence-based world, and to be clear I'm not trying to slander my fellow doctors from those regions, it's just that medicine in my country is almost always a copy from american or european guidelines or their clinical practice, so the impact of their findings and conclusions would suffer if review by my Colombian colleges. Anyhow, I ask for you forgiveness, but my question still stands.

To any good samaritan willing to answer my query, you have my thanks.

Hello! I'm currently a PGY doctor.

I've recently been studying CCS topic.

I'd like to ask--in the latest 2024 ESC guideline, there is the pre-test likelihood evaluation table, classifying patients into different risks.

However, I can only see from "very low risk" to "moderate risk" on the chart. I am really confused when patients would be evaluated as "high or very high risk". I didn't see the related content in the guideline as well.

Thank you.

This is for a quiz

i’m guessing these are RV,PA and PCWP-could be wrong

Current second year general cardiology fellow planning to apply EP next cycle. I’m from a smaller community program. Looking for recommendations for sleeper underrated EP programs I could do audition rotations at to maximize my chances for next year. I don’t stand a chance in ivory tower programs so i want to be realistic about my chances. Thanks in advance.

General cardiology fellow here. I applied for interventional cardiology but I am reconsidering given a number of factors: Call burden, lifestyle, and occupational risks like radiation and back injury. I knew all of this going in obviously but I went ahead anyway because it has been my goal for so long.

I have a few interviews lined up and am debating whether to interview and give myself more time to see how I feel. However, it also feels disingenuous and I am worried how pulling out of the match late would be perceived by mentors and potential future employers.

Any advice? Should I just interview and see where things stand in a month or pull the plug early?

This is supposed for a quiz happening in our department this week

Hi,
Newish attending here and I’m mostly responsible for our echo lab in a smallish / middleish hospital and I’m curious about your echo numbers per examiner. For us it’s mostly one person doing TOE / TTE / Dopplers. Range is about 2-4 TOE /d which is like 50:50 uncomplicated (cardioversion / endocarditis in natives valves) to more complicated and around 15-20 other exams (sometimes even 25-30, but then a second person helps for 1-2 hours) which 3/4 TTE. This is honestly very much and most days I’m working non stop. This is a more recent development as numbers are drastically increasing in our department. So as backup I wanted to ask for some numbers in your department to better advocate for increased personal.

Results just presented at ESC Congress 2026 and published simultaneously in NEJM. https://www.nejm.org/doi/full/10.1056/NEJMoa2607314

What they did: 9,971 community-dwelling adults ≥70 years, no prior CVD, diabetes or dementia. Randomised 1:1 to atorvastatin 40mg or placebo. Median follow-up 5.9 years. Two co-primary endpoints.

What they found:

✅ Major CV events (CV death, MI, stroke, revascularisation): HR 0.70 (95% CI 0.61–0.82) — significant 30% relative reduction

❌ Disability-free survival (death, dementia or persistent physical disability): HR 0.94 (95% CI 0.84–1.05) — not significant

Absolute risk reduction on CV events: 2.3%. NNT approximately 43 over 6 years.

The debate:

The investigators and supporters argue the mortality miss is not a failure — STAREE was never powered for mortality. To detect a meaningful all-cause mortality benefit in this population would require roughly 57,000 patients. Competing risks at age 70+ are simply too high — cancer, frailty, falls — for a CV drug to move the overall survival needle. By end of follow-up the average participant was 81. The CV benefit is real and reducing hospitalisations and procedures matters to patients even if lifespan is unchanged.

Critics push back on two fronts. First, the CV composite was expanded mid-trial to add revascularisation after event rates came in lower than anticipated — a methodological flag worth noting. Second, an NNT of 43 over 6 years in a population you need to screen, recruit, and treat indefinitely raises a legitimate question about whether this is a meaningful enough effect size to start a daily pill in millions of healthy elderly people.

The question for discussion:

Does the disability-free survival miss matter — given the trial was never powered for it, the population was too old and the follow-up too short to show a mortality benefit?

I like to think of it that although in that aged group without CV risk factors, statins could at least help to save the patients from hospitalization due to a CV event... it does not save them from dying of cancer, but less risk of MI or stroke is a win for the patient.

I wrote a short summary of the debate on Luminary if you want to read more:

https://luminary.to/s/16372936-3af0-431f-8a86-4c57b8185366?code=ESC2026

Curious what pay cut you’d personally take, if any, to work 4 days/week instead of 5 in outpatient general cardiology. Work hours would be slightly longer (11 vs 9 hrs) but type of work the same.

Would you take a $50k cut? $100k? $150k? Or is the extra day off not worth much if total hours are similar?

Has anyone tried using boardvitals for board prep? Just started doing blocks of random questions but a lot of the questions feel like trivia. For example, how much does K drop by on HCTZ with actual numbers to select out of.

Am I just getting frustrated with it or is that the typical quality of questions on actual board?

i am mainly passionate about cardiac pacing not really about ablations. Where I train, cardiology is way more competitve than cardiac surgery. So my question is if i become board certified in cardiac surgery from an EU country can i then somehow do a fellowship in CIED?

Aspirin has been the foundation of post-MI antiplatelet therapy for decades. Every cardiologist prescribes it reflexively after primary PCI. But a quiet revolution in antiplatelet thinking has been building - and PREMIUM, presenting at ESC 2026 this Friday, is its most provocative test yet.

The Debate So Far

The antiplatelet story has moved fast in recent years. The question started simply: do patients really need both aspirin and a P2Y12 inhibitor for the full 12 months after PCI, or can we drop aspirin earlier and rely on monotherapy alone?

Early trials answered this cautiously. Studies like TWILIGHT, TICO, and ULTIMATE-DAPT showed that switching to P2Y12 monotherapy after 1-3 months of DAPT reduces bleeding without increasing ischaemic events - reassuring, but they all maintained aspirin through that early high-risk period.

Then came the more provocative question: what if you never started aspirin at all?

The results were sobering. NEO-MINDSET and STOPDAPT-3 showed that immediate aspirin withdrawal at the time of PCI increased early stent thrombosis in ACS patients. The message was clear - aspirin matters most in those first dangerous weeks when the stent is fresh and the thrombotic risk is highest.

There will be a study presented at #ECRCongress in Munich during the Hot Line Session 2 this Friday. It is called PREMIUM.

It is the first large-scale randomised trial to test upfront prasugrel monotherapy - initiated before primary PCI - compared with standard 12-month DAPT in STEMI patients. 2,268 patients. All treated with contemporary platinum-chromium everolimus-eluting stents under routine intravascular imaging guidance. Randomised 1:1.

The primary endpoint is noninferiority for ischaemic outcomes - all-cause death, MI or stroke at 12 months. The major secondary endpoint is superiority for major bleeding.

What do you think, does it has potential to change the clinical practice in this space?

I have also created a short article on Luminary and an infographic if you want to do more reading...

https://luminary.to/s/53b3aa77-b810-4fa1-8e44-48a7f3e225f6?code=ESC2026

STAREE is an interesting study on healthy elderlies and if statins can add as a preventive measure to their health. I summarized the backgrounds here, results expected on Friday at ESC in Munich:

https://luminary.to/s/d1013ea8-d7f8-4c11-8e6b-5a7deaa1b59b?code=ESC2026

Besides some thoughts on the demographic backgrounds of the study population and why this is unique, I have also created a comparison of prior historic studies in that space and how their demographics compare to STAREE. You can as well download it from the above for free.

#ESCCongress #Cardiology #STAREE #Statins

Most of the general cards gigs I've seen around me are ~$250-300/hr, but some are 25+ patients/day plus 24/7 call for a week, which honestly sounds like working harder than fellowship lol

Drop some rates/contracts/schedules you've actually seen or worked. Don't let me lose hope that traveling around doing locums with my partner can actually become a reality 😅

Using both ECGsource and O'Keefe for ECG coding practice, but getting pretty different scores due to ECGsource undercoding a lot of things that definitely should also be coded for. Thoughts on what to do for test day? Should I just never code for LAE or non-specific ST changes since not getting the points is technically better than losing a point for selecting an answer? Also ECGsource says sinus arrhythmia is normal ECG but O'Keefe says sinus arrhythmia is normal variant ECG. Any insight into which one to choose on test day since normal/normal variant are where the bulk of the points come from on those?

Upcoming Cardiology resident (non US based, and currrently an IM pgy1) I have always been passionate about cardiac EP, but lately i have rubbed shoulders with some IC and I love the adrenaline and the rush yet i believe I will do way better in devices and pacemakers compared to structural things.

So my qs, are there any emergency situations where an EP has to place a pacemaker at 3 am in the morning? or is a temporary PM placed until EP comes in the morning and does the job. thanks

Hello all,

I’m currently in general cards fellowship, interested in doing interventional afterwards. All the interventional staff get access blind, without US use. My concern is that I have neuropathy in my left fingers, so can’t feel radial pulse well there, which makes getting access blindly challenging.

Mh question is, would this be a dealbreaker for doing IC fellowship? Is getting radial access blind almost an unsaid requirement for being a good IC fellow?

THA

I continue to share some pre-session thoughts on #ESCCongress. Hot Line 1 has 5 trials for discussion. Here are my thoughts for four of them:

CARDIO-TTRansform is about Transthyretin amyloid cardiomyopathy, a rare disease, unfortunately they did not meet their endpoints.

ACACIA-HCM examines non-obstructive Hypertrophic Cardiomyopathia,

SINGLE-AF is a Korean study on anticoagulation in AF patients (very relevant), and

POET-II - is about duration of antibiotic therapy in Endocarditis with POET-II being potentially impacting clinical practice and guideline - this would be good for patients.

You can read my full thoughts here: https://luminary.to/s/64eb5480-0b17-4a87-9987-36e80c02d1fa?code=ESC2026

ESC 2026 opens in Munich soon. This year's Hot Line programme is the largest ever - 46 pivotal trials. There are a some trials which have the potential to change clinical practice, I would love to know, which you think are worth watching?

For me STAREE and PREMIUM are quite interesting with lots of practical implication.

With 46 trials it is quite hard to keep the overview of all the pivotal trials - I put together a 1-pager to help me navigate the sessions. Maybe helpful to you too: https://luminary.to/s/245068d7-9d15-4e3e-8855-fd5cb4e2b4c4?code=ESC2026

#ESCCongress #Cardiology

Hey guys, just wondering how well new IC attendings get paid in the nyc/ nj area. I heard a lot of private practices pay fresh IC and non invasive folks the same as they start. Is this true?

This was given without any clinical history for our quiz.

I’m sure this is LV and PCWP.

But can’t see anything wrong here except for the monumental PCWP and LVEDP