The PRAMI trial was a randomized controlled trial that compared preventive percutaneous coronary intervention (PCI) to PCI limited to the infarct artery in patients with ST-segment elevation myocardial infarction (STEMI) and multi-vessel coronary artery disease. The trial found that preventive PCI of non-infarct arteries with major stenoses significantly reduced the risk of adverse cardiovascular events compared to PCI limited to the infarct artery alone. However, the trial had a small sample size. Guidelines recommend PCI of a non-infarct artery be performed separately from primary PCI, but the optimal timing remains unclear due to varying results from observational studies.
http://www.theheart.org/web_slides/1416535.do
A trial to compare Fractional Flow Reserve versus Angiography for Guiding PCI in Patients with Multivessel Coronary Artery Disease II
Primary Prevention Of Sudden Cardiac Death - Role Of DevicesArindam Pande
ICD is most cost‑effective when used for patients at high‑risk of arrhythmic death and low‑risk of other causes of death.
Specific patient populations are now recognized for whom the benefit of ICD therapy outweighs any risks
Categorizing patients on the basis of only LVEF and NYHA Functional Class can aid in identification of patients who have highest benefit from primary preventions
DANISH is a major breakthrough trial published in NEJM on 29/09/2016 regarding Defibrillator Implantation in Patients with Nonischemic Systolic Heart Failure. All content of this slide is Copy right of NEJM.
Significant, defined as a greater than 50 percent narrowing, left main coronary artery disease is found in 4 to 6 percent of all patients who undergo coronary arteriography. When present, it is associated with multivessel coronary artery disease about 70 percent of the time
http://www.theheart.org/web_slides/1416535.do
A trial to compare Fractional Flow Reserve versus Angiography for Guiding PCI in Patients with Multivessel Coronary Artery Disease II
Primary Prevention Of Sudden Cardiac Death - Role Of DevicesArindam Pande
ICD is most cost‑effective when used for patients at high‑risk of arrhythmic death and low‑risk of other causes of death.
Specific patient populations are now recognized for whom the benefit of ICD therapy outweighs any risks
Categorizing patients on the basis of only LVEF and NYHA Functional Class can aid in identification of patients who have highest benefit from primary preventions
DANISH is a major breakthrough trial published in NEJM on 29/09/2016 regarding Defibrillator Implantation in Patients with Nonischemic Systolic Heart Failure. All content of this slide is Copy right of NEJM.
Significant, defined as a greater than 50 percent narrowing, left main coronary artery disease is found in 4 to 6 percent of all patients who undergo coronary arteriography. When present, it is associated with multivessel coronary artery disease about 70 percent of the time
Lo mejor del ACC 2015 (San Diego)
Miércoles, 18/3/15 De 14:00 a 15:30
Casa del Corazón. Sociedad Española de Cardiología.
http://acc15.secardiologia.es/
SCA/Intervencionismo coronario I
Dr. Guillermo Aldama López
Servicio de Cardiología. Hospital Universitario, A Coruña
ACC/AHA 2009 Guidelines for STEMI & PCISun Yai-Cheng
ACC/AHA 2009 STEMI/PCI Guidelines
ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction (STEMI) and the ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (PCI)
J. Am. Coll. Cardiol. 2009;54;2205-2241
Circulation. 2009;120;2271-2306
Beta blockers have a variety of different uses in the management of ischemic heart disease. This presentation by Dr Vivek Baliga, Internal Medicine Physician talks about the role in ST elevation MI.
This highly energetic lecture presents the pathophysiology of S-T elevation myocardial infarction in an easy to understand style to help you best identify, triage and treat patients presenting with acute coronary syndromes. Using the latest research behind the AHA Guidelines changes, AHA National Faculty Rom Duckworth will help you better coordinate with you partners along the continuum of cardiac care. Emphasis is placed on risk factors, recognizing truly sick patients and coordinating care with hospital personnel.
Learning Objectives: Students will learn:
-The pathophysiology of S-T elevation myocardial infarction.
-The difference between STEMI, NSTEMI and unstable angina.
-Differing treatment methods and priorities for different cardiac syndromes.
-The function and importance of 12 lead ECG and prehospital diagnostic testing.
-The roles and responsibilities of EMS providers as the key element in “door-to-balloon” and “door-to-needle” time for STEMI patients.
www.romduck.com
www.RescueDigest.com
Based on the principle that the distal coronary pressure measured during vasodilation is directly proportional to maximum vasodilated perfusion.
FFR is defined as the ratio of maximum blood flow in a stenotic artery to maximum blood flow in the same artery if there were no stenosis.
FFR is simply calculated as a ratio of mean pressure distal to a stenosis (Pd) to the mean pressure proximal stenosis, that is the mean pressure in the aorta (Pa), during maximal hyperaemia.
Percutaneous Coronary Intervention [PCI] has been a revolutionary advance in cardiology, and many lives have been saved as a result of the widespread application of primary PCI. However, elective PCI has not yet been proven to save lives or reduce the risk of myocardial infarction. Despite this lack of
evidence, elective PCI has been misused and in some cases, abused for nonmedical reasons. The considerable cost of elective PCI can be reduced, and the resources could potentially be utilized for better public health outcomes. The following.article intends to highlight the lack of evidence supporting the use of elective PCI, which is a problem not only in North America and Europe but also throughout the world.
Better regulation of the elective PCI procedure could reduce health care expenditures and divert resources to cardiovascular disease prevention.
Does Preoperative Coronary Revascularization Improve Perioperative Cardiac Ou...Guilherme Barcellos
Draft que encontrei de apresentação em 201: Primeiro Encontro de Medicina Hospitalista da Argentina. Slides alguns já traduzidos, outros não - não encontrei versão final. De brasileiros no evento participaram eu, Lucas Zambon e Tiago Daltoé. Boas lembranças! Resgatei agora porque trata de evidência consolidada desde aquela época, e seguimos sobreutilizando o recurso. Ou algo novo que justifique?
http://www.theheart.org/web_slides/1225253.do
A PRECOMBAT trial Premier of randomized comparison of bypass surgery vs angioplasty using sirolimus-eluting stent in patients with left main coronary artery disease
Remote Ischaemic Conditioning: A Paper Review & Uses in Paramedic Practicebgander23
A 2 part presentation. Part 1 reviews a paper on the long-term clinical outcomes of STEMI patients undergoing remote ischaemic perconditioning prior to primary percutaneous coronary intervention. The 2nd part looks at how this technique can be used in Paramedic practice.
High Risk Left main PCI using Impella in post-TAVR patient Abdelkader Almanfi
This presentation describes a novel approach to high risk Left main PCI using Impella device for hemodynamic support in patient who already had TAVR .. this case was presented at at CRT 2016 meeting in Washington DC.
Presentation about the hazards and potential complications that could happen in any cardiac or peripheral catheterization procedure and how to avoid them
This presentation is about procedure called TAVI (Transcatheter Aortic Valve Implantation ) as a new alternative treatment to surgical valve replacement for patient with symptomatic severe Aortic stenosis who can't undergo surgery ..
Encryption in Microsoft 365 - ExpertsLive Netherlands 2024Albert Hoitingh
In this session I delve into the encryption technology used in Microsoft 365 and Microsoft Purview. Including the concepts of Customer Key and Double Key Encryption.
DevOps and Testing slides at DASA ConnectKari Kakkonen
My and Rik Marselis slides at 30.5.2024 DASA Connect conference. We discuss about what is testing, then what is agile testing and finally what is Testing in DevOps. Finally we had lovely workshop with the participants trying to find out different ways to think about quality and testing in different parts of the DevOps infinity loop.
Securing your Kubernetes cluster_ a step-by-step guide to success !KatiaHIMEUR1
Today, after several years of existence, an extremely active community and an ultra-dynamic ecosystem, Kubernetes has established itself as the de facto standard in container orchestration. Thanks to a wide range of managed services, it has never been so easy to set up a ready-to-use Kubernetes cluster.
However, this ease of use means that the subject of security in Kubernetes is often left for later, or even neglected. This exposes companies to significant risks.
In this talk, I'll show you step-by-step how to secure your Kubernetes cluster for greater peace of mind and reliability.
Software Delivery At the Speed of AI: Inflectra Invests In AI-Powered QualityInflectra
In this insightful webinar, Inflectra explores how artificial intelligence (AI) is transforming software development and testing. Discover how AI-powered tools are revolutionizing every stage of the software development lifecycle (SDLC), from design and prototyping to testing, deployment, and monitoring.
Learn about:
• The Future of Testing: How AI is shifting testing towards verification, analysis, and higher-level skills, while reducing repetitive tasks.
• Test Automation: How AI-powered test case generation, optimization, and self-healing tests are making testing more efficient and effective.
• Visual Testing: Explore the emerging capabilities of AI in visual testing and how it's set to revolutionize UI verification.
• Inflectra's AI Solutions: See demonstrations of Inflectra's cutting-edge AI tools like the ChatGPT plugin and Azure Open AI platform, designed to streamline your testing process.
Whether you're a developer, tester, or QA professional, this webinar will give you valuable insights into how AI is shaping the future of software delivery.
Essentials of Automations: Optimizing FME Workflows with ParametersSafe Software
Are you looking to streamline your workflows and boost your projects’ efficiency? Do you find yourself searching for ways to add flexibility and control over your FME workflows? If so, you’re in the right place.
Join us for an insightful dive into the world of FME parameters, a critical element in optimizing workflow efficiency. This webinar marks the beginning of our three-part “Essentials of Automation” series. This first webinar is designed to equip you with the knowledge and skills to utilize parameters effectively: enhancing the flexibility, maintainability, and user control of your FME projects.
Here’s what you’ll gain:
- Essentials of FME Parameters: Understand the pivotal role of parameters, including Reader/Writer, Transformer, User, and FME Flow categories. Discover how they are the key to unlocking automation and optimization within your workflows.
- Practical Applications in FME Form: Delve into key user parameter types including choice, connections, and file URLs. Allow users to control how a workflow runs, making your workflows more reusable. Learn to import values and deliver the best user experience for your workflows while enhancing accuracy.
- Optimization Strategies in FME Flow: Explore the creation and strategic deployment of parameters in FME Flow, including the use of deployment and geometry parameters, to maximize workflow efficiency.
- Pro Tips for Success: Gain insights on parameterizing connections and leveraging new features like Conditional Visibility for clarity and simplicity.
We’ll wrap up with a glimpse into future webinars, followed by a Q&A session to address your specific questions surrounding this topic.
Don’t miss this opportunity to elevate your FME expertise and drive your projects to new heights of efficiency.
Elevating Tactical DDD Patterns Through Object CalisthenicsDorra BARTAGUIZ
After immersing yourself in the blue book and its red counterpart, attending DDD-focused conferences, and applying tactical patterns, you're left with a crucial question: How do I ensure my design is effective? Tactical patterns within Domain-Driven Design (DDD) serve as guiding principles for creating clear and manageable domain models. However, achieving success with these patterns requires additional guidance. Interestingly, we've observed that a set of constraints initially designed for training purposes remarkably aligns with effective pattern implementation, offering a more ‘mechanical’ approach. Let's explore together how Object Calisthenics can elevate the design of your tactical DDD patterns, offering concrete help for those venturing into DDD for the first time!
Epistemic Interaction - tuning interfaces to provide information for AI supportAlan Dix
Paper presented at SYNERGY workshop at AVI 2024, Genoa, Italy. 3rd June 2024
https://alandix.com/academic/papers/synergy2024-epistemic/
As machine learning integrates deeper into human-computer interactions, the concept of epistemic interaction emerges, aiming to refine these interactions to enhance system adaptability. This approach encourages minor, intentional adjustments in user behaviour to enrich the data available for system learning. This paper introduces epistemic interaction within the context of human-system communication, illustrating how deliberate interaction design can improve system understanding and adaptation. Through concrete examples, we demonstrate the potential of epistemic interaction to significantly advance human-computer interaction by leveraging intuitive human communication strategies to inform system design and functionality, offering a novel pathway for enriching user-system engagements.
Smart TV Buyer Insights Survey 2024 by 91mobiles.pdf91mobiles
91mobiles recently conducted a Smart TV Buyer Insights Survey in which we asked over 3,000 respondents about the TV they own, aspects they look at on a new TV, and their TV buying preferences.
Accelerate your Kubernetes clusters with Varnish CachingThijs Feryn
A presentation about the usage and availability of Varnish on Kubernetes. This talk explores the capabilities of Varnish caching and shows how to use the Varnish Helm chart to deploy it to Kubernetes.
This presentation was delivered at K8SUG Singapore. See https://feryn.eu/presentations/accelerate-your-kubernetes-clusters-with-varnish-caching-k8sug-singapore-28-2024 for more details.
Generating a custom Ruby SDK for your web service or Rails API using Smithyg2nightmarescribd
Have you ever wanted a Ruby client API to communicate with your web service? Smithy is a protocol-agnostic language for defining services and SDKs. Smithy Ruby is an implementation of Smithy that generates a Ruby SDK using a Smithy model. In this talk, we will explore Smithy and Smithy Ruby to learn how to generate custom feature-rich SDKs that can communicate with any web service, such as a Rails JSON API.
Neuro-symbolic is not enough, we need neuro-*semantic*Frank van Harmelen
Neuro-symbolic (NeSy) AI is on the rise. However, simply machine learning on just any symbolic structure is not sufficient to really harvest the gains of NeSy. These will only be gained when the symbolic structures have an actual semantics. I give an operational definition of semantics as “predictable inference”.
All of this illustrated with link prediction over knowledge graphs, but the argument is general.
JMeter webinar - integration with InfluxDB and GrafanaRTTS
Watch this recorded webinar about real-time monitoring of application performance. See how to integrate Apache JMeter, the open-source leader in performance testing, with InfluxDB, the open-source time-series database, and Grafana, the open-source analytics and visualization application.
In this webinar, we will review the benefits of leveraging InfluxDB and Grafana when executing load tests and demonstrate how these tools are used to visualize performance metrics.
Length: 30 minutes
Session Overview
-------------------------------------------
During this webinar, we will cover the following topics while demonstrating the integrations of JMeter, InfluxDB and Grafana:
- What out-of-the-box solutions are available for real-time monitoring JMeter tests?
- What are the benefits of integrating InfluxDB and Grafana into the load testing stack?
- Which features are provided by Grafana?
- Demonstration of InfluxDB and Grafana using a practice web application
To view the webinar recording, go to:
https://www.rttsweb.com/jmeter-integration-webinar
2. Disclosure
I have nothing to disclose except that I am getting free
lunches, books, dinners and courses from countless number of
companies.
But for sure, No cash money or checks involved (yet)
3. Original Article
Randomized Trial of Preventive Angioplasty
in Myocardial Infarction
David S. Wald, M.D., Joan K. Morris, Ph.D., Nicholas J. Wald, F.R.S., Alexander J.
Chase, M.B., B.S., Ph.D., Richard J. Edwards, M.D., Liam O. Hughes, M.D., Colin
Berry, M.B., Ch.B., Ph.D., Keith G. Oldroyd, M.D., for the PRAMI Investigators
N Engl J Med
Volume 369(12):1115-1123
September 19, 2013
4. Study Overview
• Patients with acute STEMI were randomly assigned
to undergo infarct-vessel-only PCI or preventive
PCI (PCI to noninfarct arteries with stenoses).
• The rate of the primary outcome of cardiac
death, myocardial infarction, or refractory angina
was lower with preventive PCI.
10. Conclusions
• In patients with STEMI and multi-vessel
coronary artery disease undergoing infarctartery PCI, preventive PCI in non-infarct
coronary arteries with major stenoses
significantly reduced the risk of adverse
cardiovascular events, as compared with PCI
limited to the infarct artery.
11. Critics about the study:
- Sample size is small
-Larger number of patients were inferior infarcts
- EF was not reported in the study
12. What does the guidelines say about PCI in
STEMI and how the question of noninfarct artery
PCI was addressed in 2013 guidelines ?
13. Primary PCI in STEMI
I
IIa
IIb
III
Primary PCI should be performed in patients with
STEMI and ischemic symptoms of less than 12 hours’
duration.
I
IIa
IIb
III
Primary PCI should be performed in patients with
STEMI and ischemic symptoms of less than 12 hours’
duration who have contraindications to fibrinolytic
therapy, irrespective of the time delay from FMC.
I
IIa
IIb
III
Primary PCI should be performed in patients with
STEMI and cardiogenic shock or acute severe
HF, irrespective of time delay from MI onset.
14. Primary PCI in STEMI
I
IIa
IIb
III
Primary PCI is reasonable in patients with STEMI if
there is clinical and/or ECG evidence of ongoing
ischemia between 12 and 24 hours after symptom
onset.
I
IIa
IIb
Harm
III
PCI should not be performed in a noninfarct artery at
the time of primary PCI in patients with STEMI who
are hemodynamically stable
16. PCI of a Noninfarct Artery Before Hospital Discharge:
Recommendations
CLASS I
1. PCI is indicated in a noninfarct artery at a time
separate from primary PCI in patients who have
spontaneous symptoms of myocardial ischemia. (Level
of Evidence: C)
CLASS IIa
1. PCI is reasonable in a noninfarct artery at a time
separate from primary PCI in patients with
intermediate- or high-risk findings on noninvasive
testing. (Level of Evidence: B)
17. Multivessel coronary artery disease is present in 40% to 65%
of patients presenting with STEMI who undergo primary PCI
and is associated with adverse prognosis.
Studies of staged PCI of noninfarct arteries have been
nonrandomized in design and have varied with regard to the
timing of PCI and duration of follow-up.
These variations have contributed to the disparate findings
reported, although there seems to be a clear trend toward
lower rates of adverse outcomes when primary PCI is limited
to the infarct artery and PCI of a noninfarct artery is
undertaken in staged fashion at a later time.
18. The largest of these observational studies compared 538 patients
undergoing staged multivessel PCI within 60 days of primary PCI
with propensity-matched individuals who had culprit-vessel PCI
alone.
Multivessel PCI was associated with lower mortality rate at 1 year
(1.3% versus 3.3%; p0.04). A none significant trend toward a lower
mortality rate at 1 year was observed in the subset of 258 patients
who underwent staged PCI during the initial hospitalization for
STEMI.
19. Although fractional flow reserve is evaluated infrequently in
patients with STEMI, at least 1 study suggests that
determination of fractional flow reserve may be useful to
assess the hemodynamic significance of potential target
lesions in noninfarct arteries.
The writing committee encourages research into the benefit
of PCI of noninfarct arteries in patients with multivessel
disease after successful primary PCI
20. Prognostic Impact of Staged vs. “Onetime”
Multivessel PCI in AMI
Retrospective analysis of 668 pts from HORIZONS-AMI
• One-time multivessel PCI was associated with higher rates of
all-cause and cardiac mortality as well as stent thrombosis
compared with staged PCI
• The mortality advantage was maintained in a subgroup of pts
undergoing „truly elective‟ multivessel PCI
• In multivariable analysis, staged vs. onetime PCI was an
independent predictor of 1-year mortality
Implications: Deferred angioplasty of significant nonculprit lesions
should be the default strategy for patients undergoing primary PCI.
Kornowski R, et al. J Am Coll Cardiol.
2011;58:704-711.
21. Culprit Vessel Only vs. Multivessel and
Staged PCI for Multivessel Disease in
STEMI Patients
Meta-analysis of 4 prospective and 14 retrospective studies (n = 40,280)
Staged PCI was associated with lower short- and long-term
mortality compared with culprit-vessel-only and multivessel PCI
Multivessel PCI was linked to the highest mortality rates at both
short- and long-term follow-up
The best strategy in pts with cardiogenic shock remains
uncertain
Implications: In STEMI pts, significant nonculprit lesions should be
treated only during staged procedures, a finding that supports
guidelines.
Vlaar PJ, et al. J Am Coll Cardiol.
2011;58:692-703.
22. Multivessel Coronary Artery Revascularization vs.
Culprit-Only Revascularization in STEMI Patients
Meta-analysis of 19 studies (n = 61,764), including 2 randomized trials.
• Within 30 days, there was no difference between groups for
mortality, MI, stroke, and TVR, but multivessel PCI decreased
repeat PCI by 44% and MACE by 32%
• Over mean follow-up of 2 years, there was no difference
between groups for MI, TVR, or stent thrombosis, but
multivessel PCI lowered mortality by 33%, repeat PCI by 43%,
and MACE by 40%
Implications: A large-scale randomized trial is needed to evaluate
comparative efficacy between multivessel revascularization and a
culprit-only strategy.
Bangalore S, et al. Am J Cardiol.
2011;Epub ahead of print.
23. 55 YO male, initial presentation of CAD
Anterior STEMI – 6 hours of chest pain
ECG: Ant. ST Elevation with RBBB
100/70, pulse 95, O2Sat =96%
BP
.T
otal LAD
• Culprit
• >90% Prox. CX
• Dominant
• 50% Left Main
Small (non dominant)
RCA
24. 55YO male, initial presentation of CAD
Anterior STEMI – 6 hours of chest pain
ECG: Ant. ST Elevation with RBBB
100/70, pulse 95, O2Sat =96%
BP
What to do?
1. Culprit only (LAD)
2. LAD and CX
3. LAD now and
CX later
(Staging)
• When?
4. Other
Small (non dominant)
RCA
25. Why to perform non-culprit
PCI
• Improve hemodynamics
– Hypercontraction of non-infarct territory (especially
important in patients with cardiogenic shock)
• Prevent reinfarction
– Vulnerable non-culprit lesion can become culprit
(“pan-coronary inflammation”)
• Patient is already receiving aggressive
antithrombotic therapy
– Protected from complications?
• Decrease the need for repeat procedures
– Associated morbidity and cost
26. Why not to perform nonculprit PCI (1)
Ischemic complications may lead to
severe hemodynamic compromise
There is already myocardial dysfunction
secondary to the damage from the
culprit
There is a risk of ischemic complication
in every PCI
Risk is higher in the setting of MI due to
the generalized inflammatory condition
Risk of transformation to culprit during
hospitalization is extremely low
Patient receiving aggressive adjunct
therapy
27. Why not to perform nonculprit PCI (2)
Contrast nephropathy
Increased contrast load in the setting of
unknown kidney function in a patient
with decreased renal blood flow (due to
the infarction)
Non culprit lesion may not be associated
with future symptoms/ ischemia
Overestimation of severity at time of
acute angiography?
28. US National Cardiovascular Data Registry - STEMI
Single vs. Multivessel Procedures during Primary PCI
Hospital Mortality
Unadjusted Data
% death
P= 0.01
Guidelines not
necessarily supported by
literature
P< 0.01
Cavender et al. Am J Cardiol
2009
29. Four prospective and 14
retrospective studies
involving 40,280 patients
were included
Pairwise comparison
among 3 post culprit PCI
strategies:
1. Culprit only
2. Staged revascularization
3. Complete revascularization
J Am Coll Cardiol 2011;58:692–703
30. Short Term Mortality – Pairwise Meta-Analysis
Prospective RCT
Registry
Prospective and retrospective data
lead to different results
Suggestive of significant selection bias
Combined
Culprit
Multivessel
31. Conclusions
Retrospective studies are strongly limited by
selection bias and prospective randomized
studies are small and inconclusive
Staged revascularization emerges as the
preferred approach for stable patients
Non-culprit revascularization strategy should
be individualized based on patient‟s
characteristics
32. Back to the Patient
“individualized” decision for this patient:
Stent the non-culprit first to enable
safer treatment of the LAD lesion
Limited reserve due to the
specific
anatomy