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It is Time to Try Something New!

The internet has revolutionized medical education. Going through medical school– the resources are endless! It’s fun trying to figure out what’s best for your learning style but given the sheer volume of all the great content it can also be overwhelming.

Podcasts became one of my favorite ways to learn while in medical school. The internist in me craves the part of the day when I can listen to the attending think out loud. It’s all about understanding an expert’s thought process so you can begin to develop your own when it comes to cool and complex pathophysiology. Podcasts allow accessibility on demand. What a gift – and there are so many fantastic medical podcasts in production today. I couldn’t be more thankful to the doctors and educators who put their time and energy into providing free and fantastic education for so many of us.

As my career develops and I focus my interests, CardioNerds has become one of my of favorites. They take this concept of listening to experts think out loud to another level. I recently listened to a “CardioNerds Rounds” episode which involved an expert, Dr. Kittleson, sharing her thoughts on challenging hypertrophic cardiomyopathy cases. It was riveting in the way that she laid out a wonderful foundation for those still learning and at the same time discussed nuanced management that doesn’t always follow a script. Now that is cool.

Another aspect of the CardioNerds platform that has been admittedly less approachable for me is the Twitter Journal Club. As a resident, learning about cutting edge research and practice changing guidelines is not only rewarding because it delights my academic curiosity but its crucial in improving patient care. With an unending repository of gigantic new trials that continues to grow every single day, it is difficult to decipher these alone. That it where #CardsJC1 (the CardioNerds Twitter journal club) is magic.

I strongly believe the power of medicine specialties lies within the team aspect. I know our reputation has humorously involved discussing hyponatremia for an hour on rounds, but truly when the whole team is invested in discussing something new or controversial it is so much fun! That is what #CardsJC can provide, experts dissecting and explaining the meaning of a trial so it’s not just taken at face value but what it means for advancing patient care. This is how you learn in medicine, not just by memorizing, but by deepening your understanding; wrapping your head around how something came to be and where it is going. As a second year resident, I found the best teachers are usually masters of their content. This is especially highlighted when your own interns and med students want to learn more about a topic – I’m usually most successful when I take the time to prepare and be intentional.

#CardsJC gives us access to this. CardioNerds is a multimodality digital education platform with a mission to democratize cardiovascular education1,2. They held their first Twitter journal club about a year ago in February 2021. They are thoughtful in involving leading experts, trial authors, guidelines authors, and society leaders in the conversation2. Twitter’s unique platform allows for this innovative new approach to journal club. Additionally, for young learners it can be intimidating to speak up in traditional journal club settings where you barely grasp the basics much less feel comfortable challenging methodology or ideas. Twitter once again allows for anyone to engage on their own terms without the terror of having to raise your hand in a room full of highly accomplished people – we’ve all been there!

In addition to the nuanced conversations, #CardsJC comes with detailed trail summaries, infographics, and carefully crafted tweets1. This is an effective, practical, and revolutionary way for busy participants in all stages of their careers to engage with new data and integrate this into their practice. It’s a way for us to engage in rich discussion with those who may not have been accessible to us in the past. It’s also a way to create great archives of information you can refer to later, especially the trial summaries.

If you were like me and hesitant to engage with this platform in the past because it was unfamiliar – there’s even a video tutorial1! I really enjoyed this because it makes the process simple and approachable. This main #CardsJC page also includes trial summaries from past journal club discussions. Overall, I highly recommend joining the next #CardsJC on March 29th to get your feet wet! It’s sure to be a fantastic discussion about an important upcoming topic – but I won’t give away any clues just yet.

References:

  1. Cardionerds Journal Club – join the conversation on #cardiotwitter! Cardionerds. (2022, January 18). https://www.cardionerds.com/cardsjc/
  2. Dugan, E., Ferraro, R., Hamo, C., Ambinder, D., & Goyal, A. (2021). The cardionerds #cardsjc: How twitter journal clubs elevate the scientific discourse. Journal of Cardiac Failure, 27(9), 1034–1036. https://doi.org/10.1016/j.cardfail.2021.04.012

“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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The Needle Moves Slowly on MINOCA

I remember being a medical student and listening to a podcast where I first heard the term MINOCA (myocardial infarction with nonobstructive coronary arteries) in 2019. I was deciding between internal medicine and OBGYN at this time, and learning about heart disease specific to and common in women naturally grasped my attention. Dr. Bairey Merz from Cedars-Sinai provides a fantastic overview of the disease process and evaluation. I kept thinking about all the ways we’ve made incredible strides in heart disease over the years. Now, I was thinking they were unequal.

Dr. Brent Gudenkauf, a PGY-2 at the Johns Hopkins Hospital, et al. recently published a review in the Journal of the American Heart Association entitled “Role of Multimodality Imaging in the Assessment of Myocardial Infarction with Nonobstructive Coronary Arteries: Beyond Conventional Coronary Angiography1. They do a wonderful job of taking us through diagnostic criteria, preferred imaging modalities, and guideline recommendations regarding MINOCA. This term is still not commonplace outside of cardiology, and in the early days some thought these patients were having “false positive MIs” as they outline in the paper. This led to mostly women missing out on necessary diagnostic work up and targeted therapies. Today we have specific diagnostic criteria from the AHA and ESC including positive serum myocardial biomarkers and clinical evidence of MI (which can include ischemic symptoms, new ST segment changes, new LBBB, new pathologic Q waves among others) and no epicardial coronary lesions >50% stenosis on angiography.2,3

What I find disheartening is how slowly our needle has moved in terms of therapies. As they highlight in this paper, even after diagnosis of MINOCA 25% of patients continue to experience angina5 and experience worse quality of life compared with MI-CAD (MI associated with obstructive coronary artery disease) due to persistent anginal symptoms and inadequate treatment with existing antianginal therapies. They were less often treated with beta blockers and less often referred to cardiac rehab5. It is clear that this patient population of majority young women is faring worse than its traditional myocardial infarction counterpart in terms of therapies and quality of life.

For these reasons, we should all develop a good understanding of diagnostic pathways and targeted treatments. The recommended imaging modality is IVUS (intravascular ultrasound) or OCT (optical coherence tomography) 2,4. As a young trainee myself, I am not familiar with either of these modalities and was introduced to these concepts via #AHA21. OCT is an optical analogue of IVUS and can “differentiate tissue characteristics such as fibrous, calcified, or lipid-rich plaque and identify thin-cap fibroatheroma”6. During PCI, OCT can also provide information about dissection, tissue prolapse, and thrombi6; this is significant given SCAD (spontaneous coronary artery dissection), in situ thrombosis, and epicardial and microvascular spasms are all causes that can lead to MINOCA1. Cardiac MR is also useful when MINOCA is suspected as it will show late gadolinium enhancement and can also uncover mimics like myocarditis and Takotsubo cardiomyopathy. Additionally, if embolism to coronary arteries is suspected then thrombophilia workup is recommended. They do a wonderful job outlining this algorithm in Figure 2 in the paper by Gudenkauf et al.1 We should all be working to familiarize ourselves with this figure and its recommendations and integrating this into our evaluation for chest pain.

Although the advancements in diagnosis and evaluation are exciting and important, there are no randomized clinical trials evaluating treatments for patients with MINOCA. The MINCOA-BAT trial is an upcoming randomized multi-center study which will hopefully help to move the needle forward in evidence-based targeted therapies (clinicaltrials.gov, NCT 03686696). This excellent review by Gudenkauf et al should be shared widely as this is an important and still too often underdiagnosed and undertreated condition among our patients.

 

References

  1. Gudenkauf, B., Hays, A. G., Tamis‐Holland, J., Trost, J., Ambinder, D. I., Wu, K. C., Arbab‐Zadeh, A., Blumenthal, R. S., & Sharma, G. (2021). Role of multimodality imaging in the assessment of myocardial infarction with nonobstructive coronary arteries: Beyond conventional coronary angiography. Journal of the American Heart Association. https://doi.org/10.1161/jaha.121.022787
  2. Tamis‐Holland JE, Jneid H, Reynolds HR, Agewall S, Brilakis ES, Brown TM, Lerman A, Cushman M, Kumbhani DJ, Arslanian‐Engoren C, et al. Contemporary diagnosis and management of patients with myocardial infarction in the absence of obstructive coronary artery disease: a scientific statement from the American Heart Association. Circulation. 2019; 139:e891–e908. doi: 10.1161/CIR.0000000000000670
  3. Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli‐Ducci C, Bueno H, Caforio ALP, Crea F, Goudevenos JA, Halvorsen S, et al. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST‐segment elevation: the Task Force for the management of acute myocardial infarction in patients presenting with ST‐segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018; 39:119–177. doi: 10.1093/eurheartj/ehx393
  4. Agewall S, Beltrame JF, Reynolds HR, Niessner A, Rosano G, Caforio AL, De Caterina R, Zimarino M, Roffi M, Kjeldsen K, et al. ESC working group position paper on myocardial infarction with non‐obstructive coronary arteries. Eur Heart J. 2017; 38:143–153. doi: 10.1093/eurheartj/ehw149
  5. Grodzinsky A, Arnold SV, Gosch K, Spertus JA, Foody JM, Beltrame J, Maddox TM, Parashar S, Kosiborod M. Angina frequency after acute myocardial infarction in patients without obstructive coronary artery disease. Eur Heart J Qual Care Clin Outcomes. 2015; 1:92–99. doi: 10.1093/ehjqcco/qcv014
  6. Terashima, M., Kaneda, H., & Suzuki, T. (2012). The role of optical coherence tomography in coronary intervention. The Korean journal of internal medicine, 27(1), 1–12. https://doi.org/10.3904/kjim.2012.27.1.1.

“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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#AHA21: Matching Into Cardiology Fellowship: The Inside Scoop from Program Directors

We were lucky enough to hear from some exceptional PDs and APDs during #AHA21. The process of applying to cardiology fellowship can be daunting. These discussions provide amazing tips and insight on the process so we can best prepare.

What catches your eye on CVs?

Although this will vary by program and individual, a few themes were consistent amongst the panelists. Most programs and directors will be looking for continuation of a story and a common thread between your research, personal statement, and letters. You want to convey who you are and why you have an interest in cardiology. “It’s a two-way street” meaning fellowships also function as a part of a larger clinical and research program. They look for applicants who will fit into their culture and further the values of their program.

Additionally, PDs and APDs will look at the residency training programs, whether you are local and want to stay local, and your research. For your research projects, multiple panelists mentioned quality was more important than quality. The emphasis was showing you could follow a project to completion. “More than case reports or review articles, I look for a substantive experience in research.”

How much weight do you put on the personal statement? Should anything be avoided?

This should be used as a place to tell your story. “What attributes does this person have that will put their trajectory where we want our fellows to go? Does this person have resilience, are they able to turn disadvantages into advantages?”

The main themes that came across in the panelists answers to this question were humility, resilience, and a willingness to learn. Additionally, multiple people highlighted that this is a good place to address anything unusual that could cause confusion in your application – do you have an unusual timeline? Are there gaps in your career? Did you take breaks to do other things? They also mentioned that this would be a great place to highlight how your background prior to medicine/hobbies lend to your interest in cardiology. With this in mind, it’s important to remember this is different than a medical school application and you should be cautious with how provocative or creative you are in your writing. It was also mentioned that you can emphasize your love of a subspecialty but should also remain open-minded to the field as a whole. “The point of fellowship is to introduce you to the field so you can navigate the next steps in your career” and multiple panelists mentioned numerous fellows change their focus throughout fellowship and exploring is encouraged.

Tips for the virtual interview?

“It can be challenging to convey your narrative when you’re not in person. Find a way to project your narrative to someone who may have nothing in common with you.” Make sure you practice this with a loved one or your colleagues. Recognize your ticks, be careful when you’re reading from your screen when answering questions because interviewers notice. Applicants should also be aware that they will be asked behavioral questions (Ex. Tell me about a mistake you made when caring for a patient. Tell me about a challenging patient interaction). Practice these beforehand and think ahead about the kinds of answers you might give.

Be aware of how you look on your camera. Record a mock interview on zoom and watch it. Even small details like lighting and not have distracting objects placed in your screen can have a big impact in the age of virtual interviews. Attend the program orientation session the evening before. Do not turn off your camera, dress professionally, and don’t be late to zoom sessions. Research the program and ask the faculty about it! Show them you are invested and know about the program. It is still not clear whether interviews will be virtual or in-person for the next interview cycle.

Post-Interview Communication?

The main advice here was similar to what we heard during residency interviews: do not lie. Do not tell multiple programs they are your number one choice. Keep in mind, many people change their mind throughout the interview season and ultimately you do not want to make decisions early in the process. With this in mind, telling a program you are enthusiastic and interested can be very helpful. This is especially true during virtual interviews, where it can be difficult for programs to gauge interest and investment. If you genuinely feel you found your top choice, most programs encourage hearing from you. If you are trying to match to a different geographical location, this can also be a good opportunity to reiterate the reasons you want to move. Notably, you need to be mindful about over-communication.

Hearing from those on the other end of the interview process was an excellent opportunity to focus on what is important. Ultimately, its about your love for cardiology and passion for furthering the field! Find you network and enjoy this time as you explore and determine what you want to do in your career.

This program is part of the FIT Program at #AHA21.  The panelists include Drs. Eric Yang, Salim Virani, Carlos Alfonso, Naomi Botkin, Melvin Echols and was moderated by Drs. Aubrey J Grant and Agens Koczo.  All FIT program at AHA Scientific Sessions were produced and moderated by FITs for FITs. 

 

“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.”