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SCAI expert consensus update on best practices in the cardiac catheterization laboratory: This statement was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), and the Heart Rhythm Society (HRS) in April 2021

Naidu, Srihari S; Abbott, J Dawn; Bagai, Jayant; Blankenship, James; Garcia, Santiago; Iqbal, Sohah N; Kaul, Prashant; Khuddus, Matheen A; Kirkwood, Lorrena; Manoukian, Steven V; Patel, Manesh R; Skelding, Kimberly; Slotwiner, David; Swaminathan, Rajesh V; Welt, Frederick G; Kolansky, Daniel M
The current document commissioned by the Society for Cardiovascular Angiography and Interventions (SCAI) and endorsed by the American College of Cardiology, the American Heart Association, and Heart Rhythm Society represents a comprehensive update to the 2012 and 2016 consensus documents on patient-centered best practices in the cardiac catheterization laboratory. Comprising updates to staffing and credentialing, as well as evidence-based updates to the pre-, intra-, and post-procedural logistics, clinical standards and patient flow, the document also includes an expanded section on CCL governance, administration, and approach to quality metrics. This update also acknowledges the collaboration with various specialties, including discussion of the heart team approach to management, and working with electrophysiology colleagues in particular. It is hoped that this document will be utilized by hospitals, health systems, as well as regulatory bodies involved in assuring and maintaining quality, safety, efficiency, and cost-effectiveness of patient throughput in this high volume area.
PMID: 33909349
ISSN: 1522-726x
CID: 5052702

[S.l.] : Core IM, 2021

5 Pearls on Dual Antiplatelet Therapy (DAPT)

Katz, Greg; Harmon, Evan; Villines, Todd; Iqbal, Sohah; Ragosta, Michael; Kassapidis, Vickie; Trivedi, Shreya P
(Website)
CID: 5325832

Differential radiation exposure to interventional cardiologists in the contemporary era [Meeting Abstract]

Koshy, L M; Iqbal, S; Xia, Y; Serrano, C; Feit, F; Smilowitz, N R; Bangalore, S; Thompson, C A; Razzouk, L; Attubato, M; Shah, B
Background: Exposure to low-dose ionizing radiation is associated with malignancies. Lead garment specifications in the cardiac catheterization laboratory are not currently regulated, potentially resulting in unprotected areas.
Method(s): Interventional cardiology attendings and fellows wore 7 dosimeters, one externally on the thyroid shield and six inside the lead apron: bilateral axilla, chest wall, and pelvis. Radiation protection included a lower table-mounted lead drape, upper ceiling-mounted lead shield, and use of 7.5 frames per second during fluoroscopy. All procedures were performed with operators standing to the right of the patient. The primary endpoint was operator radiation exposure to the left versus right axilla. Radiation exposures in millirem (mrem) per participant over the study period are shown as median [interquartile range] and compared between left- and right-sided measures using paired Wilcoxon tests.
Result(s): Nine participants (66% female) wore dosimeters during 231 cases. Transradial coronary angiography was selected in 81.1% of cases and PCI was performed in 32.1%. A sterile radiation drape placed on the patient abdomen was used in 18.6% of cases. Median dose area product and fluoroscopy time for the participants ranged from 29.0-60.5 Gy cm2 and 6.2-13.5 minutes, respectively. Radiation exposure at the left axilla was higher than the right axilla (5 vs. 0.9 mrem, p=0.018) but did not differ between left or right chest wall and left or right pelvis (Figure).
Conclusion(s): This analysis demonstrates insufficient protection in the left axillary area. The use of additional left axillary protection should be evaluated. (Figure Presented)
EMBASE:632520456
ISSN: 1522-726x
CID: 4558522

Patient and Cardiologist Perspectives on Shared Decision Making in the Treatment of Older Adults Hospitalized for Acute Myocardial Infarction

Grant, Eleonore V; Summapund, Jenny; Matlock, Daniel D; Vaughan Dickson, Victoria; Iqbal, Sohah; Patel, Sonal; Katz, Stuart D; Chaudhry, Sarwat I; Dodson, John A
Background. Medical and interventional therapies for older adults with acute myocardial infarction (AMI) reduce mortality and improve outcomes in selected patients, but there are also risks associated with treatments. Shared decision making (SDM) may be useful in the management of such patients, but to date, patients' and cardiologists' perspectives on SDM in the setting of AMI remain poorly understood. Accordingly, we performed a qualitative study eliciting patients' and cardiologists' perceptions of SDM in this scenario. Methods. We conducted 20 in-depth, semistructured interviews with older patients (age ≥70) post-AMI and 20 interviews with cardiologists. The interviews were transcribed and analyzed using ATLAS.ti. Two investigators independently coded transcripts using the constant comparative method, and an integrative, team-based process was used to identify themes. Results. Six major themes emerged: 1) patients felt their only choice was to undergo an invasive procedure; 2) patients placed a high level of trust and gratitude toward physicians; 3) patients wanted to be more informed about the procedures they underwent; 4) for cardiologists, patients' age was not a major contraindication to intervention, while cognitive impairment and functional limitation were; 5) while cardiologists intuitively understood the concept of SDM, interpretations varied; and 6) cardiologists considered SDM to be useful in the setting of non-ST elevated myocardial infarction (NSTEMI) but not ST-elevated myocardial infarction (STEMI). Conclusions. Patients viewed intervention as "the only choice," whereas cardiologists saw a need for balancing risks and benefits in treating older adults post-NSTEMI. This discrepancy implies there is room to improve communication of risks and benefits to older patients. A decision aid informed by the needs of older adults could help to better convey patient-specific risk and increase choice awareness.
PMID: 32428431
ISSN: 1552-681x
CID: 4440332

IMPROVING FELLOW COMFORT WITH STATIN PRESCRIPTION IN PATIENTS WITH CORONARY ARTERY DISEASE AND HUMAN IMMUNODEFICIENCY VIRUS ON ANTI-RETROVIRAL THERAPY [Meeting Abstract]

Jemal, N; Webster, T; Pitts, R A; Iqbal, S
Background Despite increased cardiovascular mortality in patients with HIV, studies have shown suboptimal rates of statin prescription among qualifying patients. Our initial trainee needs assessment survey revealed a lack of comfort and modifiable barriers to prescribing statins to patients with CAD and HIV on anti-retroviral therapy (ART). We sought to create a tool to mitigate these barriers and improve comfort and self-reported practice in prescribing statins to this population. Methods A 1-page tool detailing statin-ART co-administration regimens, common drug interactions and potential side effects was created and introduced to 24 cardiology and 8 infectious disease fellows at NYU School of Medicine. Ten weeks later, a post-intervention survey was conducted to assess comfort, barriers, and self-reported practice when prescribing statins to patients with HIV. Data was de-identified by a 3rd party. Results were excluded for lack of consent for study participation and incomplete and/or duplicate survey responses. Results Of the included 11 cardiology and 6 infectious disease fellows, 53% report using the tool in clinical decision making over 10 weeks. Of these, 78% report the tool increased comfort initiating and/or adjusting statin therapy and 89% report the tool increased overall comfort managing statins in patients with HIV. In our prior needs assessment survey, the majority of fellows cited one or more barriers to prescribing statins to patients with HIV and a minority reported always considering HIV status when deciding to initiate statin therapy. After introduction of the tool, however, over half of fellows report no barriers to prescribing statins to this population and 100% report they will now always consider HIV status when deciding to initiate statin therapy. Ultimately, 65% of fellows plan to use the 1-page tool in the future and 82% recommend that it be provided to future trainees. Conclusion Introduction and use of our 1-page tool improved trainee comfort, reduced known barriers, and improved self-reported practice when prescribing statins to patients with HIV. Integration of such a tool into the curriculum can improve trainee education in caring for a vulnerable population.
Copyright
EMBASE:2005038757
ISSN: 0735-1097
CID: 4358952

Reduced radiation exposure in the cardiac catheterization laboratory with a novel vertical radiation shield

Panetta, Carmelo J; Galbraith, Erin M; Yanavitski, Marat; Koller, Patrick K; Shah, Binita; Iqbal, Sohah; Cigarroa, Joaquin E; Gordon, Gregory; Rao, Sunil V
OBJECTIVES/OBJECTIVE:Investigation of novel vertical radiation shield (VRS) in reducing operator radiation exposure. BACKGROUND:Radiation exposure to the operator remains an occupational health hazard in the cardiac catheterization laboratory (CCL). METHODS:A mannequin simulating an operator was placed near a computational phantom, simulating a patient. Measurement of dose equivalent and Air Kerma located the angle with the highest radiation, followed by a common magnification (8 in.) and comparison of horizontal radiation absorbing pads (HRAP) with or without VRS with two different: CCL, phantoms, and dosimeters. Physician exposure was subsequently measured prospectively with or without VRS during clinical procedures. RESULTS:Dose equivalent and Air Kerma to the mannequin was highest at left anterior oblique (LAO)-caudal angle (p < .005). Eight-inch magnification increased mGray by 86.5% and μSv/min by 12.2% compared to 10-in. (p < .005). Moving 40 cm from the access site lowered μSv/min by 30% (p < .005). With LAO-caudal angle and 8-in. magnification, VRS reduced μSv/min by 59%, (p < .005) in one CCL and μSv by 100% (p = .016) in second CCL in addition to HRAP. Prospective study of 177 procedures with HRAP, found VRS lowered μSv by 41.9% (μSv: 15.2 ± 13.4 vs. 26.2 ± 31.4, p = .001) with no difference in mGray. The difference was significant after multivariate adjustment for specified variables (p < .001). CONCLUSIONS:Operator radiation exposure is significantly reduced utilizing a novel VRS, HRAP, and distance from the X-ray tube, and consideration of lower magnification and avoiding LAO-caudal angles to lower radiation for both operator and patient.
PMID: 31793752
ISSN: 1522-726x
CID: 4249872

A phase I/II multisite study of nivolumab and carboplatin/paclitaxel with radiation therapy (RT) in patients with locally advanced esophageal squamous cell carcinoma (ESCC) [Meeting Abstract]

Wu, J J; Atkinson, E C; Leichman, L P; Patel, H; Iqbal, S; Lee, Du K; Bizekis, C; Goldberg, J D; Thomas, C R; Cohen, D J; Becker, D J; Siolas, D; Beri, N; Oberstein, P E; Ku, G Y
Background: Preoperative chemoRT is a standardof- care as shown in the CROSS trial (N Engl J Med 2012;366:2074-2084), Surgery is sometimes deferred in pts with clinical CR (cCR) based on lack of overall survival benefit (J Clin Oncol 2005;23:2310-2317, J Clin Oncol2007;25:1160-1168). Nivolumab has activity in advanced ESCC (Lancet Oncol 2017;18:631-639), and adding it to chemoRT may improve outcomes.
Method(s): This phase I/II study was designed to assess the safety and tolerability and efficacy of nivolumab added to chemoRT (6 weekly carboplatin AUC 2, paclitaxel 50mg/m2, RT 50.4 Gy in 1.8 Gy fractions 5/7 days) for pts with TanyN1-3 or T3-4N0M0 ESCC. The phase I primary endpoint is 'unacceptable toxicity' at 28 days after the last dose of chemotherapy. The phase II primary endpoints are cCR (endoscopy + PET/CT) and pCR rates for pts undergoing surgery. Nivolumab is given q2W x2, then concurrent chemoRT with nivolumab q2W x3. If no cCR, pt proceeds to esophagectomy, then adjuvant nivolumab q2W x3; if cCR, pt has an option of no surgery but receives nivolumab q2W x3.
Result(s):From 7/20/17 to 12/27/18, 6 pts were enrolled. No unacceptable or grade 5 toxicities were observed. The most common grade 1/2 AEs in >1 pt were anorexia, myelosuppression, elevated AST and nausea. Grade 3/4 AEs in >1 pt were lymphopenia and leukocytopenia. 2 pts required hospitalizations (dyspnea 1, colitis 1). All pts completed therapy; 1 pt had dose delay due to grade 2 esophagitis; 2 pts progressed, 4 achieved cCR. Of 4 pts with cCR, 2 pts chose surgery and both achieved pCR. None of the 4 pts recurred.
Conclusion(s): ChemoRT with nivolumab is tolerable with manageable toxicities in locally advanced ESCC. Enrollment to the phase II portion ended because of slow accrual. Adverse Events. Grade 1 &2 in > 1 pt: 4/6: Anorexia & Anemia 3/6: Leukocytopenia Neutropenia Thrombocytopenia Nausea & Elevated AST 2/6: Hypomagnesemia Hypokalemia Grade 3 & 4 in > 1 pt: 5/6: Lymphopenia, 2/6: Leukocytopenia
EMBASE:630962197
ISSN: 1527-7755
CID: 4326192

DEVELOPMENT OF A DECISION AID FOR OLDER ADULTS WITH NON ST ELEVATION MYOCARDIAL INFARCTION [Meeting Abstract]

Dodson, John A.; Summapund, Jenny; Iqbal, Sohah N.; Spatz, Erica Sarah; Barnett, Mallory; Sibley, Rachel; Chaudhry, Sarwat I.; Dickson, Victoria V.; Matlock, Daniel D.
ISI:000522979103266
ISSN: 0735-1097
CID: 4440262

CARDIOLOGY FELLOW PERCEPTIONS ON SHARED DECISION MAKING IN LEFT MAIN CORONARY ARTERY DISEASE: DEVELOPING A PATIENT DECISION AID [Meeting Abstract]

Barnett, M; Iqbal, S
Background: While coronary artery bypass surgery (CABG) has traditionally been the treatment for left main coronary artery disease (LMCAD), current guidelines support percutaneous coronary intervention (PCI) as an alternative in select patients. Shared decision making (SDM) may guide patients to a revascularization strategy that best matches their preferences and values; however these skills are not routinely taught in training. Developing a patient decision aid (PDA) may facilitate the SDM discussion. Method(s): We created a survey for cardiology fellows in an academic program. Confidence in knowledge of data and comfort in communicating treatment options for LMCAD were assessed. Fellows were asked to rate factors important in a revascularization strategy discussion using a Likert scale. Result(s): Twenty fellows completed the survey. 90% reported treating patients with LMCAD. However, the majority reported feeling less than somewhat confident in their knowledge of data for CABG versus PCI for LMCAD (60%) and less than somewhat comfortable in communicating the data to patients (55%). The factors rated important to be included in a discussion for LMCAD treatment are listed in Table 1. Conclusion(s): Despite significant involvement in treatment for LMCAD patients, our data suggests that fellows do not feel confident in their knowledge or comfortable with communicating treatment options. Fellows identified important factors for a discussion, which may be incorporated into a PDA to improve SDM for LMCAD. [Figure presented]2019 American College of Cardiology Foundation. All rights reserved
EMBASE:2001643408
ISSN: 1558-3597
CID: 3811792

ENHANCING CARDIOLOGY FELLOWS' PROCEDURAL INFORMED CONSENT DISCUSSIONS USING A FORMATIVE OBSERVED STRUCTURED CLINICAL EXAMINATION [Meeting Abstract]

Iqbal, S; Kalet, A; Rosenzweig, B; Zabar, S
Background: To foster patient engagement and trust, cardiovascular procedural informed consent (IC) discussions must go beyond the routine of risks vs benefits and incorporate shared decision making (SDM). Most trainees report learning the IC process through peer observation with little emphasis on skills that enable SDM. Experiential learning with immediate faculty feedback may make it more likely that fellows incorporate these critical advanced skills into their IC practice. Method(s): We developed 3 observed structured clinical examination (OSCE) cases designed to highlight all aspects of the IC discussion for invasive cardiac procedures. We adapted validated standardized patient checklists and created a faculty observation and feedback tool. After the program, fellows completed a survey assessing the likelihood they would incorporate SDM skills into their practice. Result(s): 28 cardiology fellows successfully completed the IC OSCE. Figure 1 demonstrates that while the majority of fellows reported already routinely discussing risks and alternatives a minority reported using patient engagement skills. The majority reported they are very likely to incorporate these assessments into practice. Conclusion(s): Cardiology fellows participating in this formative IC OSCE identified SDM skills they intend to incorporate into their IC discussion practice. The clinical impact of teaching high level learners important patient engagement skills via this approach should be further studied. [Figure presented]2019 American College of Cardiology Foundation. All rights reserved
EMBASE:2001643962
ISSN: 1558-3597
CID: 3811772