75. Case Report: Coronary Vasospasm Presenting as STEMI UCSF
Worldwide cardiovascular disease affects the lives of hundreds of millions dedicated cardio nerds everywhere are working hard to fight this global epidemic. These are their stories. Welcome back Carter exists other than Dan. Thanks for joining us as toured fellowship programs across the country. As part of a Cardi nerds can series produced in collaboration with the American College of Party Fellow and Training Section. Each episode will feature a cardiology fellowship program fellows from that program will present teach about a fascinating case and share. What makes their hearts flutter about their program. Each case discussion followed by an e CPR segment from a content expert and a message from the program director. Before we dive in, just remember who you are an independent educational platform this podcast is not meant to be used. For medical advice views expressed do not necessarily reflect the opinions or policies of employers. 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We have with US doctors, Emily Cedarbaum Ben Kellerman and Matt Furstenfeld and I'm GonNa ask you to introduce yourselves to our guests here but I just have to say that in welcome you to the show and welcome you to the Cardi nerds family very happened all if you guys. Here, but I've been waiting to have Ben Kellerman especially on this show as someone who has started residency with and just learn such a great deal of medicine from Ben's always been such an incredible role model in his approach to patients to colleagues and clinical medicine clinical reasoning. So excited to be here to learn from all a few today, very special episode for us. So guys tell the audience where you are. Hi I'm Emily Cedarbaum. I'm so excited to join you from. UCSF I'm a second year fellow I'm interested in heart failure or pulmonary hypertension epidemiology and the social determinants of health I am originally from the Pacific northwest went to University of Washington for Undergrad Medical School in an MP age and I moved down to San Francisco for residency at UCSF and decided to stay on for fellowship. I am Ben Coleman I'm super excited to. Be here on the podcast I'm a fourth year cardiology foul either challenge kind of loving everything during my training. Some presume the somewhat less common trained pathway with the dedicated critical care training this year and follow. I-I've interventional cardiology training 'cause I loved everything in cardiology really would be going the most like by time in the Cath. Lab in in the Su- particularly taken care of Cardi Jiang shocking. You Corners Syndrome cardiac disease. Hi, I'm Matt Dr Seinfeld and I'm glad to be here. I'm a third year cardiology fellow interested in global cardiology general noninvasive cardiology, HIV implementation science disparities. This year I'm working on my masters in clinical research in doing research. With Dr Priscilla Shoe a world leader in HIV cardiology I'm from SAN JOSE. East Coast at Yale. Penn. than nyu before returning home for cardiology fellowship at UCSF. My wife is a pick you fellow at Stanford, and we have a two and a half year old toddler amazing Matt Ben Emily Welcome to the show and I'm always gets the hit these off. So he always gets to shut up to the people that we love from before we started the show and so I'm just GonNa the opportunity to save that Dan Kelman one of my best is definitely saw his passion for critical care. See you like definitely rubbed off a mate definitely had a big part of why. I'm in cardiology and why I love critical care and intervention as well. So then you haven't aged since the day I last saw you which that was a great day, which we cannot get you on the air not safe for work but guys. So excited to be in San Francisco actually have been there before multiple times because I did have family there and I loved it and I honestly just did all of what the regular tourists do. So could you guys take us to someplace where niche and we're the cool kids hang out so we can talk about some serious cardiology, the fisherman's warf. The only. Orchids now. To Alcatraz. Shipping. Never been out. To Alcatraz on Halloween the it was very scary. Kind of fun. Those are all amazing places. When I'm not in the hospital I try to be outside I have a ninety pound dog who loves to be outside hiking, backpacking, going to the beach exploring all the things so that they area has to offer my favorite places in the city are the huge public parks that were so lucky to have. There's miles of trails places, Golden Gate, Park, the presidio lambs end as a particularly special park for me because I just got married there in June in pandemic wedding and I'm also looking forward to trip Yosemite next month, which is close by. Coming from the Chili Midwest regionally on the East Coast and Baltimore, which gets cold I. Really Love the natural beauty in San Francisco and was mentioned lands end is a favorite spot in the city with my favorite spot in the bay area's just across the Golden Gate Bridge in Mount. Tam like a twenty minute drive across a bridge in here in this beautiful hilly mountains. Overlook the ocean. You can hike and run and bike some probably my favorite spot to go hang out and watch the waves in the ocean and emily and Ben. We really love hiking camping to in July we camped in the redwoods near Peschiera went to tide pools we're headed to Tahoe next week actually but I have to agree with emily that land's end is pretty special. All my gosh. You guys are really just warming my heart for college I went to UC Davis in literally every weekend that we had off we would try to find time to go to San Francisco and just hang out and enjoy the nineteen the day seeing the waterfront the museums images are so much goodness culture natural beauty that happens in San. Francisco. So it's just so amazing too heavy guys take us there again to relive those wonderful days we are here in Atlanta and by the way, emily congratulations on being married. That's super exciting, and so here we are we living those memories. Let's do what we love doing when we're hanging out with friends. Let's get to some cardiology would he goes have for us? So we have a great case at UCSF, we're lucky to have a three hospital system. It gives us a really well rounded training experience. Each of the three hospitals has specific strengths and unique patient populations. So I'd love to tell you about a really interesting. He is that I saw console service at our county hospital where we spent two months of each clinical year, we were called down to see a fifty seven year old man with a history of alcohol use disorder cirrhosis, atrial fibrillation Alpha Leukemia with iron overload, an active cigarette use who presented to the emergency department. After experiencing humus at home, he was amicably stable at first he was actually admitted to the floor service. Oh my God come back in general internal medicine with giving me a presentation on bedside rounds in the intermediate care unit. This is bringing a lot of bells. This reminds me of the case I wrote about in my application for residency. It's wild. You haven't heard a lot of cardiology stuff yet. The other great thing about this case was actually all three of us were involved in the case at various times, but let's dig in more. So can you tell us more about his iron overload? Of course, his iron overload was thought to be due to alcohol and alcohol use. He was previously managed with lobotomy but treatment was limited by his anemia unfortunately than he was lost a follow up but have very recently reestablished care and was starting to work with the hematology oncology team was taking any medications. Yes. He was taking motto parallel told Point Five, be it aspirin eighty-one daily Ibuprofen as needed and a handful of vitamin supplements. Everybody definitely take vitamins and supplements. His heart was in the one hundred and ten to one hundred and twentieth within e C. G showing atrial fibrillation blood pressure was ninety S over-sixties. He was saturating one hundred percent on room air and he was in no acute distress with exam. His lab showed Hemoglobin at eight point one that was down from about ten point two, two weeks prior ferry ten was over four thousand yet a normal reno panel electrolytes his Einar was one point three, his lactate was four point two t belly was two point two and his ast and lt or one, sixteen and sixty, five respectively. While guys, this sounds like a really impressive case and were you guys consulted for atrial fibrillation an or the instability? Why exactly where you consulted? That was the question I was Gonna ask say there's worrying science for jibe waiting but not necessarily cardiology. I'm not sure why we need to be involved. I was not yet involved emily. Why don't you tell us how how involved in this case? That's a great question. So at this point, we had not quite been involved yet, but he had been started on treatment for an upper. Gi. Bleed with an IV PPI and Octavia tied. He was giving Mahto for atrial fibrillation with our VR and. He then actually had a melanoma stool associated with worsening are VR hypertension and further hemoglobin dropped from eight point one to six point six. So he was transferred to the ICU for a bedside scope, and at that time, the team saw a gastric barracks that was spurting blood. The team was unfortunately unable to intervene on the Eric. So he was planned for a trip down to the Interventional Radiology suite however, when he was getting prepped up for his hypertension worsened and he was started on multiple pressures. Wow. This is a serious situation that's spiraling out of control and I've definitely seen this especially with our PSORIATIC patients. But before we even go further I think it's like a good opportunity to think about HR fibrillation and our VR and who your patient is. There's a big push to get rate control in your patient or rhythm control. But depending on how you're gonNA handle your patient with each fibrillation with our vr you may go one of two ways array control strategy or rhythm control strategy, and this is a great case that I think. Highlights how much we think about our patient when we approach the strategy, obviously, there are amicably compromised that they need to be carver did you gotTa cardioversion but when you're thinking about your patient and particularly with Ray Control, you gotta think about them handling slow rates versus handling higher rates, and in this particular patient, we have somebody who has roses and I'm not sure if this roses from alcohol disorder or potentially related to the iron overload. But if so or not even related, he potentially has iron in the heart as well and that would. Basically, set him up to be somebody that may potentially not tolerate too much ray control. So if the patient is unstable because of the GIBE lead and it's not something that I consider to be related to high heart rates related to fibrillation I may be more gentle on the atrial fibrillation at ray control side and focused more of my efforts on the GI. Resuscitation, which is how we're seeing this patient. Go here going now the almost thinking as you know, iron overload as a potential infiltrative carve out the until I know otherwise obviously if. I had more access to data and knew that the heart is functioning perfectly and there's no evidence of infiltrator cardiomyopathy than I potentially would be more aggressive with rate control. If I thought it would help with his human dynamics but these are just things that fly around my mind when I see a patient in the emergency room or kind of the bat with this kind of medical history. Yeah. His rates weren't that high they were only in the one tends to win twenty, and obviously the highest priority is to try the reversible underlying causes VR. Absolutely I feel like once a week at least on console psychic. The consultant team that impatience with a Feb with chronic. RV are really is just their version of sinus tactic Cardia in you treat whatever is underlying that type of Libya Hemorrhage, whatever it might be, and it will generally treat the rates as well. Yet these are really important points because when you have a V are VR is it purely the? That's driving the heart rate or is it in response to the underlying Hema dynamic trigger Ben just like you're saying this is probably in response to the underlying trigger right? We think about the amount of blood loss that will cause vital signs arrangements. It's hard to hang our hats on the heart rate here but heart rate is going to be the first thing that changes it will go up. But by the time you have a low blood pressure, you've already lost fifteen hundred cs two. Liters of blood. So by the time that a patient who's bleeding has hypertension, they've lost a ton of blood, and so the heart rate response here is probably an added nurture trigger to try to maintain the cardiac output, which is hard times your stroke volume, which is low in this patient presumably because of low pre lit from impending camera shock. So I think just for the audience, I would be extremely wealthy to try to control the middle blockers in a patient who has bleeding with hypertension. Absolutely at this point that the nicotine was doing the opposite back, they were used as oppressors in fluids try to support the blood pressure and they were all over this appropriately managing the patient emily padded cardiology got involved. How are we able to be helpful? Unfortunately, despite the best efforts of the McHugh team giving volume resuscitation blood. Vs oppressors he ended up suffering a code with unstable VAT CPR. Voices, and a shock he was started on 'em your own trip, and then subsequently also on a lady came drip. When he had continued runs a wide complex tech Accordia, a mass transfusion was initiated surprisingly the postcode. revealed an inferior stemming he had st elevations in leads to three. and V six and depressions in one AV will to MP3. Wow so far the patients had a GI bleed reclined mass transfusion protocol of ut arrest malice demi the opposite of items razor more things that you can count. Let's committed to go through our differential diagnosis rest the nation's on NBC G. Math. What's on your mind? You see US y'all vision and are there specific aspects of this patient's presentation or EC influence your thinking? In the setting of receiving ephron that can cause transient as ovation's but these ones persisted. So the first thing to think about is acute plaque rupture, but there are several other possibilities we have to consider hurry card ideas can cause diffuse St Elevations Stress Cardiomyopathy, viso spasm, coronary artery dissection electrolyte abnormalities demand Ischemia abnormalities are among the other causes of St Elevations on an electrocardiogram. Important to think about Catholic activation for semi it's also important to remember these other possible causes of St Elevations. To begin with the clinical presentation of massive jam, bleeding is not typical for acute coronary syndrome. However, this patient has inferior and lateral allegations with evidence of post your St Elevations as well as Involving that cardiac geography inferior poster lateral are highly suggestive of injury related to civic coronary artery. Furthermore, the patient had cardiac arrest with raises the likelihood of coronary, syndrome, and his initial rhythm was a ventricular Karya. Already, points Matt, at this point, unstable patient is having a massive Gi bleed and estimations I'm way. How did you decide what to do next? Let's him before emily, you jump in I gotta say guys, this is like an cardiologists worst nightmare leg you normally like maybe you have a tr- opponent gi bleeding. You're like, okay it's clearly demand or it's clearly related. Let's sort out the bleeding but when push to shove with this easy g which Matt really elegantly described where seeing s the allegations in two three in the F. with. Early are waves and posterior s depressions. These are really concerning an inferior ample stereo am I and specifically usually, but this level of three greater than two I'd be thinking about the right coronary artery being involved. So really attributing it to a vessel but also in the setting of St Elevations acutely like this in the setting, of Arrhythmia, I'm thinking of Trans Mural infarct mural injury. So this is really putting us in the corner that there's something focal going on here and I definitely want to hear how you manage. US next to this. Is a really challenging and tricky situation just to remind everyone for people who aren't as familiar with this like when you go to the Cath Lab, it's not just a procedure that you could do without happen. If you go radio, you'd WANNA use Heparin to prevent radio inclusion, and then if you going growing, you don't have to use heparin upfront. But certainly, if you are going to be wiring coronary artery, which you potentially would do here, you really have to anti coagulate this patient and it's one of those damned if you do damned. If. You don't situations and so this is really challenged. Then these are great points and it doesn't even bring up the fact that we also have to give anti platelets to keep that stand open. So a lot of issues here. Exactly. If those were the exact discussions that we were having, this was a really challenging case, a a multidisciplinary discussion that we ended up having in figuring out the best course of action we realized it would be impossible to anticoagulant or GIF tap to this patient before treating his active Gi bleed the GI. Spurt him. So despite the stem beyond easy g, he was taken to the irs sweet for coiling and obliteration of gastric barracks. Subsequently, Stat Echo was performed by Dr Ben Callon at the bedside and it showed wall motion abnormalities in the inferior and lateral walls and LV have a forty to forty five percent severe mitral regurgitation luckily normal RV function and only a very small pericardial fusion in that setting his opponent I rose from nineteen to one sixty, eight to. To fifty five and his presser requirement increase despite successful management of the GI bleed while just to say the first thing actually I did after hearing about the osteology was called Catholics to talk about what to do I was certainly a couple of the whole situation and then I spent several hours sitting with the I. R. Team while they treated the believe just in case I didn't know what was going to have to guide but now it sounds like it's Good treat it getting more unstable. So I think this is what I hinted off this very sick patients like good morning, emily welcome chefs. What were you thinking about? What did you think about the ECHO? How did it change how you thought about him and given the bleeding? What could you offer what a great gift to give to a the morning fellow? This is how I typically receive patients. Every. Without fail every time I would hand off to emily on Monday morning whereas. It was something like this. Yes. Amazing. Educational for me. I've walked off time in the Catholic. Every Monday for Ben Agents. A So this echo is definitely worrying the inferior and lateral wash snap normalities were in the territory of his S T. In combination with his elevated opponent, we now have evidence of myocardial ischemia and infarction in a territory likely attributable to coronary ISCHEMIA. The worst shock was particularly concerning giving we felt that he had been resuscitated from his Gi bleed pump failure in Cardio genyk shock where possible would warrant a trip to the Cath lab. Additionally, the presence of worsened Mitral regurgitation raised concern for mechanical complication of as m I the might be even contributing. To a shock while that's a lateral thinking about for a sick patient, all of a sudden on a Monday morning, he mentioned worsening agenda. Shock is an indication for a trip to cap also mentioned Mitral regurgitation as complication of an unauthorized semi how these patients with your the fell. That was you that morning it was you nobody else has a Catholic play into your thinking and how you decide what to do for him specifically. As. We move forward recognizing acute mitral regurgitation in the context of M I is so important has lot of bearing because if this indeed is a PAP rupture for mechanical complications, high chance, the patient may eventually cutting drastic surgery, and so it's really going to influence your next few steps because your plan to give anti platelet agencies specifically twelve, but she would give if you're intending to A. Is GonNA interfere with any possible surgical intervention but I would say that in a lot of patients especially, if a poster wallace involved, this may be schemic Mr from tethering of the related to the Post Remedial Capri muscle rather than a PAP muscle rupture in trying to find that earlier on is is can be helpful because it'll really drastically change the way you approach a Korean. Standing and anti platelet agents, and just to speak a little bit more about that schemic. Amar. There's kind of two flavors of schemic Amara. One is from like an old m I where remodeling, and so the wall that's associated with the path muscle might be pulled apart or dilated outer even and original, and that would actually pull the pat muscle away and remember these pat muscles are basically tethered to the valve and their job is to contract when the valve is being force closed by the ventricular pressures and they basically hold those flaps of the mitral valve and play like a parachute so that it catches the blood doesn't allow it into the left Atrium but remember that these. Muscles have to actually relax and contract in order to basically maintain the fidelity of the mitral valve and so if the pack muscle becomes ischemic, what will happen is it'll contract down and when it does. So it doesn't relax and allow the mitral valve to function normally and doing. So it allows for acute mitral regurgitation and remember that when the left Atrium as we made the point on. Several episodes already when the left Atrium is not primed, well to accept that extra volume load from the left ventricle that blood immediately gets shoved into the pulmonary vascular and could result in really acute pulmonary Dima. Now, we haven't had really an actual PAP rupture. So this is reversible and so restoring blood flow can actually reverse this Schema, and so that's why sometimes ischemic Mr in the setting of. Acute Coronary Syndrome could be very transient like the patient starts the flash and then you may get them less schemic with nitrates or other kinds of medicines basically get the molasses schemic and then that Ischemic Amar will go away and you may not even hear it with your the scope or see it with your echo when the become a schemic again, it gets revealed again and so that. Is Not something that's atypical to be seen in the Cath lab and so somebody like this, who really had their e C. G changes like pretty immediate in front of our eyes those would be things that I'd be thinking of especially if they're now going into pulmonary Dima in this particular setting, especially given an inferior posterior that we're seeing where one of those pat muscles just happens to lay. In our particular case, he wasn't really in. Pulmonary Dima yet, but ben's stat echo did pick up some are in. We were really thinking that it was more likely to be ischemic Mr from dysfunction of the PAP Larry Muscle rather than the flail leaflet from a ruptured poplar muscle for example, in the case like this, where the patient is getting so sick before our eyes I usually think about reasons to pursue emergent invasive and geography or to bring them down to the Cath lab in general. On especially in these patients with acute coronary syndrome, there's a few indications to go through. One Is S. T. elevations, which he already has. Another is genyk shock, which he may also have unstable ventricular arrhythmias which he had and mechanical complications as well as refractory chest pain, which we couldn't really ask him about. Because at this point, he was too unstable. The cavs a great place for these patients because of how much can be done their coronary angiography and re vascular ization can treat the inciting macario. Right, heart catheterization can identify low cardiac output in shock state also hurt Catheterization can evaluate for mechanical computations including right heart failure. The VSD if you do a shot run mitral regurgitation where you might see, Big v Waves and lastly at balloon pump or other mechanical circulatory support can be utilized while you're there in the cath lab to treat ongoing shock. Wow I heard amish call the Catholic the table truth. So it sounds like there's a lot degree learn to the map and I think it important point since. A big spacious in whether it would tolerate anti coagulation. It's important to recognize that there's a lot of the cap that can offer both diagnostic and therapeutically that may not require anti coagulation. For example, right? Heart Cath identify both the shock state, as well as the humidity of the Mechanical Complication Coroner geography as the ends described view US federal access doesn't necessarily require anti coagulation in the balloon pump potentially could be placed particularly if you think that his shock is due to low cardiac output or severe for details. Cardiac. Output and if it's kept up one to one as the pumps inflating with every heartbeat may not require anti coagulation for that during that time period. So when you guys do, we are still very worried because he was only a couple of hours out from his life threatening bleed. So we decided to trial a Hepburn Bolles and drip as well as an aspirin load. Before taking down to the Cath Lab, that way we could observe him to see if he was able to tolerate this without re bleeding from the gastric barracks. After he tolerated this medication for several hours with stable hemoglobin checks, he was taken down to the Cath Lab Matt was the cat fellow at the time that can you take us through the Cath findings for sure? We were really nervous about this case we nervous about his Gi bleed but the GI team and I are team which we spoke to reassure us that he was unlikely to replayed from his treated Eric's we ended up using right radio and right break. You'll access remember we had already tried him on Heparin Bowl Syndrome. So we were less worried about the cute use of. Heparin during the case on right heart. Cath. pressure was twelve is mean pulmonary artery pressure was twenty six. His Wedge was twenty two with an L. VP of twenty and his cardiac output was six with an index of three point four. So mildly elevated filling pressures with normal cardiac output while he was on northern Efren actually can I ask you? Do you have the? Systolic diastolic just. As RV functioned with a pappy because it thinking about what the next steps may be. It may be human dynamic support if needed or mechanical true support rather and understanding or localizing the source of been trickier dysfunction could be really helpful in determining the next steps yet his. Stolac was thirty seven and his diastolic was twenty which correlated with his LV. Matt, were you surprised by these numbers or yeah I very surprised I expected his cardiac to be much lower and I expected his filling pressures to be higher than they were despite his massively he'd been resuscitated with a lot of fluid lot of blood A. so I was definitely surprised by these numbers. I would just GONNA. Ask you know what is s Vr was at this point because potentially maybe he has a what appears to be normal cardiac output VR is very low the mason. Okay. Was this like a face Oh, dilatory phase of hemorrhagic shock or a genyk shock where the filling pressures Andy caddick apple may seem okay. Extra potentially help precisely the cause hypertension. His S VR was about seven hundred through very impressive numbers. And thing I do recall from the tracings is that there wasn't significant V wave suggestive of really severe mitral regurgitation. So he had mildly elevated filling pressures with a normal cardiac output a wall on some norepinephrine had persistent. Seo. Time still going to the Catholic one other surprise was that this was about twelve hours or so after his initial St elevation showed up on the. And he hadn't started to out yet definitely suspicious that maybe there's more to this. So I was just GonNa say when you have numbers that don't really reflect what you expect. The first thing that you start to think about is the fidelity of your actual testing and I'm sure that basically zeroed over lines have made sure that all the tracings were as expected look like legitimate tracings and then one thing that I do with a dilution is you can also look at the sat the could be very helpful and basically if you're chronic output is like pretty bad and your ad is pretty low, then you're like, Kay this kind of works together and on the other hand if you're. Not on the low side and your credit but or index is also nonetheless idea like okay. That goes together kind of fact, checking yourself within the same tests it could be very helpful yet defect which admittedly is not with a measure is correlated decently well with Thermo election but I think Matt's point is important that indirect is really Matt, your gold standard for cardiac output, your best closest to the gold standard, which is a direct cause. You're several delusion if you do it systematically when you're in the lap so that's you measure it three times and if they're. Within ten percent of each other you take good and if they're not you five and if you do it in a systematic way, always the same, it's a reliable tested. You shouldn't have to be with some rare exceptions using he was also indicated and critically also there are a lot of assumptions of an indirect thicker making make it somewhat less accurate. Yet I think that we did five years. The first correlated just to be sure because it didn't make that much sense to us at first and we did the right heart cath before we did the coronary. Angiogram. He did have a at about sixty percent. So everything lined up together. And why did you decide to do the cat I? I think at this point, we were twelve hours out from his initial st elevations and we just really wanted to know what was going on with this shock thought that would inform what decisions we might make in terms of next steps if we found something. All right. Sounds good. So the die don't lie as somebody. So we decided to shoot the left coronary already, I because based on his electro-cardiogramme, we suspected the right was the likely culprit. His left had a mild lesion maybe thirty percent in the L. A. D. and seventy percent lesion in the second bag branch of the led is cirque looked. Okay. Then we turned our attention to the right coronary where we found in eighty percent at a distance ninety five percents lesion that we thought the culprit for this demi take me through an important point dummy. We know from trials like culprit shock in observational data going in when someone's in shock and fixing everything probably isn't good strategy maybe associate with harm you identify the culprit lease that you thought it was. A and not that diagonal leisure ninety figure that out. First of all, we had the clue of the electrocardiogram. So that helps us localize when you have Trans Mural in far you can think about where the SEO electro-cardiogramme, how that maps onto the anatomy. The second thing is we had the Echocardiogram to correlate wall motion abnormalities in that same distribution. So really everything was fitting together and that was the most severe lesion and given the fact that he was still having. Even twelve hours in we thought maybe this plaque rupture event if that's what happened. Maybe in the setting of his Gi bleed, he'd been transient. The vessel, we hadn't been doing electric cardiograms continuously all twelve hours. We really thought that was our best guess at the. That's great. The ekg suggest isky me on the inferior wall in the postal lateral walls. That's your post you're descending artery in your poster lateral branch. This gives your RCA supplied both a poster I mean artery in the poster lateral branches based on the G in the echo you're confident that the was the culprit putting a stent and how'd you decide you? You're putting a bare metal stand people talking about or drug wooden sense. What'd you do? So one thing that are masterful teachers in the Catholic here teach us is that important to get the best pictures? You can size your stance if that's what you're gonNA do next and so we're taught to always inject dialers. Now we pause in Dr Ourselves, do we really want to do that in this patient on pressures, but we had these multiple lesions and it was definitely not the classic story for a plaque rupture event. So we decided to inject Nitroglycerine check for visa spasm remarkably, the lesions completely resolved in Seo Ovation's on CG disappeared in the lab and the nor epinephrine we were able to just wean it off and his blood is actually went up. Wow incredible. It was great. Guys looking at these films they're really impressive, and again they're going to be available on the blog that comes out with Definitely Click on the episode show notes in check him out. These are super impressive films but even in the first shots those pre Vasil later shots I am noticing something very interesting about this right coronary artery you see the catheter. Engaged in the right corner artery and you see a very nice normal caliber or or size artery at the proximal part. But immediately, it looks almost like a snakehead and then immediately becomes like the snake body as the right coronary artery goes all the way down the eighty groove and then basically ends up becoming the PDA in the V branch and so it's like this like kind of head shape normal sized diffusely thinned all the way down but. Then on top of that like towards the snake's tail in my analogy, it gets really tight, which is again what we calling the culprit lesions. So even like in these first shots and there's some evidence to me that potentially there's like a mismatch between different parts of the artery than the other part of the artery and an almost like spasm all the way through the entire Ari with different vocal parts that are worse than others but this is the. Opposite of what you would expect with Catheter. Induce vases. Fathom, it's the quite the opposite. Actually we're the artery and the Catheter engaged is actually not spasm and it's difficult to that this that where you see the spasm almost starting from way up top in the artery, and then when you see these basically follow up images, the entire artery resumes the caliber of the original proximal right corner. Hari. Which basically tells you that the entire arteries spasm down in. Those initial shots without vasodilator. But within the area of spasm, there are certain areas that are more spasm than others, and then when you actually look at the film's where there is, the die leaders have been given and the artery looks pumper will you can see is that there are areas where the artery was the tightest in initial films. There is some disease there. So there are some coronary artery disease at the sites where the lesions looked obstructive that basically. Exposing, after we took away that Jesus spasm from the artery with the dialers. Interesting really interesting. Definitely recommend you check out these films. Yeah. It was crazy case steady turned out to be predominantly due to coronary spasms, which is wild. And I have to say if I was his patient and our to choose causes ideologies of a steady, this is exactly what I would have chosen for myself because it means that you don't need a stent and therefore you don't need anti platelet agents to keep best at. In somebody who came in with a human dynamically significant verse, you'll bleed for sure this was absolutely the best case. For him in in this particular case, giving in to coordinate visa daily also seemed a little bit risky in somebody already on as oppressors and maybe even a little counterintuitive but it really was the key to this case. Then can you guide us through the physiology behind Vasil spasm what we do about it? Not. Sure. So Corey visits phenomena derangement of EPA Cardio, coronary vascular tone weeds, profound construction Associated Scheme Ya. The EPA cardio dysfunction may or may not be associated with micro vascular function, but it's often occurs only with the cardio statism. The Classic Teaching About his medals engine up that's where you have typical engineer with associated EKG designed their self limited results with nitrates. Administration is often associated with emotional distress or changes in sympathetic tone risk factors for Korn invasive specimen could cigarette smoking symphathise mimetic drugs like cocaine or methamphetamines magnesium deficiency medication effects including serotonin urging agents or catecholamines, and instrumentation as Matt and Dan. Mentioned with. And seems to be more common impatience under fifty in there may be genetic predisposition as well off in a short time. Frame is helpful in distinguishing Vasil spastic engineer from acute coronary syndrome because it typically is transient reversible and results. In fact, the we see a lot of post arrest patients. It's not uncommon that you see transient sti. Immediately, post cardiac arrest occur within minutes often the setting of for news during isolation. Then resolve on a repeat ekg. What is unique in this case is the persistence of St Elevation in the Cardio Scheme that persisted the point as demonstrated by elevated proponent in. Walnut. snapper maladies however given cocaine smoking risk factors for Vases Bassim end for you cornered syndromes patients with Phantom often have focal obstructive coronary disease as well. So cases that don't fit a classic pattern of is specimens such as this case, Warren in geography for evaluation, underlying plaque rupture or for something that surprises, you like a plaque rupture. Event, that's not due to visit spasm as Dan mentioned it's important to be able to identify angiographic geographic patterns that are more suggestive of spats as a composed of plaque ruptures distinguished from plaque rupture in several ways often the non diseased vessel as smooth and has no focused disease. So the rest of the vessel is non diseased and then there is a lesion there's long smooth concentric tapered as opposed to an ulcerated e centric lesion that you typically see impact rupture and as Matt mentioned for nearly all coronary Angiogram inter-korean administration of visit Dieter agencies useful to remove the confound ineffective coronary vase a spasm Distinguish spasm from obstructive plaque therapy for corner visa acutely in the lab involves injection of visit later, agents like Rapa milk. Carpenter, nitroglycerine typically, coronary long-term therapy for vases spasm uses oral nitrates and calcium channel blockers as well as advocated for smoking cessation control these assassin. That was great teaching on Coronary Basil Spasm and again. Thank God. That's what this patient had because it really simplifies the next steps moving forward but I have to recount were feebles, interesting cases. I had when I was in the ICU as a first year was a patient who came in with also an infra procedure s ovation. Am I with positive proponent elevation ongoing chest pain and so he went to the Cath lab in also had her. Ca Vasil spasm that proved with glycerin and that was a diagnosis spasm. But going back in that patient's particular history prior to developing his sudden onset chest pain he was on a diet and working out and doing the best things you could for his health but he essentially drink a milkshake with random additives mature what was in it he doesn't either. But shortly after drinking the milk milkshake, he developed whole body hives and so he's having. An allergic reaction, and so in this case, it was essentially an allergic Vasil spastic engineering and the name for that Syndrome is Kuna Syndrome K. O. U. N. I S. Syndrome which is Jay Patel, my intervention fellow talking at the time, and so I just such a fascinating central you get an allergic reaction that leads to coronary disease that can present in three different forms. It can be triggered by any host of allergies triggers like drugs environmental. Factors infections but there are three types type. One is Vegas spastic allergic Angina were essentially is physical specimen can progress to infarction type two is allergic Michael Infarction where you have a patient preexisting coronary disease actually has plaque rupture because of that inflammatory you anti-thai three is stent thrombosis, and in these patients in particular, they've shown that if you do coordinate aspirated find MSL mass. So that is a very ordinary ideology and this is less common now. Moved away from using Antigen ICK stent polymers with nickel and rather cobalt now. So it was just such a interesting syndrome with allergy causes of coronary syndromes and your patients are reminded me of that because ekg coordinator was similar. That's like a fascinating case. In our early, we're all young Carter nerds, but our careers are punctuated by very impressionable clinical situations like when you just described and I had a similar situation of a patient who is on the ecology center with a severe profound from aside opinion related to is chemotherapy at he presented very similarly to this wasn't having a GI bleed, but he was really hypertensive and was on epinephrine because of it, and then eventually ended up having really profound seal allegations and this time it was anterior different a different flavor by very similar anterior, really classic St Elevations, and so we ended up deciding back and forth and we ended up talking to down colleges there was A. Big POW very similar course we ended up going to the lab and finding legions very similar, but they were in the L. A. D. and coming back with a guide ready to stand and basically gave the dialyzers and Lo and behold like these focal lesions just like disappeared and they came back and the players were given again they disappeared and even though this patient had a really good outcome for the patient and are talking about the not he continues to have the St elevations just it was in shock all night long and unfortunately did not make it till the morning despite maximal these are dilated but while supporting his pressure was challenging and so vases spasm could be a real humid. Compromise and so when I reflect on our patients case over here, where we have this patient who's really not doing well, he dynamically has an insult from bleeding but also has some cardiac focused insult as well ends up getting the resuscitation for the bleeding ends up coming the lab and surprises us with these pretty benign right heart cath findings, and then subsequently we find out that this is visa spasm the way this together and maybe you guys did as well is that really the guys shot was from. His bleeding as we expected and it didn't help to have ischemia at the same time because while visas fathom is occurring, there is a scheme and that's evidenced by this wall motion molly. So there's is actual Schema and I wonder if during the time where he's hypertensive because of all the bleeding and also because of as a spasm, maybe he did have a little bit more Mr that we expected. But then after that twelve hours and we resuscitate with volume and blood and also corrected his jibe lean with. And now we come to the Cath Lab. He just has this insult with the RCA and the that wasn't enough to make him have the severe human dynamic compromise that he had yesterday when he had those two hits and that's why the right heart cath were surprising, and then eventually he had a much better outcome and I think, I'm it's your point thinking about people with allergic Dave Spasm. This is the opposite because you think about what you treat anaphylactic reactions with its effort in his case I think he was getting Beza spasm from the nor up an effort on the effort he got during the code and the continued visit presser us for his shock. He was really a setup for this right because he not only had underlying coronary disease in the area is also was given constructors to essentially keep them alive and so totally make sense that this he was set up for this. Exactly. So initially, we just have waited at the effort and he remained really stable. He was transferred out of is a you and was getting very close to discharge when he had a two minute episode of hypertension and Breda. Cardio. With recurrence of the inferior St Elevations, it only lasted for two minutes and it went away at that point, we decided to start an oral nitrate and plan to start a calcium channel blocker. If he's assassin record, he was also encouraged to. quit smoking smoking as a significant risk factor for coronary basis basim like we learned from Ben Earlier, his repeat echo showed normal systolic function moderate Mr and the previously seen wall motion abnormalities where no longer present he was discharged with close follow up after this two week hospitalization. So this was a case of an upper GI bleed requiring vase oppressor support led the cardiac arrest with stem It was all caused by corner. Vasil spasm in ultimate resolve with Inter corner visit. or a long term therapy with calcium channel blockers nitric. What if a tastic case guys and thanks bringing it up it's so helpful and really got US thinking about so many different important key points in cardiology. But one thing that I did want to go back to what you said earlier on in the case you mentioned that we were dealing with two conflicting issues and you reached out to discuss the case with your attending and I just wanted to highlight that is such a beautiful thing. The the cardiology really allows for that collaboration and that basically putting minds together. It's basically built like that. By the fact that we have carved out the people putting their heads together within eventual teams ended eventual teams putting their heads together with General Cardiology the prevention teams. The whole field is really built by that cross collaboration and I could see even by the way that you guys handed off this case to each other that was really embedded into the fabric of your program and the fabric of your clinical practice. So guys why don't you guys tell us what made you choose cardiology and particularly what drew you to? UC. F- for your training. Creates a third. So many things I love about being here at UCSF. One of the biggest draws for me as our three hospital system it lets us have such a wide range of clinical experiences. It'd be really difficult I think to find that any single hospital we have the main university hospital at UCSF. Then we also have the Department of Public Health County Hospital the general and we have our va hospital where we get the privilege of treating our veterans. They're also so many research opportunities here. The faculty are extremely approachable and other anything about our program is are flexible. Third Year we have to intensive clinical years. Basically all of our clinical rotations upfront and the third year is traditionally a research year, but it can actually be used to pursue classes further you're experiencing imaging or Cath, or to pursue your other academic interests, and it's it has just so much flexibility to work with. Of course, being in the beautiful area doesn't hurt at all and may very favorite thing I have to say about UCSF is getting to my amazing co fellows. I am so lucky to get to work with them and hang out with them. It's it's a really fun and Supportive Group of people, and we all get very close during the years of fellowship. UCF is an incredible place, the quality of teaching and mentoring standing I think the three hospital system particularly the county hospital. You just see things that I wouldn't see anywhere else in you end up growing so much through that in through your. Experiences every Thursday. Morning, we have a an hour-long deep dive in the case just like this, and there is so incredibly through these cases that fouls managing even though it's early in the morning the room, it's now a virtual room but the room has always packed with just amazing clinicians and senior faculty members who come to pass along these amazing paroles for each case, and so even though I'm on my critical carrier off and on other services have pre around instead is still try to join law doing my pre rounding and hear about the cases. So when and Dandridge. Present case the hardest question it was like, what case do we present? Every week, there's a case just like basically and I think the great thing about that is at the end of really at the end of your second year if you'll incredibly comfortable with your general cardiology skills between your time at all three hospitals so whether it's procedures whether it's cases whether it's concerts, things like this you're comfortable handling even if it's two in the morning or afternoon sometimes and then I think the best thing for me is Mike. O. Fellows we used to stay in hang out together until all the work was done it ended up being a group process people used to tease us because we would walk into the ICU with four people to do one p until we were all signed off was just such a supportive place even though during Covid, we haven't had as much in person time. We still have weekends Zoom Happy Hour hangouts that we've organized. Ourselves is a lot to love. My all's metering experience I wouldn't trade for us. I completely agree the sides returning home to the bay area. Top two reasons I came to UCSF where this strengthening clinical training across the full spectrum of general cardiology. Especially, the opportunity to take care of patients at a safety net type institution, and secondly UCSF strength in global health training opportunities in research like emily ban. I'm especially grateful to have amazing co fellows are class organized a second year retreated Napa last year, and we really also have a great relationship very collegial. With our attending cardiologists then talking to his attending early in the morning, we really get along well with our attending and frequently tax them like emily I do appreciate our three different hospital sites. I think that our program really is about learning by doing and so much of our first learning, how to do calf echo doing consults. But even as the first year fellow, you get to be first operator during stems general you to put him pacemakers get to tease even a fibrillation. As the second year fellow, I did become much more comfortable doing all those things than than you get to really take on a lot more independence especially during your time at the Va. It's has a lot of bread and butter cardiology but the San, Francisco via is really special because it's the referral center for coronary in structural cases. So we get cases from Oregon from Nevada Oliver Northern California with really amazing interventional attending there it's such a formative experience. To become ready for independent practice with amazing support in the team atmosphere there, and now I'm really enjoying diving headfirst into research being back in school as part of my masters in clinical research just turned in my final projects for our summer term, and one of the Nice things is fully paid for I. Don't have to worry about any of the tuition costs in really have protected time to pursue those goals of mine of becoming a global health cardiologists. And just want to emphasize one thing that Matt mentioned but did really highlight when we're talking about amazing uses at San, Francisco? General there are no advanced fellows. The fellas at the hospital are general cardiology phones. So this whole case from two in the morning when they called me about the not tell ten pm the next day with acted the corner angiogram was general cardiology fellows. So we manage all the post arrest patients, the stimulus, the balloon pumps, the TEEPEES, terminent pacemakers, all the device interogations always things run through the general cardiology follow, and if you need help there's. Always Super Fellas APN advanced heart failure in interventional who are available for phone concerts in your attendance are incredibly available th to talk to you and help you and do things with you and very comfortable doing procedures with new fellow. But you get a level of kind of I operator in hands on experience that you wouldn't get really I think many other places and it's pretty great experience. It's definitely a fellow favorite. Jones. You guys, you're making me have so many warm feeling and fuzzy's about UCSF and I think three hospital system brings such an incredible diversity of clinical experience and exposure and training. It was very apparent when I interviewed there and it was just is such a strength of the program and of course, the opportunities for mentorship research and you get to do all of this in such a gorgeous city. So thank you so much for taking us out around town had such a blast learning from you. Terrific aches and beautiful pearls couldn't imagine a better way to spend our. What's Today Tuesday I'm having such a fun time I. Forget the. End Day of the week. Thank you so much for having us on. Thank you thanks for inviting US assume much fun you guys. So excited to hear now from Dr Ben on fine to is one of the most loved algae attendance as the General Hospital thank you so much emily and a big hello to the cardio nerds nation. My name is Ben on I am a professor of medicine at UCSF and a general non invasive cardiologists at San, Francisco, General Hospital. After listening to a few nudes podcasts I can understand why so many students trainees and providers have really fallen in love with cartoon nerds and now treated as a go to resource for amazing cases in cardiology all done in a very welcoming and fun style. because. Of that, I'm honored to be here with you and super excited to provide you with some learning points that I took away from this really fascinating case the I I do want to congratulate are three amazing fellows. Ben, met Emily for presenting this case you all such a wonderful job, not only in your thoughtful care of this patient, but also in your fantastic discussion of the case on the PODCASTS. Now, let's jump into this really interesting case. For Review this is a case of a fifty seven year old man with a history of alcohol use disorder psoriasis not anti-crime gration off Attala Mia. An actor smoking who presented to the hospital with him tendencies and found to have an active jibe lead those complicated by shock malignant Arrhythmia s the elevations on E. C. G. and ultimately diagnosed with Corner Vasil spasm. Now. There are three particularly interesting areas of discussion that I wanted to focus on this case. The first deals with the management of a in critically ill patients. The patient presented with a massive bleed, and he'd been an amick instability suggestive of hypoglycemic shock in this setting was noted to have a fed with. VR. No Feb is very common in patients admitted to critic rigor units and new onset a fibrin the hospital has been associated worst outcomes. A FIB has the potential to cause a number of namic cardiac arrangements impairment of LV filling seen fast, irregular heart rates loss of atrial contraction and AV synchrony found a FIB can all contribute to reducing cardiac offline? This can worsen hypertension in patients who are already in shot. Loss of atrial kick can be particularly detrimental to patients with Di. Stock is function who have worsened lv compliance and depend on each contraction for most of the LV filling. This can lead to elevations, left sided filling pressures and pulmonary congestion. A fifth can precipitate a worse Mark Artis due to increasing oxygen demand from elevated heart rates an increased end diastolic pressures. Will v can have these unfavorable human namic and clinical consequences? The keep control of aphids may not be necessary in all critically ill patients. Now, of course, if the patients present with human. Napa compromise from a with VR then immediate rhythm management with Carter Versions Cooley. Indicating. However if a FIB is not the primary driver of the critical illness or the fifth is not significant impact in Human Amex, the urging control may not be as critical understanding the trigger. For a FIB or the driver of the rapid response is an important initial step to of management in the ICU a number of eighth of triggers a present including increased inflammation electrolyte abnormalities, elevated catecholamines, state, and couldn't use of as oppressors, and with Choline, surge the VR May represent an appropriate physiologic increase in heart rate to augment cardiac output in the face of higher metabolic demands. Now, controlling heart rate in this case may actually be harmful for the patient. Several groups have looked into the impact of a in. Cardio. Jack Shock. Patients Subgroup, analysis from the culprit shot trial showed that in patients presenting with an acute M. I and shock the presence of a FIB did not significantly worsened mortality or increase the risk of recurrent mchardy infarction or stroke. Therefore, an initial approach to managing a fifth in the ICU patient may be to explore and eliminate triggers. This may include treating infections correcting. Abnormalities choosing appropriate visit oppressors in our patient he presented with an initial problem of hemorragic shock that was the main driver of his humor, their necks he was in fifth with an initial interest rate of one, hundred, ten to one hundred twenties those driven likely by an increase in sympathetic activation in attempts to maintain cardiac output in the face of hype over Libya in Namibia from his active leading additionally, the concurrent use of bid at presser agent likely also contributed to tackle cardio. Therefore. It was appropriate for the team not to aggressively treat his VR but rather targeted their efforts at managing a fifth trigger with fallen resuscitation correcting has underlined bleeding. In addition to a managing the second area that I found really interesting in this case. Was a clinical dilemma related to dealing with a possible stemming in the setting of a jibe lead now, patients presenting with stemming an acute jeb lead are not common in the acuity trial. Only one point three percent of all ACS cases had clinic significant jibe leading. However when they do present together, the often bring up multiple clinical conundrums now, the decision. To bring someone to cap lap to intervene during a semi should be based upon evaluating the benefits of opening included artery against the procedural risks in the vast majority of patients. This calculus favors the benefits of acute intervention. Particularly, if they're high risk features including carcinogenic shock malignant the RID MEA or mechanical valve complication, all of which were possibly present for patient. Data, from the shock trial demonstrated significant survival benefit at six months for patients presenting with Cardio Genyk shock who treated with emergency. We've aspiration as compared to patients who were randomized suggest initial medical coach. While the benefits of revitalization in steamy are clear. There are associated risks would jibe leading. Massive bleeding post stemming can result in hypoglycemic shock worse in Ski Lia reinfection and reduce cardiac function. The acuity trump also showed us that patients who had major bleeding associated with acs had higher rates of death reinfection and need for revitalization additionally patients who developed post acs bleeding and require blood transfusions often have high rates of cardiac events and mortality. In addition to considering the impact of leading the decision whether to take a patient cat lab may be impacted by the severity or extent of the. For an uncomplicated inferior stemming, which has a favourable diagnosis immortality of less than ten percent deferring intervention may be reasonable. But if there was a large answer, am my Cardio Jank shock or mechanical valve complication things that point toward significant higher mortality that may be reasonable to consider taking the patient lab for intervention even in the setting of a signal lead. If taken to the cat lab, the Intersectional Team May consider strategies to open included vessels without sensing and possibly avoid the immediate use of do antiquated therapy. Some of these invasive strategies may include in initial tempt with Rombas aspiration or plane balloon angioplasty, and a subsequent decision on whether a student should be placed could be contingent on whether there remains residual around us reduce timmy flow or ongoing human amick compromise. If sensing is planned, pay procedure Heparin may be favored given that it can be quickly reversed in terms of P two Y, twelve receptor inhibitors. Kagwa Lord may be the preferred agent given its rapid onset reversal binding of the P two y twelve receptor and slightly faster offset compared to grow. In our Pishin given the history of massive bleeding pre procedure, anti coagulation was started with happen, which allowed the team to test whether the patient with tolerate additional anti coagulation. Luckily, the patient did not need vascular even the absence of inclusion. And that brings me to the third area that I found really interesting about the case, which is the manifestation of Basil Spasm impatient. bleed as mentioned in the case Corny Basil Spasm US involves transient focal or diffused nearing a one or more arteries. The pathogenesis of Baseless Basim is thought to be due to an imbalance of sympathetic impera, sympathetic activity, endothelial dysfunction, or micro vascular disease. There are a number of triggers including cigarette smoking stimulant drugs such as cocaine and amphetamines, allergic reaction, and corner instrumentation. Even the short duration cardiac markers typically negative in patients presenting with Cornyn Basil's spasm. Diagnosis of Basil Spasm can be suggested by defying. Se. Elevations with chest pain on twelve EC. G or ambulatory is monitoring visits. Fathom can be confirmed. I'm corny and geography using provocative tests such as the administration of Acetylcholine in management using volve symptomatic treatment with calcium channel blockers or nitrates. Now in our patient presenting with SC elevation an easy g in the setting of lead the diagnosis evasive spasm was clear after the left Heart Cath demonstrated spasm, and in retrospect it was easy to understand that he had multiple triggers for visceral spasm including active smoking presence of corn, atherosclerosis recent and ongoing visa present therapy as well as increase autonomic simulation associated with a shock. However prior to the left heart, Cath, there are a number of factors that made it challenging to consider a diagnosis of Vasil Spasm Upfront I. The patient had prolonged SC. Elevations for several hours and elevated cardiac markers which would not be typical for transient visible spasm. Additionally, the patient had ongoing shock malignant Arrhythmia Wall, motion abnormalities, and significant mitral valve regurgitation that all were suggestive of Papa complications from a semi. These findings would have been atypical for Corny Basil Spasm in this setting therefore is appropriate to have a presumptive diagnosis of a stemming fortunately, the diagnosis of Vasil Spasm was made in the Cath lab and appropriate treatment was provided. The patients quickly improved in was able to wean off all of his vase oppressive therapies. The patient ultimately went on to recover. This case really had it all. It was super interesting based upon the high acuity and complexity of care. Associated with a jab lead possible stem and all the human amick cardiac arrangements. It was challenging due to the clinical conundrums that came with thinking anti coagulation incenting in a patient with an active jubilee it also headed atypical. Zebra diagnosis with Corny vessels spasm I want to thank our amazing fellows, Emily Matt, and Ben for caring for this patient and presenting this case also want to thank the cartoon nerds nation for this great opportunity to provide commentary to this case, it has been such a superfund experience. So thank you so much. Take care everyone and happy learning. Now for a word from our beloved program, Director Qasim Hi this is author Qasim of the program director easiest I'm a non invasive cardiologist focuses on structural echo novel therapies for heart disease I run the court lab here. I'm also very interested in medical education research would like to think the cardio give me an opportunity to speak about our cardiovascular program is very admirable that they're using these podcasts showcase specific disease entities, fellows in programs across countries especially during a time where virtual earning has become more. As you just heard Ben Madden Emily discussed a wonderful case of difficult to manage shock patient competing pathologies. A massive GI bleed stemming critical thinking was vital to successfully managing this patient active collaboration between I G. The floor cardiology team in the interventional team was essential for this case this case highlights is one of the many amazing cases are Trini. See here at UCF as well as the breath and depth of pathology across three amazing sites are at Long Hospital County Hospital, which safety net. Hospital, in our San, Francisco Va Medical Center, all of which have state of the art care where our fellas take center stage in the diagnosis in management of patients are intimately involved with every critically ill cardiac patients are fellows also mentioned this, but it's worth emphasizing further that one of the other things that defines our training program is the degree to which are core fellas have significant graduated autonomy. You don't hold back. We let them do quite a bit early on with the appropriate supervision. At the county I assist with stem is in the cath lab helped place in pumps eighty device checks. Trans Venus Pacers tease to help with the imaging during Mitra clips and Taveres at our San Francisco va work with a whole host of advanced fellows. MOFFITT long provide amazing care her fellows very comprehensive and rigorous training in their first two clinical years at the end of their second year, they're able to function in many cases at an attending level seeing this transition fellowship is one of the most rewarding. Parts of my job is rector given that it's interview season. We get a lot of questions about what we're looking for among people interested in our training program first and foremost I would say we're looking for people with passion in particular area, whatever it may be something that drives the training to WanNa help advance how a practice cardiology great to see trainees shering interview really light up about something they've done a really want to do I feel it's our job to really help them realize that passion intriguing. One size fits we have crafted several training pathways for Fellas who've been interested in emerging areas including cardio oncology, crinkle care cardiology, global cardiology medical education in artificial intelligence to name a few are training program doesn't lock anyone into specific mold training tries to provide everyone choices in the tools they need to be successful. That's being a basic translational uncle researcher and Educator Administrator leading practitioner out in the community advocate health policies or an entrepreneur or any combination of the above like to think that we have something for everyone here fact. We've had several fellows go into industry of started companies that have been very successful barriers proximity with tech companies. Certainly, a great benefit for those interested in taking advantage of partnering with Industry Sin Francisco is also very richly diverse city with people from all different backgrounds and cultures is the city that values that diversity Mike Weiss Ucsf in our training program highly values diversity as we select our trainees in whether that means that someone is underrepresented in medicine or his traveled a long distance to get a career in medicine take knows. It's amazing. The people you'll meet air. Some of our international medical graduates have come from developing countries or wartime countries with minimal resources in risen to the challenge of being very successful here in the US. He also have folks who have grown up in the US where the very first person in their family to go to college. UCSF has a rich history over the last several decades in supporting marginalized groups. This is very well outlined in our office of diversity website which encourage everyone to visit. We seek fellows from a wide array of backgrounds as they will be best able to take care of diverse array of patients that trickles all the way up to our fellowship. In Division. You'll see an emphasis here from the division to focus on health disparities in antiracism during training actually have an anti-racism. Working Group anti-racism Journal, Club within the division. We feel that these are important aspects that trainees should be more aware of in order to better take care of. Patients finally, I'd like to say that many of the training programs featured here on Cardio nerds have been wonderful collaborators colleagues especially during this very difficult year with covid nineteen, which has made us rethink how we train our fellows interview applicants in a virtual environment leave a program director serving, and there have been countless examples of sharing knowledge and resources across programs that many fellows can benefit from cards. I. Think fits in with the small very well. So thanks again for lying ucsf up to take part look forward to working with you again in the future. What an amazing episode a huge thanks to the fellows and faculty for enriching us with another terrific discussion and an incredible edition to the Carter case. Report series. Be. Sure to check out the show notes for all the case media available review key take on points and discussion points and links to the program. If you liked the educational takeaways, graphics delivered directly to your email up for the heartbeat, the Cardio nurse newsletter by clicking on the link in the episode show notes. Thank. The ACC, relevant training session chaired by Dr Notion reasons for their incredible support in collaboration and a very special thanks to our phenomenal production team for elevating the platform column Tommy. UNICEF. Rick Ferraro. Evelyn Song and Verghese internal medicine senior residents as the Johns Hopkins Hospital, as well as the team men had mentor and University of Maryland Cardiology fellow kearns decide if you love the show as much as we do be sure to spread the word reading reviews or your favorite podcast platform and consider becoming a patron of the show on patriotic. All right. Time to make like S. and split. I think some background noise can do that again. Emily's eating popcorn over here.