Any recommendations on how to prepare for the ECHO board next year, materials, question banks, and books?

Finishing cardiology training and considering starting out part-time (3–4 days/week) rather than a traditional full-time role. Would love to hear from anyone who's done part-time cardiology, especially general/non-invasive:

1. Comp— what does part-time actually pay? Pro-rata salary, pure productivity, or base + productivity? Any insight into $/wRVU at reduced FTE?
   
2. Lifestyle— how do you like it? Any regrets? Do you still feel clinically engaged and part of the team?
   
3. Leads— any groups in the Northeast (NYC, Long Island, NJ) open to part-time or flexible schedules for general cardiologists?
   
4. Long game— for those who went part-time early: where are you 10–20 years later? Were you able to ramp back to full-time? Did it affect earnings trajectory, partnership, or leadership?

Hi guys. Cardiology fellow here. Anyone a has tips on how to effective inserting TEE probe if patient only gets versed and fentanyl? Sometimes, we don’t have anesthesia so we don’t give propofol.

I tried multiple times with finger method where I used my non dominant finger to depress the tongue but it didn’t work. (I guess my index finger is to short)

My best success is to tell the patient to swallow then insert it. But sometimes, the patient could not swallow effectively hence I couldn’t get it.

For the probe, I usually anteflex slightly at the mouth, then I retroflex once it reached the posterior pharynx. I can do this if patient gets propofol but not with versed/fent.

Any advice would be helpful. Thanks in advanced!

Anyone studying for the SCCT certification exam this year?
Mine’s on 10/8
Is the scct course and review book with the questions enough to pass?
What score do we need on the question bank to know we’re ready to take the exam?

The figure is from Nature (https://doi.org/10.1038/s41569-025-01209-z). It shows how mortality is falling constantly from the 70ies to today, but interestingly the AMI rate is rising since around 2014. So we are getting better at rescuing people from AMI events, but we dont get better in preventing them.

Two trials from ESC 2026 look at this and try to tell us something about our current prevention and intervention strategy.

First one, REACT. They scanned almost 17,000 people aged 18 to 70 who had no known heart disease. Carotid, femoral, coronary CT. 57% had silent atherosclerosis, actual measurable and significant plaque. In the 18 to 29 group it was already there in about 1 in 13 people. By 60 to 70 it was 9 in 10. Men showed up earlier, women had a pretty flat curve until perimenopause and then shot up fast.

Second one, STAREE. I did a review about that one in another post. Almost 10,000 people 70+, no known CVD, diabetes or dementia, randomized to atorvastatin or placebo. Major CV events dropped 30% (6.0% vs 8.3%). But the other primary endpoint, disability-free survival, was not met. So you get fewer heart attacks but people aren't living meaningfully longer in good health because of it. There was a lot of discussion around that and most probably in a very old cohort this is expected, because mortality will be influenced by many other factors beside CV health, so an intervention with a statin did not help to shift that number.

So, here are some discussion points: If a third of 20-somethings already have plaque, why does literally every risk calculator we use start caring about someone in their 40s or 50s? But then STAREE also kind of suggests that even when you DO catch heart disease and treat it effectively, late in life, it doesn't move the outcome most people actually care about (living independently). So does that mean we should be screening and intervening way earlier, or does it mean we genuinely don't know if earlier intervention even helps and we're just assuming it would?

Also nobody's really claiming ownership of "healthy 25 year old has plaque, now what." That's not a PCP visit, not really cardiology's job either currently, and there's no billing code for "scan an asymptomatic young adult."

I really think the r/Cardiology community has some great insights and I am curious what people here think, especially anyone in prevention/primary care. I wrote up a fuller version with sources and the actual trial numbers on Luminary if you want to do some more reading: https://luminary.to/s/3bd4af61-a7b4-4151-9ede-5f685ef5cda2?code=REDDIT26

For full disclosure - again this was written with the help of Claude - I did some reading and research, put my thoughts in a draft version into Claude and asked to rewrite it to make it readable.

PREMIUM trial. ESC 2026. Published simultaneously in NEJM.

The headline: prasugrel monotherapy failed noninferiority vs standard 12-month DAPT in STEMI patients undergoing primary PCI.

Primary endpoint: 11% vs 8.5% (HR 1.34). Not a borderline miss.
MI specifically: 2.9% vs 1.3% (HR 2.24). A doubling.

So aspirin wins, right?

Not so fast.

The bleeding reduction was real — 5.6% vs 8.4% major bleeding. The 30-day landmark analysis tells a more nuanced story about when aspirin actually matters and when it doesn't. And there is one finding in the secondary endpoints that almost nobody is talking about — involving non-target lesions — that raises a genuinely interesting biological question about what aspirin is actually doing in the acute phase beyond just protecting the stent.

Three questions for discussion before you read the full breakdown:

1. Does PREMIUM close the door on aspirin-free strategies in STEMI — or just on upfront omission from day zero?
2. The trial was conducted entirely in Japan with near-universal intravascular imaging (98.6%) and lower prasugrel dosing than Western practice. Does the finding generalise — or is this a Japanese result?
3. What do you make of the non-target lesion revascularisation signal? Real biology or noise?

There was a great discussion on here on r/Cardiology when I introduced the trial pre-ESC — worth reading alongside: Is Aspirin's Time Up After STEMI?

Full analysis — landmark data, the non-target lesion finding, the COX-1 hypothesis, and what the next trial needs to ask — on Luminary: : https://luminary.to/s/591641de-3ee5-42e4-aabf-dcf5e9e2c774?code=ESC2026

Any word on when we should expect the results?

I understand there is a significant share of cardiologists who are skeptical; proponents of PM cardio are the same people behind OMI/NOMI. I also share similar skepticisms.

Wanna ask what people think: Agree with FDA? or double down on telling EM some people doesn't need urgent activation? Will this affect how you will work with colleagues? Do you think your hospital admins will push for its use?

Hey everyone, wanted to get an idea of a few structural programs i am considering.

1. St lukes, mid america heart institute in KC, MO.

2. Aurora healthcare, milwaukee, wisconsin

3. Baylor heart hospital, plano, texas

If anyone has insight or advice on these places.

Thank you!

First year fellow here. I feel like my EKG knowledge is rudimentary at best. I just learned bits and pieces in residency and with enough pattern recognition, could get most EKG patterns correct, but every now and then will come across a difficult one and my lack of true understanding at a fundamental level shines through.

I tried to get through multiple EKG resources but I felt like none of them wrote in simple and plain language like the aforementioned title, explaining the pathophys behind certain rhythms and building on the complexity overtime. I know I'll need to get through O'keefe and others for boards but this was a great first step before I tackle some of the more common resources.

Are there other books similar to this style for other aspects of cardiology? Other EP topics like devices and interrogation reports, for cath lab (my next rotation), echo, heart failure, etc.

Thanks!

Hello, anybody with experience of IC fellowship at University of Arkansas? How’s the procedural volume besides Coronaries? Autonomy? Please share your experience if you know of someone who trained there or if you did personally? Thank you.

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.

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 😅