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Key Takeaways From the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

What’s new in the treatment of heart failure? The 2022 AHA/ACC/HFSA Guideline for the Management was just released in the beginning of April! While much of the ground it covers might not seem particularly groundbreaking to anyone who has been paying attention to discussions on #MedTwitter, #CardioTwitter or the latest clinical trials over the last 2-3 years, it codifies the guideline directed medical therapy (GDMT) that we have all come to know and love for the treatment of heart failure with a reduced ejection fraction (HFrEF). These new guidelines also provide the first-ever guideline recommendations for patients with (heart failure with a preserved ejection fraction) HFpEF and heart failure with mildly reduced ejection fraction (HFmrEF), though the strength of recommendation for these conditions is not as strong as those for HFrEF.

Here are some key takeaways from the new heart failure guideline!

  1. Quadruple therapy GDMT for HFrEF

The latest guideline officially provides class IA recommendations for the use of the following medications in the treatment of HFrEF (defined as LVEF 40% or lower) in patients that have at least NYHA class II symptoms:

  1. Angiotensin-converting enzyme (ACE) inhibitors (ACEi) [i.e. lisinopril] or angiotensin-receptor blockers (ARBs) [i.e. losartan] or angiotensin receptor blocker/neprolysin inhibitor combination (ARNi) [i.e. sacubitril-valsartan]
  2. Beta blockers [i.e. metoprolol, carvedilol]
  3. Mineralocorticoid antagonists [i.e. spironolactone]
  4. SGLT2 inhibitors (SGLTi) [i.e. empagliflozin, dapagliflozin]

The first three classes were previously recommended for the treatment of HFrEF but prior American cardiovascular society guidelines did not include such a strong recommendation for the use of SGLT inhibitors.

  1. We now have HFimpEF

HFimpEF now refers to heart failure in someone who previously had HFrEF but whose LVEF has improved to >40%. The guideline strongly recommends continuing GDMT for patients that fall into this category.

  1. We now have HFmrEF recommendations

The guideline now provides a class 2A recommendation for the use of SGLT2i in the treatment of symptomatic HFmrEF (defined as LVEF 41-49%). It also provides class 2B recommendations for the use of ARNi/ACEi/ARB, beta blockers and MRAs in these patients. These recommendations confirm what some physicians/cardiologists have already begun doing in practice, though the level of evidence to support the use of these medications in HFmrEF as it is for patients with HFrEF.

  1. We also have new HFpEF recommendations

For the first time ever, the guideline recommends medications for the treatment of symptomatic HFpEF (defined as LVEF 50% or greater). Similar to its recommendations for the treatment of HFmrEF, it provides a class IIA recommendation for the use of SGLT2i and class 2B recommendations for beta blockers, ARNi, ACEi, ARB and MRAs, especially if the patient has an LVEF that is closer to 50%. Again, as we know, the level of evidence to support these practices is not as strong as it is for HFrEF. Still, this represents a change from previous guidelines which provided limited options for treatment of HFpEF.

  1. ICD or CRT is still recommended for primary prevention in certain cases

This guideline continues to recommend an implantable cardioverter-defibrillator (ICD)  in a subset of patients, particularly those whose LVEF remains less than or equal to 35% despite being on maximally-tolerated GDMT (there are nuances to this that we will not get into here). Similarly, as before, the guideline also continues to recommend cardiac resynchronization therapy (CRT) for patients who have an LVEF less than or equal to 35%, sinus rhythm, left bundle branch block with a QRS duration of at least 150 ms, NYHA class II-III symptoms.

  1. New recommendations for diagnosis and treatment of cardiac amyloidosis

The new guideline provides class I recommendations for checking serum and urine immunofixation electrophoresis and serum free light chains in patients (which would help diagnose AL amyloidosis) in patients for whom there is clinical suspicion for cardiac amyloidosis. Similarly, there is a class I recommendation for bone scintigraphy to evaluate for transthyretin (TTR) amyloidosis in patients for whom there is sufficient clinical suspicion for amyloidosis (left to the clinician’s judgment). Genetic testing is also recommended if a patient is diagnosed with TTR amyloidosis. For the first time, the guideline provides a class IB recommendation for the use of tafamadis in patients with transthyretin cardiac amyloidosis. And finally, the guideline gives a class IIA recommendation for use of anticoagulation in patients with concurrent atrial fibrillation and cardiac amyloidosis, regardless of CHA2DS2-VASc score.

 

“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 health matters. If you think you are having a heart attack, stroke, or another emergency, please call 911 immediately.”

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On Demand: Health Equity at #AHA21

As you may know, health equity was a major focus of the AHA 2021 Scientific Sessions, with numerous sessions that focused on cardiovascular health disparities, equity in treatment of cardiovascular disease and plenty of original health equity research. Here is a run-down of some great presentations about important topics in cardiovascular health equity from #AHA21, all of which are still available for viewing at your leisure ON DEMAND! [Please note that this list by no means comprehensive; there were many other amazing presentations which I did not have space to include here].

Fixing the Root Cause: Addressing Systemic Racism and Social Determinants of Health in Heart Failure [Oral Presentation]

This excellent and comprehensive presentation by Dr. Khadijah Breathett, MD, MS, FACC, FAHA, FHFSA showcases data from numerous studies that have found racial disparities in heart failure incidence or heart failure outcomes, vast racial disparities in access to advanced heart failure care (such as heart transplant or left ventricular assist devices), racial and gender bias in treatment of heart failure and strategies for advancing equity in treatment of heart failure. This presentation can be found in the Embracing the Melting Pot to Reduce Heart Failure: Genetics and Social Determinants of Health Session.

Association Between Community-Level Violent Crime and Cardiovascular Mortality in Chicago – A Longitudinal Analysis [Oral Presentation]

This study, conducted by Eberly et al, utilized data from the Illinois Department of Public Health and Chicago Police Department to examine the association between longitudinal changes over three time periods from 2000 to 2014 in violent crime and cardiovascular mortality rates (such as total cardiovascular mortality or coronary artery disease mortality) at the community level in Chicago, IL. They found that decrease in a community’s violent crime rates was significantly associated with a decrease in cardiovascular and coronary artery disease mortality rates. This study was presented in the Social Determinants of Cardiovascular Health Session.

Race, eGFR, and Cardiovascular Risk: A Tale of Modern Structural Racism [Oral Presentation]

This wonderful talk by Dr. Nwamaka Eneanya, MD, MPH, FASN provides a comprehensive overview of an incredibly timely and important topic. In this presentation, Dr. Eneanya establishes a clear throughline between structural racism, utilization of race in calculation of eGFR, resulting racial disparities in access to chronic kidney disease-related care (e.g. dialysis or kidney transplantation) and racial disparities in CKD-related outcomes, as well as recommendations for future non-race based approaches to define and manage chronic kidney disease. This presentation can be found in the Race, Bias and Barriers in the Cardiovascular Care of Patients with CKD Session.

Racial and Gender Differences in Lifetime Healthcare Costs Across Cardiovascular Risk Factors [Oral Presentation]

This study, conducted by Khera et al, utilized data from the Dallas Heart Study and the Dallas-Fort Worth Hospital Council Database from 2000 to 2018 to examine the relationship between factors such as race or sex and cumulative lifetime health care expenses. They found that lifetime health care expenses were substantially higher in Black individuals and men, and increased substantially with increases in cardiovascular risk factors, with many of these differences emerging after age 60. This study was presented in the Addressing Critical Questions of Health Equity and CVD Session.

Association of Cumulative Social Risk Score With Cardiovascular Outcomes in the Multi-Ethnic Study of Atherosclerosis (MESA) [Oral Presentation]

This study, conducted by Hammoud et al, utilized data from the prospective Multi-Ethnic Study of Atherosclerosis (MESA) cohort to assign a social disadvantage score (SDS) to MESA Participants based on income level, education level, single-living status and perception of lifetime discrimination (e.g. mistreated by neighbors, mistreated by police, etc.). They examined association between SDS and atherosclerotic cardiovascular disease (ASCVD) and all-cause mortality; they found that as social disadvantage score increased, so too did incidence of ASCVD and all-cause mortality. This research was presented in the Social Determinants of Cardiovascular Health Session.

Neighborhood Social Vulnerability is Associated With Major Adverse Cardiovascular Events and Deaths Among Patients Hospitalized with COVID-19: An Analysis of the AHA COVID-19 Cardiovascular Disease Registry [Poster presentation]

This study, conducted by Islam et al, utilized data from the American Heart Association COVID-19 Cardiovascular Health Registry to examine the association between neighborhood social vulnerability and major adverse cardiovascular events for patients hospitalized with COVID-19. They found that patients who resided in more socially vulnerable neighborhoods and were hospitalized with COVID-19 were more likely to experience adverse cardiovascular events during their hospitalization.

Income and Antiplatelet Adherence Following Acute Coronary Syndrome: An Administrative Claims Analysis [Oral Presentation]

This study, conducted by LaRosa et al, utilized data from a large and diverse health claims database to examine the association between household income status and antiplatelet adherence. They found that lower income status was associated with a greater likelihood of non-adherence with antiplatelet therapy after primary coronary intervention for acute coronary syndrome. This study was presented in the Social Determinants of Cardiovascular Health Session.

The Association of Social Risk Factors with Hypertrophic Cardiomyopathy Procedures and Mortality: US Nationwide Inpatient Sample, 2012-2018

This study, conducted by Johnson et al, utilized data form the U.S. Nationwide Inpatient Sample to examine the association between social risk factors, septal reduction therapy (e.g. septal myomectomy and alcohol septal ablation), ICD implantation and in-hospital mortality for patients with hypertrophic cardiomyopathy (HCM). They found significant heterogeneity in these outcomes by patient race, sex, income status and rurality.

“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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Highlights from #AHA21: Coffee and SGLT2 inhibitors!

So much great work is being shared at the AHA. I’d like to put a spotlight on two studies that stood out from Day 2 of #AHA21!

The CRAVE  Trial

The Coffee and Real-Time Assessment of Atrial and Ventricular Ectopy (CRAVE) trial attempted to address an urban myth that has been around for decades: coffee could contribute to arrhythmias. But is this actually true? The objective of this study was to assess in a more structured and scientific way to study the effects of coffee on individuals in the ambulatory setting. In this randomized crossover trial, 100 participants were each given a Fitbit Flex 2 (an accelerometer that can records step counts and number of hours of sleep), a Zio Patch (a continuously recording electrocardiogram [ECG] device), and a continuous glucose monitor to measure glucose levels. Study investigators also obtained blood samples to extract DNA to determine whether participants exhibited fast or slow caffeine metabolism genetic variants.

Participants were randomly assigned using a mobile app to either consume or avoid coffee on a day-to-day basis. Coffee consumption was validated via geo-location trackers, money incentives and daily surveys. Study investigators then compared days when people were assigned to drink coffee with those in which they were assigned to avoid it. Increased coffee consumption did not lead to an increase in atrial arrhythmias (in fact, it was associated with less supraventricular tachycardias [SVT]). However, increased coffee consumption was associated with more premature ventricular contractions (PVCs). Genetic analyses of DNA samples from participants showed that faster metabolizers were more likely to have more PVCs.

In the analysis of the Fitbit data, coffee intake was associated with 1000 additional steps on those days in which coffee was consumed, but with less sleep that same evening. Slow metabolizers of caffeine were more affected and were more likely to have reduced sleep. There were no differences in serum glucose levels with regard to coffee intake.

Study investigators concluded that coffee consumption did not lead to increased atrial arrhythmias but did increase PVCs and that coffee consumption. It also led to more physical activity, may lead to less sleep, with differential effects depending on how well people can metabolize caffeine. This is further evidence that the physiologic effects of caffeine intake are complex and varied in different populations, and should be further studied.

https://www.youtube.com/watch?v=AAc0JnX90NA&ab_channel=AHAScienceNews

The EMPULSE Trial

The Empagliflozin in Patients Hospitalized for Acute Heart Failure  (EMPULSE) trial was a randomized, placebo-controlled trial that assessed the safety and efficacy of the sodium glucose transporter cotransporter-2 (SGLT2) inhibitor empagliflozin in 500 patients who were hospitalized for acute decompensated heart failure (regardless of whether or not they had diabetes, HFpEF or HFrEF). This last distinction is key as many recent studies of empagliflozin have focused specifically on diabetic patients or patients with heart failure with reduced left ventricular ejection fraction (HFrEF). Primary outcomes included death, number of heart failure events (HFE), time to first heart failure event, change in baseline Kansas City Cardiomyopathy Questionnaire (KCCQ-TSS) after 90 days of treatment. Participants were randomized to empagliflozin 10 mg daily (and continued for at least 90 days) or to a placebo during their acute heart failure hospitalization.

After 90 days of treatment starting during their hospitalization for acute decompensated heart failure, participants who received empagliflozin were 36% more likely to see a clinical benefit (a composite of time to death, number of HFEs, time to HFE, and change from baseline KCCQ-TSS). There was a 35% percent reduction in death or first heart failure event. There was also greater weight loss, greater reduction in NT-proBNP and there were no safety concerns associated with taking the medication. Findings were similar in patients without and with diabetes, those with HFpEF and HFrEF as well as those with a new heart failure diagnosis or those with chronic heart failure.

In conclusion, this study showed that empagliflozin was both safe for patients to start taking during a hospitalization for acute decompensated heart failure and led to lower likelihood of death or new heart failure events – among other benefits – if the medication was started during that hospitalization, regardless of one’s diabetes status or ejection fraction. More work needs to be done to better understand the mechanism by which SGLT2 improve these clinical outcomes, though some speculate that their benefits have to do with the diuretic effect of the medication. In a similar vein, EMPEROR-Preserved Trial published in the New England Journal of Medicine earlier this year showed that empagliflozin reduced the risk of cardiovascular death or hospitalization in patients with heart failure with a left ventricular ejection fraction of at least 40%, regardless of whether or not they have diabetes.

Studies such as EMPULSE and EMPEROR-Preserved provide further support for utilization of empagliflozin in all patients with heart failure – not just those with a reduced ejection fraction (for which a number of studies have already shown clinical benefit, and for which SGLT2 inhibitors are already standard of care). Lively discussions in the medical community are ongoing as to whether we should be placing all patients – with reduced and preserved ejection fraction –  who are hospitalized with heart failure on an SGLT2 inhibitor, prior to discharge.

https://www.youtube.com/watch?v=Vtflg2v8m8A&ab_channel=AHAScienceNews

 

“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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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.”