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Patients with concurrent heart failure and kidney disease are not getting proper GDMT

We have all seen the story play out before: a patient with heart failure with reduced ejection fraction (HFrEF) who is new to a hospital system is hospitalized for acute decompensated heart failure. A look at their complete metabolic panel shows a Cr of 2.0 mg/dL (with a corresponding eGFR of 35 mL/min/1.73m2), and despite diuresis, the Cr does not really budge. What was initially thought to be an acute kidney injury from possible renal vascular congestion or from renal hypoperfusion turns out to be a more longstanding chronic kidney disease (CKD). Because the medical team has only met the patient for the first time during this hospitalization and they “do not know where the kidney function is going to shake out,” the patient is perhaps started on a beta-blocker but no other guideline-directed medical therapy (GDMT). The patient is discharged from the hospital on only one guideline-recommended agent. Patients like this, with concurrent HFrEF and CKD, can easily get trapped in a vicious cycle in which they are recurrently hospitalized with heart failure exacerbations and varying degrees of kidney injury; their kidney function becomes an impediment to starting the crucial GDMT which will lower their mortality, reduce their likelihood of being hospitalized again, and even improve their quality of life.

This anecdotal experience is supported by data from a new study published in the Journal of the American College of Cardiology (JACC), “Kidney Function and Outcomes in Patients Hospitalized with Heart Failure.” This study utilized the Get With the Guidelines-Heart Failure (GWTG-HF) registry and analyzed over 365,000 hospitalizations with heart failure, including about 157,000 patients hospitalized for heart failure with a reduced ejection fraction (HFrEF, EF ≤40%). Hospitalized patients had kidney function all across the spectrum, ranging from those with a normal estimated glomerular filtration rate (eGFR) of ≥90 mL/min/1.73 m2 (10% of patients) to those on dialysis (5% of patients). As patients’ eGFR decreased (as kidney function worsened), in-hospital mortality rates for heart failure patients increased from about 1% for those with a normal eGFR to 4-5% for those with an eGFR <30 mL/min/1.73m2 or on dialysis.

Among patients with HFrEF, those with lower eGFR or on dialysis were less likely to be discharged on GDMT such as beta-blockers, mineralocorticoid receptor antagonists, angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), or angiotensin receptor II blocker-neprolysin inhibitors (ARNI), than those with normal renal function. This pattern was consistent regardless of race/ethnicity and sex. Patients with worse renal function (measured as lower eGFR at time of discharge) were also less likely to have an appointment made after discharge.

These disparities in quality metrics for heart failure patients, particularly those with CKD, are disheartening because 1) many patients with heart failure also have concurrent chronic kidney disease and 2) hospitalized heart failure patients with worse kidney function already experience worse clinical outcomes, such as higher mortality (as shown in this and other studies). Though the use of evidence-based medical therapies is often suboptimal among all patients with HFrEF, patients with comorbid HFrEF and CKD are an especially vulnerable group who would especially benefit from treatment with medications that are proven to improve outcomes. Additionally, though they seem to less frequently have post-discharge outpatient appointments made, these patients would benefit from more (and not less) post-hospital monitoring.

This large contemporary study of patients from a major heart failure registry highlights a gap that we must address among heart failure patients at various stages of kidney disease. More work must be done to prevent or slow the progression of chronic kidney disease in heart failure patients. Finally, special attention should be given to the utilization of guideline-directed medical therapy in this vulnerable population of patients in order to help improve their outcomes, particularly when they are hospitalized for acute decompensated heart failure.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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Listen to Your Heart: How to Prepare Yourself for A Career in Cardiology

The road to Cardiology fellowship can be a confusing one. Residency, with its breakneck pace and punishingly long hours, is already a Herculean challenge in and of itself. Simply completing residency is its own feat. Attempting to set yourself up for the next stage in your career in a hyper-competitive specialty adds an entirely new layer of complexity. Trainees on this path towards post-residency training in Cardiology often find themselves asking critical questions: How can I figure out if Cardiology is truly the right field for me? How can I prepare myself for fellowship? What can I do to make myself a competitive applicant?

As you can imagine, the real answer here is that there is no one right way to approach the journey of becoming a cardiologist. Everyone must forge their own path. Still, I would like to share some lessons I have learned from my experiences as a Cardiology-bound resident.

Trade into Cardiology rotations

The only way to find out if you like Cardiology is to ensure that you actually have exposure to it. Sometimes, this means trading into additional Cardiology rotations and increasing your exposure to both cardiologists and potential Cardiology mentors who can talk to you about this career. Only by rotating in Cardiology rotations can you decide if this is a field that you would like to pursue further!

Seek out outpatient Cardiology experiences

Much of the exposure that Internal Medicine residents have to Cardiology during residency comes in the form of inpatient Cardiology rotations (Cardiology wards, Cardiac ICUs). While these are wonderful entry points into the field, they represent only a fraction of the breadth and depth of Cardiology. They may even erroneously lead you to think that most Cardiology happens inside of the hospital (surprise: much of it happens in the outpatient setting). I did not realize this myself until I participated in an ambulatory Cardiology elective. I strongly encourage you to explore the world beyond the CCU or Cardiology wards, so that you can develop a more realistic view of how you will spend the majority of your clinical time later in your career.

But don’t do too much Cardiology!

A common misconception among residents, regardless of their intended career, is that they should only pursue experiences in their field of interest. While this is admirable and might make you feel more prepared for fellowship, you must remember that nothing can truly prepare you for a career in a subspecialty except for fellowship itself. You will have entire years of your academic life set aside to learn how to be a cardiologist. However, after residency, you will no longer have the opportunity to improve upon your weaknesses in other areas of Internal Medicine. One of my mentors once told me that I should use my spare elective time to learn about other subspecialties so that I can become a better and more well-rounded internist. You will have plenty of time to learn about Cardiology during the fellowship. Use this precious extra time to learn about other things that will make you a better doctor, and ultimately, a better cardiologist.

Seek mentors out early

One common mistake that I see people make is that they wait too long connect with potential mentors. Applying to Cardiology fellowship applications is an extremely competitive process.  Thus, it can only help to have mentors in your corner who help you think about your career goals, give you feedback about your fellowship application, help you plan research projects, connect you with other mentors, write letters of recommendation on your behalf, and go to bat for you when the time comes. However, mentor-mentee relationships are not born overnight. You need to dedicate time to building a relationship with mentors that understand you and advocate for you. Allow time to see if you and a mentor hit it off and give your mentor a chance to get to know the real you. The only way to accomplish this is to start early.

Find projects that excite you

It can be really tempting to fall into the trap of taking on as many research projects as possible with the sole purpose of “fluffing” your resume, without regard to a project’s value or quality. Remember that everything you put out into the world is a reflection on you; you should be willing to stand proudly by any work that you produce. Be judicious. Select only those projects in which you are genuinely invested. Don’t just pad your resume with countless meaningless abstracts or manuscripts. Quality will always triumph over quantity.

Set realistic research goals

At the end of the day, your primary job in residency is to be a resident. Sometimes you will be too busy to do research. Sometimes you will be too drained to do research. Sometimes you need to recharge instead of doing yet more work. That’s OK. You cannot do it all. During my first meeting with one of my mentors, we talked about pursuing smaller projects that I could realistically complete during residency rather than trying to take on huge untenable projects. In retrospect, it was incredibly thoughtful and kind of my mentor to be so deliberate. It helped me set more realistic goals about what I could accomplish during residency and it made my research experience more fulfilling. You are a very busy resident. You should accordingly select realistic, sustainable and completable projects.

Join the online Cardiology community!

There is a very active Cardiology community on social networks such as Twitter, talking about the latest high-profile articles, debating new guidelines, and sharing amazing tweetorials or interesting clinical experiences. Social media offers a great opportunity to get to know and make connections with people in the field. I “met” some people on Twitter before I formally met them on the interview trail. It was nice to already have that connection with others in Cardiology. It made me feel from the very beginning that I belonged to a larger Cardiology community. Moreover, it has enhanced both my learning and my excitement about becoming a cardiologist!

Integrity is everything

No matter what you do, put your best foot forward every time. Your reputation really does matter. Though it seems large, Cardiology is also a tightly knit community and people do talk. You will want to develop a reputation as a hardworking, honest, conscientious and reliable person. Actions always speak louder than words. Remember that everything you do will be a reflection on you and your character. When in doubt, ask yourself, can I proudly stand by this decision a month or a year from now? Do the right thing every time. Don’t cut corners. Work hard and be kind. Whether you do good or bad things, people will take notice, and they won’t forget.

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

 

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You May Turn Off Your Cameras Now: Trials & Tribulations of the Cardiology Fellowship Zoom Interview Trail

Last month, I dedicated my blog post to tips for prospective Cardiology fellowship applicants. In this companion piece, I would like to share my experience on the Cardiology fellowship virtual interview trail. Part of my motivation is to provide additional information for Cardiology fellowship applicants, but also to shed light on various approaches – both successful and unsuccessful – to the virtual interviews. There was much hand-wringing this past year about the diminishment of the fellowship interview experience, which by necessity became all-virtual due to the COVID-19 pandemic. In some ways, it was better – the lack of travel made it more affordable and increased flexibility. In other ways, it was worse – being on camera for seemingly endless hours and feeling as if programs were invading your private space at home. Here are some takeaways from the 2020 Cardiology fellowship virtual interview season.

Virtual interviews are convenient

Say what you want about virtual interviews, but there is no denying that they are more affordable, convenient and flexible. Residents working 60-80 hours a week suddenly did not have to spend thousands of dollars traveling around the country. Applicants did not have to leave the comfort of their own home or office to interview around the country and as a result did not have to work as hard to find extra coverage. These decreased barriers democratized the interview process. However, virtual interviews also encouraged applicants to apply to more programs, clogging up the application pile and making it harder for fellowship program directors select among many highly qualified applicants.

Virtual interviews are surprisingly exhausting

Although Zoom interviews were convenient, many applicants found them to be mentally and emotionally draining. No matter how hard you try, Zoom cannot replace a real-life social interaction that is influenced not just by the things that you say or your facial expressions, but by the environment around you and the participants’ body language. Much of this context is lost during a video interview. Instead you are left with the feeling that you must be “on” all the time, lest the person on the other side of the camera misperceive you as being uninterested. That is not to say that you are not being closely observed at an in-person interview, but that this feeling of being under the eye is heightened when you are staring at a blinking green camera dot on your laptop for hours on end. As a result, the overall experience ended up being more tiring than I anticipated.

We could all stand to spend less time on camera

Although I have always thought of myself as an extroverted person, I found it difficult to be on camera for more than a couple of hours at a time. In fact, I greatly appreciated when program directors or coordinators took care to encourage us to take a break and turn off our cameras during gaps in between interviews. During these breaks, I would get up, stretch, and in a few cases even left my apartment to go for a short walk around my neighborhood.

A virtual interview does not need to last an entire day

I grew to appreciate efficiency and brevity in a virtual interview day. One interview day lasted for nine hours. By the eighth hour, I felt exhausted and unable to retain any further information. I had heard what I needed to hear about the program; those last few hours did not augment my experience. The most memorable part of the day ended up being the relief I felt when I logged off as the sun was setting. That overall experience would have been more pleasant, and the same amount of information would still have been conveyed, if the day had ended a few hours earlier. Therefore, I would argue that the ideal interview day length is four to five hours: a program should be able to conduct interviews and transmit all key information to applicants in, at most, six hours.

It’s hard to get the “pre-interview dinner” right on Zoom

Some programs chose to host a pre-interview Zoom “dinner” the night(s) before the interview, while others did not. Looking back on it, this decision did not affect how I viewed individual programs. I found one-on-one conversations in which I could talk with current fellows, especially fellows with whom I had some kind of personal connection, to be much more helpful than stilted virtual “dinners.” The experience with these Zoom “dinners” was variable. Some were well-run, leaving little ambiguity about what we were supposed to do at any given time and controlling the pace of conversations in a way that avoided awkward pauses. Others were disorganized to the point of being uncomfortable to sit through. These sessions are challenging because while some people prefer to be very active participants, others wish to more passively observe and take in information. It is difficult to cater to both of these types of people in a way that feels natural.

My recommendation: if you are going to host a Zoom, the session should be heavily structured so that 1) participants know exactly what to do at any given time, 2) applicants are given the space to ask questions without having to compete with others (short, timed breakout room sessions help with this), 3) providing discussion topics to fellows in case a group of applicants is unusually quiet and 4) ending sessions in a timely fashion so that participants do not have to sit in excruciating silence when everyone has run out of things to discuss. Efficiency is your friend here, as well.

You CAN still get a “feel” for a place without physically being there

Program directors and applicants were concerned that we would not get a good “feel” for individual programs without physically being there. I found conversations with fellows and attendings at various programs to be incredibly helpful in filling this gap. To my own surprise, by the end of most interview days, I logged off feeling as though I had a pretty good sense of what each program valued and ways and whether it might be a good fit for me.

Virtual interviews should be an opportunity to re-think how we do interviews

Instead of perceiving it as a crutch, program directors should view the virtual aspect as a chance to revitalize the interview day and distill it to its essentials. In some interviews, it felt as though programs were trying to recreate the entire in-person interview day on Zoom. This is a flawed approach because not everything translates well to Zoom. For example, pre-produced videos about the program do not need to be played in real-time during the interview day – applicants can watch these on their own time. Likewise, some PowerPoint presentations could also be pre-recorded for applicants to view in advance. The end result would be a leaner, more efficient interview day in which the limited on-camera time is spent interacting with others, so that applicants come away with a more nuanced and comprehensive understanding of each program without spending an entire business day on camera.

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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So You Want To Apply To Cardiology Fellowship: Tips From the 2020 Application Cycle

The fellowship match process for Cardiology, an increasingly saturated subspecialty with an ever-expanding applicant pool, is extremely competitive. However, the 2020 application cycle proved to be an entirely different beast, with the COVID-19 pandemic and the inability to interview in-person adding layers of complexity to an already confusing process.

Applicants and fellowship program directors alike wrung their hands over the impersonal nature of Zoom interviews (how could you really feel the “vibe” of a place from a Zoom?). Sure, costs decreased because programs were not “wining and dining” applicants and applicants did not have to travel while working full-time. But this democratization of the application process had the adverse effect of leading many applicants to apply to many more programs. Cardiology program directors were overwhelmed by record numbers of applications. Concurrently, applicants were distressed about not receiving interview invitations. It was tough.

As someone that just matched into Cardiology, I would like to offer some unsolicited advice for future fellowship applicants:

DO be judicious in how you build your Cardiology resume

Fellowship applicants are told that they need to join projects or produce manuscripts to “show interest” in Cardiology. While it is important that you explore Cardiology outside of your clinical rotations, it is also important to choose quality over quantity and not over-commit to projects for the sole purpose of buffing your resume. For each possible project or extracurricular activity, be a little bit selfish and ask yourself, what will I get out of this experience? Will you acquire new skills? Will you gain valuable new insight or knowledge? Will you build relationships with great mentors? How will that project fit into your personal narrative or your career interests within Cardiology? Your time is precious. Spend it developing meaningful, in-depth experiences that help you grow as a future cardiologist, not just checking off boxes.

DO give yourself time to make your personal statement about YOU

Writing is hard. I love writing, but I find it uniquely painful and time-consuming. My first drafts are awful; I go through countless edits before landing on a final product that I can tolerate. Writing personal statements is EXTRA hard because we are bad at writing about ourselves and framing our lives and career goals into a short, neat narrative. Instead, we resort to narratives about patients (nice, but says nothing about who YOU are) or generic maxims (ditto). Your personal statement needs to be PERSONAL. It should be about YOU, the journey you took to get to where you are today, and the journey you hope to embark on next. What MUST the reader absolutely know about you by the time they get to the end of the essay? Does a sentence or paragraph reveal anything about you or does it serve a purpose in telling your story? If the answer to either of these questions is “No,” cut that sentence/paragraph out. Be brutal. Lastly, find out who in your life is a good editor and ask them for lots of feedback.

DO be realistic / DON’T take away opportunities from other people

Some applicants are overly confident and do not apply to enough programs. Some apply to way too many, ultimately interviewing at programs in which they are not truly interested, thus shutting out other applicants who would have loved to interview at those programs. How do I know if I am a competitive applicant? How many applications is too many?, you might ask. The only way to know is to make a list of programs to which you’d like to apply and show it to trusted advisors (e.g. your program director). Solicit their honest feedback so that you can make an informed decision about what you need to do to be able to match.

DO research the institutions to which you apply and interview

There are many great Cardiology fellowship programs. There are no “best” programs. The best program for you is one that aligns with your career goals. Different programs have different flavors, strengths, and weaknesses. While interviewing, I realized that some programs were a great fit for me and my specific interests, while other, equally amazing programs were not. The only way to figure out whether a program might be well-tailored to your interests is to research programs before you apply (search online, talk to people that know the program), research them again before your interview, and ask lots of questions during your interview day. If you know before you even apply that a program would not be a good fit for you, why apply there?

DO pre-plan your Zoom interview space

Are you the kind of person that goes with the flow? Or do you get anxious and feel the need to exert control over your surroundings? If you are the former, then great! If you are more high-strung, however, plan your Zoom space out in advance so that there are no unpleasant surprises on Game Day. Where are you going to place the camera? Does your laptop need to be propped up so that the camera is in line with your eyesight? Do you need additional lighting so that others can see you well? Is there too much noise from your surrounding milieu? Does your location have a reliable internet connection? Do you wish to display anything behind you while you are on Zoom? Note that anything you display on screen [e.g. books, artwork] is an open invitation for the interviewer to ask you questions about said item.

DO talk to acquaintances at fellowship programs

Now that interviews are on Zoom, it is as important as ever to talk to current Cardiology fellows and solicit their honest opinions about programs. I found talking one-on-one with people I knew at various fellowship programs to be more helpful in giving me a sense of that program’s “vibe” than just about anything else I heard on interview day. Ask to talk one-on-one with a fellow at every program with which you interview (i.e. someone who attended your medical school or residency, who is from a similar area or who has something in common with you). After these conversations, I felt more confident that I knew what I needed to know in order to make informed decisions about where to place programs on my rank list.

DO think about your “5-10 year plan” and career goals

We all dread the interview question about our “5-10 year plan.” However, rest assured that you will be asked about it at virtually every interview. The fellowship is the final training ground before you launch into your career. Because many people often stay at their institution after fellowship, your fellowship interview in some ways doubles as a faculty interview. The program will view you as a long-term investment and they want to know what you would bring to the department. With that in mind, think about your narrative. How will you “package” yourself? Sure, everyone knows that things might change in the future, but as things stand right now, what niche will you carve out for yourself if you become faculty in the department after fellowship? You should be ready to answer these questions.

DON’T be afraid to preserve your spirit

Interviewing can be fun, but it can also be stressful when paired with an 80-hour-per-week job. Find ways to decompress before, after, or during your interview day. Exercise as needed, spend time with family, debrief with friends, take breaks. For self-care, on Zoom interview days, I would select a 30-60 minute window when I was not on camera and leave my apartment to grab a coffee (yes, I went to the coffee shop in a suit!). It broke up my day, reenergized me, and made me feel like I was at a real in-person interview.

DO be yourself
You should always be professional and courteous to others. However, that does not mean that you need to be a robot! Do not be afraid to let your personality shine. You will have more interesting interactions with others and you will come across as more relatable. More importantly, depending on how the people on the other side of the screen respond, it may help you decide if a program is the right fit for you. Never be anyone other than yourself. You deserve to be at a program that will welcome you for who you are.

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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Let’s Ban the Phrase “Social Issues”: Social Justice and Advanced Heart Failure Therapies

Everyone on our unit seems to know Tina. Tina is a 50-year-old Black woman. She is single, has two kids and does not have stable housing, currently living with an abusive man in one of the poorest neighborhoods in Baltimore. She has nonischemic cardiomyopathy and has been admitted numerous times to the inpatient Cardiology service.

Each time, she is admitted for acute decompensated heart failure, diuresis aggressively to euvolemia, and discharged. She has not “tolerated” previous attempts to start guideline-directed medical therapy (GDMT), so the only heart failure medication she takes at home is an oral diuretic. “Behavioral issues” are flagged all over her chart: she has left against medical advice, has demonstrated “poor insight” into her medical condition, and has refused medications and treatments.

This admission is no different. When I first meet her, she is teetering on cardiogenic shock, twenty pounds above her dry weight, dry heaving and confused, her extremities cool. She quickly turns around with inotropic support and diuretics and is now doing a lot better. I’ve managed to convince the team to re-trial GDMT and we have her on a low-dose ACE inhibitor and spironolactone. The nurses on our floor have also taken a liking to her and have banded together to help care for her on her own terms. Tina is doing all of the things we are asking of her.

But what will the future look like for Tina? She has entered that unfortunate spiral in which all patients with advanced heart failure find themselves: recurrent and increasingly frequent hospitalizations, progressive decline, and seemingly no way out. One day on rounds, we discuss her options. A member of our team mentions offhand that she is obviously not a candidate for advanced therapies due to her “social issues” and her lack of adherence to prescribed therapies.

Every time I hear the words “social issues” in the hospital, I shudder and think about how loaded the phrase is. It’s a catch-all euphemism that physicians use to describe patients who face obstacles extending beyond their medical environment and into their social or contextual environment. These patients, like Tina, share certain characteristics: they are female, Black or brown, poor and live in socioeconomically deprived neighborhoods. Moreover, these patients with “social issues” do not qualify for advanced heart failure therapies such as left ventricular assist devices (LVADs) and heart transplants.

Indeed, this trend is supported by the medical literature. A recent study published in Circulation: Cardiovascular Quality and Outcomes found that women, Black patients, Latinx patients, Medicare and Medicaid patients, and those living in lower-income areas were less likely to receive LVADs than their more privileged white, male, insured counterparts living in higher-income areas.1 Likewise, another recent study published in Circulation found that a patient’s race influenced decision-making around selection for a heart transplant.2 Disparities also extend to outcomes related to these advanced therapies, as highlighted by a Circulation: Heart Failure study that found socioeconomic and racial disparities in outcomes after a heart transplant.3

In the face of such evidence, we must challenge the status quo on behalf of our patients with “social issues.” We must question the presumption that they are simply ineligible for advanced heart failure therapies. We must investigate the role that personal, social, and contextual factors have played in bringing them to the precipice of death from end-stage heart failure. We must ask ourselves how their lifelong experiences with racism and discrimination in the hands of healthcare providers affect their trust in us. We must ask ourselves which societal forces of socioeconomic oppression and structural racism make it difficult for them to obtain the care they need to live a better life. And finally, we must look inward and acknowledge the ways in which we as health care providers perpetuate racism and discrimination against them through our own words, discussions, and actions.

Most importantly, we must figure out how to right this injustice, so that we do not just take it for granted that patients like Tina cannot access LVADs and heart transplants. We need to determine what we must do to help these patients receive the same advanced interventions that their privileged contemporaries are offered.  Everyone should have equal access to these therapies; our work as cardiologists, physicians and good citizens of our society is not done until the words “social issues” are banned from our lexicon and are no longer used to disqualify patients from receiving life-saving therapies.

References:

  1. Wang X, Luke AA, Vader JM, Maddox TM, Joynt Maddox KE. Disparities and Impact of Medicaid Expansion on Left Ventricular Assist Device Implantation and Outcomes. Circulation. Cardiovascular quality and outcomes. 2020;13(6):e006284.
  2. Kuehn BM. Race May Influence Transplant Decision Making in Heart Failure: Studies Also Detail Disparities in Hypertension Diagnosis, Statin Prescribing. Circulation. 2020;141(8):694-695.
  3. Wayda B, Clemons A, Givens RC, et al. Socioeconomic Disparities in Adherence and Outcomes After Heart Transplant: A UNOS (United Network for Organ Sharing) Registry Analysis. Circulation. Heart failure. 2018;11(3):e004173.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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A Resident in a Virtual Sea of Cardiology: My #AHA20 experience

As a current Internal Medicine resident and one of the youngest members of this year’s class of AHA Early Career Bloggers, my #AHA20 experience was equal parts thrilling, educational, and overwhelming. This was my first time attending the AHA Scientific Sessions and my second virtual conference experience after this year’s QCOR 2020 Scientific Sessions.

On a personal level, although it was convenient to virtually attend from my couch or work rather than fly across the country, I found it challenging to balance my time attending the conference with my clinical work: I was rotating on the Medical ICU at the time and was on call at times during the conference. Nevertheless, the more affordable and virtual nature of the conference and the ability to view sessions that I missed on-demand felt more inclusive to me. I also really appreciated the number of sessions dedicated to early-career trainees and attendings.

It was difficult at times to keep up with a large number of sessions or choose from the rich diversity of options, but overall I loved that there was a little something for everyone. I particularly enjoyed sessions about current state of care for heart failure, controversial trials such as OMEMI, STRENGTH and exciting, ingeniously-designed trials like SAMSON, and the big topic of #AHA20, the intersection of COVID-19 and cardiovascular health.

Most strikingly, the fact that the conference was all-virtual allowed for greater democratization of the dissemination of cardiovascular knowledge. In addition to all the wonderful content supplied by the AHA, there existed in parallel an equally comprehensive and all-consuming universe of discussion on Twitter. I found myself partaking in quite a few amazing Tweetorials or Twitter discussions about different topics presented at #AHA20! Any presentation you could think of was further broken down into bite-sized pieces of information by numerous expert cardiologists in the field. You could ask any question, and a leading expert in that area who had also viewed the presentation could answer your question to help you better understand the topic! As a trainee, I thought this made it easier for me to engage with other conference attendees in a medium with which I, as a millennial, am very comfortable. I also thought that the continued reinforcement of takeaways from the conference via my Twitter news feed helped me retain more knowledge than I usually do after I leave a conference. Although there was a deluge of content to wade through, the ability to re-watch sessions or re-read discussions about them made it easier to reinforce my learning.

Attending #AHA20 virtually as a trainee and getting to engage in the incredible online discussions both during and after sessions on Twitter was a very enriching experience for me. The ability to interact online and in real-time with other trainees, fellows, and attendings around the world made me feel as though the whole experience was more equitable, democratic, and accessible to early-career attendees like me. Finally, most of all, it engendered in me an even greater excitement to begin my Cardiology training in July 2021 and to continue conducting research that I can hopefully present at future AHA meetings.

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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Last Day of #AHA20: COVID-19 Galore!

The last day of the amazing #AHA20 featured a series of COVID-19-related research presentations.

First, data from the AHA COVID-19 Registry, a large database collecting data about COVID-19 patients and outcomes around the country, were shared. The registry includes data from 109 hospitals and over 22,500 records of patients who were hospitalized with COVID-19. Notably, large numbers of COVID-19 patients in this registry had cardiovascular risk factors such as hypertension and diabetes. Prior cardiovascular disease was also common. The disease was additionally noted to have a high morbidity and mortality rate, with more than 20% of hospitalized COVID-19 patients requiring mechanical ventilation.

One interesting study examined racial and ethnic differences in the AHA COVID-19 Registry of patients hospitalized with COVID-19, focusing primarily on the association of these factors with in-hospital death as the primary outcome and secondary outcomes such as major adverse cardiovascular events (MACE: death, myocardial infarction, stroke, new onset heart failure or cardiogenic shock) or COVID-19 cardio-respiratory disease severity scale. Notably, Black and Hispanic patients accounted for >50% of hospitalizations in this Registry, suggesting significant over-representation of Black and Hispanic patients compared with the census demographics in their areas. Cardiovascular risk factors such as obesity and hypertension were also more common in Black and Hispanic patients. Mechanical ventilation and need for renal replacement therapy were more likely in Black patients. Overall in-hospital mortality was high at 18.4%, and particularly high for those older than 70 years old.

In fully adjusted models taking into account age, medical history and sociodemographic features, there was no statistically significant difference in mortality and MACE among different racial or ethnic groups, though Asian patients had a higher COVID-10 disease severity on presentation. These findings suggest that though race and ethnicity are not independently associated with worse in-hospital outcomes in COVID-19 patients, Black and Hispanic patients bear a greater burden of morbidity associated with COVID due to their disproportionate representation among patients hospitalized with CVOID-19. This study was simultaneously published online in Circulation.

One additional study examined the association between body mass index (BMI) with a composite of in-hospital death and/or mechanical ventilation (primary outcome), as well as with MACE (a composite of in-hospital all-cause death, stroke, heart failure, myocardial infarction), deep vein thrombosis and renal replacement therapy (secondary outcomes). Patients with a higher BMI were more likely to be admitted to the hospital with COVID-19. In analyses adjusting for age, sex, ethnicity, comorbidities, cardiovascular disease and chronic kidney disease, higher class obesity was associated with higher likelihood of in-hospital mortality or mechanical ventilation. MACE was not associated with obesity class. Deep venous thrombosis or pulmonary embolism were not associated with obesity class. Class I, II and III obesity, however, were noted to have a higher likelihood of need for mechanical ventilation, regardless of age. Moreover, when stratified by age, BMI >40 kg/m2 was associated with a higher risk of in-hospital death only in lower age groups (<50 years old). These findings suggest that better public health messaging may be required for younger obese individuals who may underestimate their own risk related to COVID-19. This study was also simultaneously published in Circulation.

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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Late-Breaking Highlights: Fish Oils and Frustrations in Lipid Management

It was another exciting day of virtual sessions at #AHA20, led by intriguing findings from a few late-breaking trials!

 

First, the STRENGTH and OMEMI trials added nuance to ongoing discussions about the cardiovascular benefits of fish oils and cardiovascular risk reduction. The REDUCE-IT trial, published in the New England Journal of Medicine (NEJM) in 2019, showed that the highly purified fish oil icosapent ethyl improved cardiovascular outcomes in high-risk participants who had elevated triglycerides despite statin therapy. The STRENGTH and OMEMI trial, however, may temper enthusiasm about the use of fish oils in high-risk patients.

 

The STRENGTH trial randomized 13,000 participants in 22 countries to an omega-3 carboxylic acid or corn oil placebo, with a primary endpoint of cardiovascular death, myocardial infraction, stroke, coronary revascularization or hospitalization for unstable angina. The trial was stopped early due to “futility,” though it still achieved 1580 of the target 1600 endpoints needed for results to be sufficiently powered. Compared with those receiving corn oil placebo, participants in the omega-3 fatty acid group experienced a 19% reduction in triglycerides, 20% reduction in C-reactive protein and 269% increase in plasma eicosapentanoic acid (EPA; icosapent ethyl is a highly purified and stable version of this fatty acid). Despite these biochemical differences, there was no difference in the primary outcome between the two groups, 54 months after randomization. The major adverse outcome, atrial fibrillation, was significantly more likely in the treatment arm.

 

Why do STRENGTH findings differ from those of REDUCE-IT? STRENGTH and REDUCE-IT participants had similar triglyceride levels, but patients in the STRENGTH intervention arm had lower EPA levels than those in the REDUCE-IT treatment arm. Moreover, REDUCE-IT contained more participants with established CAD. Additionally, STRENGTH used a corn oil placebo, while REDUCE-IT used a mineral oil placebo. Corn oil has been shown to have a neutral effect on triglycerides and potentially some cardioprotective effects, while mineral oil may result in unfavorable increases in triglycerides and LDL. Some may argue that the use of mineral oil in REDUCE-IT might have exaggerated the efficacy of icosapent ethyl.

 

The OMEMI trial, meanwhile, randomized 1,000 elderly, 70-82 year old patients (who had had a myocardial infarction [MI] in the 2-8 weeks prior to enrollment) to 1.8 grams of omega-3 fatty acids or a matching corn oil placebo for 2 years. It excluded participants who could not tolerate fatty acids or who had diseases that would impact their ability to survive the 2 year study period. OMEMI found no difference in the composite primary outcome (non-fatal MI, unscheduled revascularization, stroke, hospitalization for heart failure or all-cause death). There were no significant differences in key clinical subgroup analyses, and there was a greater (though not statistically significant) risk of atrial fibrillation in the treatment arm. There was no difference in major bleeding.

 

Taken together, findings from STRENGTH and OMEMI complicate the picture of fish oil utilization and raise further questions about whether the cardiovascular effects of fish oils in some populations are beneficial or neutral. More work needs to be done to better elucidate the effects of fish oils on cardiovascular risk reduction in high-risk patients.

 

Nevertheless, while STRENGTH and OMEMI made waves owing to their potential practice-changing implications, I left the day feeling particularly inspired by the SAMSON trial. This ingeniously designed trial enrolled 60 participants who had stopped taking statins due to symptoms arising within two weeks. Any symptom was eligible if it was severe enough to lead to statin discontinuation in that time span. The most common symptoms were muscle aches, fatigue, and cramps. Participants were given four bottles containing atorvastatin 10 mg tablets, four bottles containing placebo pills and four empty bottles. Each month, they were randomly assigned to take the contents of one of the bottles, in a crossover fashion, with no washout between months. They were asked to rate the severity symptoms they experienced using a mobile phone app. They were also asked 6 months after the conclusion of the trial if they had resumed taking statins. Investigators combined symptom ratings, reporting average symptoms levels during “statin”, “placebo” and “no treatment” months.

 

SAMSON found that the severity of symptoms reported was substantially higher during statin months than during no treatment months; however, this was also true for placebo. Reported symptom levels during statin and placebo months were no different from each other. The nocebo proportion was 0.9; that is, 90% of symptoms reported during statin months were elicited by taking placebo tablets as well. Even more importantly, half of the participants resumed statins again after the trial!

 

SAMSON serves as a lesson to aspiring cardiovascular researchers that even a small study can have a major impact. It displays respect and empathy for the patient experience by acknowledging rather than denying that patients do experience side effects from statins. However, it also strongly suggests that these symptoms may be attributable to the act of taking a pill rather than the medication content of the pill itself. Lastly, SAMSON proves that patients who realize that statin side effects may not actually be specific to statins themselves may be willing to resume taking statins. These findings further support the foundational concept that we as physicians must respect our patients by engaging them in shared decision-making and give patients an opportunity to understand the science, rather than simply telling them what to do.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”