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Get with the Guidelines (GWTG) – Stroke Patient Registry Use in Primary and Comprehensive Designated Stroke Centers during COVID-19 Pandemic

This year many of the professional conferences that traditionally took place live have had to change to virtual mode due to the global COVID-19 pandemic and its related social distancing rules.  The International Stroke Conference and Nursing Symposium was no exception. Yet it presented an excellent opportunity for many to attend, especially those who could not have joined the conference in-person had the opportunity to participate virtually.  Healthcare professionals, academicians, researchers, and supporters of stroke prevention were able to join from different places in the world, under different time zones. There were many options for participants to engage and interact in the many discussions and presentations through the online platform.

Earlier I had the opportunity to write about various topics presented during the #ISC21 (you can read them here: “Reducing Disparities through Diversity and Inclusion in Stroke Science, Clinical Trial Enrollment, and Community Engagement”; “Transformation of the GWTG – Stroke Patient Registry to into a National Representative Database of Acute Ischemic Strokes (AIS) in the U.S.”).

Today, I wanted to interview a couple of conference participants who could share with you about their experience attending this virtual conference. I also wanted them to share with you their experience with the GWTG Stroke Registry and the prevention of stroke in the midst of the COVID-19 pandemic. My guests for this post-conference interview are Ms. Jessilyn Pozo, Baptist Health South Florida System-Wide Stroke Program Manager, and Dawntray Radford, Stroke Coordinator for South Miami Hospital (You can follow them for more information here).  This transcript is a lightly edited version of the interview we conducted on webcam, shortly after the 2021 International Stroke Conference.

Catherina: How was your experience at the 2021 International Stroke Conference (ISC) delivered in virtual mode?

Dawntray: The International Stroke Conference was definitely different this year. However, I was appreciative that they (AHA) were able to extend the sessions’ timeframe so that we would be able to take a deeper dive, engage in deeper discussions opposed to the 10-15 minute sessions that we normally would have (in a live conference).  I think I got a lot more information (from the presentations and discussions), especially within the different scheduled presentations.  Therefore, I think there was an added bonus of extending the sessions’ timeframe.

 

Dawntray Radford, BSN, RN Stroke Coordinator South Miami Hospital

 

Jessilyn: This is my second time attending ISC. I went last year to Los Angeles for it. Although I do like the live version more, I liked that we were able to see lectures recorded and delivered on-demand. There were a lot of interesting topics this year, specifically hot topics with Tenecteplase1, which many hospitals are leaning towards converting its use. There were different topics like the nursing care guidelines, and reports from recent studies released.  We were able to take many good notes, and we were able to pause and write down things and keep going with the lectures.  I really enjoyed attending the conference, but I am excited for it to be live next year.

 

 

Jessilyn Pozo, BSN, RN, SCRN BHSF System-Wide Stroke Program Manager Baptist Hospital of Miami

 

Catherina: How would you describe your role in the stroke program at your organization?

Jessilyn: I oversee the stroke program for the Baptist Health system. Baptist Hospital of Miami is our comprehensive center. Dawntray Redford runs the South Miami Hospital stroke program, which is a primary stroke center, certified by the Joint Commission.2  She worked tirelessly to get it certified with no Requests for Improvements (RIFs).  So kudos to her! We are working with West Kendall Baptist Hospital to become a primary stroke center. We are working to have a few of our other entities to be acute stroke ready. We have oversight of the stroke program at each individual entity and as a system to provide standardized great stroke care for all patients.

Catherina: Please tell us Ms. Radford about your role in the stroke program at South Miami Hospital.

Dawntray: We went through our first initial certification as a primary stroke center.  There are a lot of moving parts in the program that we need to monitor.  In addition to providing care, since we are a primary stroke center, there is an urgency of transferring stroke patients to the comprehensive center.  This shows to our community and Emergency Medical Services (EMS) that we have the capabilities of readily identifying the acute stroke patients when they arrive and transferring them out at a target time of sixty minutes. Based on the feedback we received from the certification survey by the Joint Commission, it was very impressive! Because of the national times, the average goal is to push for at least 90 minutes.   The literature suggests and has proven (benefits) from taking about 2 hours to 3 hours to actually have a patient transferred out to an equipped hospital.  Emergency medical services (EMS) had tried to propose to bypass the primary stroke centers and go to the comprehensive one. They did not want these two-to-three-hour delays of the patient transferred because of so many logistics of trying to transfer a patient from one hospital to another system, as we had to go through that transfer process.  With the streamlined process at our Institute, the Miami Neuroscience Institute, we have our own streamlined process and our dedicated transfer center.  We can actually execute our transfers in sixty minutes.  We worked very hard with our internal system of identifying patients before they even arrived to our institution. We are having that proactive approach of readily identifying that patient that has that large vessel occlusion. We already have a transfer center in place before the patient even arrives. This would make our numbers soar to that target timeframe for patients to get excellent stroke care.  During our certification survey, we got compliments on our timeframe, less than the 90-minute-to-120-minutes timeframe, as we probably may be set back a new benchmark for the nation.

Catherina: What are the benefits of the GWTG Stroke Registry at your organizations?

Jessilyn: We are very lucky to have a data analyst team that is driven and just solely dedicated to the management of our stroke data. They are the ones who check on our stroke alert times; make these dashboards with turnaround times that they input in Get With The Guidelines. The Get With The Guidelines Stroke Registry helps us to stay on track.  It keeps us on our toes, making sure that we meet the (stroke) goals.  We aim to provide the care that we need to (deliver to stroke patients) based on the guidelines and the standards.  This (registry data) allows for feedback on how our programs are doing.

Dawntray: The use of The Get With The Guidelines at South Miami Hospital is imperative, especially with the fact that we have different stroke units. The staff at the stroke units would like to see how they are doing as an individual unit, so they know where they need to improve individually as opposed to the hospital as a whole.  Especially with the Emergency Department, their metrics would be different from the metrics of an inpatient unit.   At least with the registry, I could take the different core quality measures and give the appropriate information specific to their unit.  I use the registry 100% to monitor our quality measures and performance improvement measures.

Catherina: What has been your experience with stroke patients seeking stroke care in the midst of the COVID-19 pandemic?

Dawntray:  We definitely have seen a decrease in the volume of care, especially with EMS and the patients that walk in.  Eighty percent of our patients would arrive by their private vehicles. Many patients did not come through EMS during the pandemic.  We noticed at least 50% change in our volume for at least the first two months of the COVID pandemic.  We have also seen an increase in ischemic strokes with clots, with occlusive strokes in patients that were positive for COVID. They developed COVID first.  The developed stroke as a secondary diagnosis.

Jessilyn: From the comprehensive center standpoint, being like the hub of the system, we have seen internal patient transfers from our sister hospitals. These patients were initially admitted for COVID care. They developed an acute ischemic stroke and were transferred over for neuro intervention.  Unfortunately, these have been the trickiest patients. They were on the younger side, ended up being hypercoagulable. Our interventionalists are amazing! However, they do say it is more difficult, they find more clots. It is not just one. They seem to find several clots.  These patients also tend to reocclude, even though they have had a successful thrombectomy. Therefore, I think COVID has really posed quite a challenge in stroke care for all.

Catherina: What suggestions do you have for healthcare professionals in educating patients about the prevention of stroke, especially during this COVID-19 pandemic?

Jessilyn: I think one of the biggest issues in stroke is that as high as it is, 80% of the strokes are preventable. Stroke should probably be out of the top 10 issues that are the cause of mortality in our nation or in the world.  A lot of it has to do with the fact that people do not recognize the symptoms.  It also has to do with getting them in here (hospital) for early treatment.  We have those 24 hours for them to be a possible candidate for stroke care.  A lot of them do not just even recognize the symptoms or the risk factors of stroke.  They do not understand things that they just do in their daily life, that if they were to change one of these minute things, it can help them decrease their risk of stroke and relieve them from possible debilitating life symptoms.

Dawntray: (During the pandemic) we reached out to our marketing department.  We have a Facebook page where we have a post on Fridays.  (We posted) on recognition of the signs of early stroke: FAST: Face, Arm, Speech, Time of recognizing stroke, calling 911.   We also had information on what (symptoms) to look for.  We had a message built in to the post as well, stating that, “we know that you may be afraid to come in, that you want to stay at home, but you choose to be aware of, of not being afraid to seek services, to come in to the hospital where it is safe.”   “We take a lot of preventative measures to protect ourselves and to the community during the pandemic”.   We are just letting them know what the signs and symptoms were and not to be afraid to come in and to seek care (at the hospital).   We are just giving them that comfort that it is safe to come into the hospital.  Because that is what they feel… it was not safe, so they were afraid to come in (during the pandemic).

Catherina: Thank you for the opportunity to interview you and look forward to the next ICS conference.  Anything that you would like to share out there with stroke coordinators, any advice or word of guidance?

Jessilyn: Just hang in there.

Dawntray: You have to be inventive. Just know that a pandemic cannot hinder you from providing the care that you provide every day.   You just have to be creative, find a better way, a different way of still executing what you do on a daily basis.

I would like to thank Ms. Jessilyn Pozo and Ms. Dawntray Redford for sharing their experiences during this 2021 Virtual International Stroke conference as well as their experiences with the GWTG Stroke Registry, Primary and Comprehensive Stroke Program, and stroke prevention during the COVID-19 pandemic. For more information, you can reach them at JessilynP@baptisthealth.net and DawntrayTW@Baptisthealth.net

 

References:

  1. Warach SJ, Dula AN, Milling TJ Jr. Tenecteplase Thrombolysis for Acute Ischemic Stroke. Stroke. 2020;51(11):3440-3451. doi:10.1161/STROKEAHA.120.029749
  2. The Joint Commission. Primary Stroke Center Certification. (2021). Retrieved from https://www.jointcommission.org/accreditation-and-certification/certification/certifications-by-setting/hospital-certifications/stroke-certification/advanced-stroke/primary-stroke-center/
  3. American Heart Association. Get with the Guidelines Stroke Registry. (2021). Retrieved from https://www.heart.org/en/professional/quality-improvement/get-with-the-guidelines/get-with-the-guidelines-stroke

“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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Reducing Disparities through Diversity and Inclusion in Stroke Science, Clinical Trial Enrollment, and Community Engagement

As part of its mission to be a relentless force for a world of longer, healthier lives, the American Heart Association (AHA) has been working diligently to eliminate barriers to health equity in the U.S. diverse population through education and research, raising awareness through their many programs and initiatives.  In the stroke arena, we continue to face significant inequities related to stroke incidence, prevalence, care, and outcomes in ethnic minorities.1  Consequently, there has been a number of initiatives launched to address these disparities.  The Health Equity and Actionable Disparities in Stroke Symposium, a collaborative initiative of the American Heart Association and National Institute of Neurological Disorders and Stroke, took place in 2020 with the goals of reducing inequities in stroke care and research. It also aimed to accelerate the translation of research findings to improve outcomes for racial and ethnic minorities.1

This year the American Heart Association continues the efforts to promote awareness of the importance of diversity and inclusion in stroke science.  A roundtable session took place on Friday, March 17, during the last day of the prestigious 2021 International Stroke Conference.  A panel of experts shared their views and presented alternatives to improve diversity and Inclusion in the healthcare workforce, clinical trial enrollment, and community engagement.  The expert roundtable included experts in the field such as Dr. Emelia Benjamin, MD ScM FAHA, Michele Evans, MD, Michelle Jones-London, Ph.D., Bernadette Boden-Albala, MD MPH, Fern Webb, Ph.D., Candace Whitfield, BS, Trudy Gaillard, RN Ph.D., Mellanie Springer, MD MSc. Mr. Olajide Williams, MS served as the moderator of the roundtable. The panelists presented a fresh and clear view of the diversity and inclusion barriers encountered in the research arena.  They also offered alternatives to support inclusion and diversity in the development of research protocols, proposal procedures through institutional review boards, and through community engagement, with the use of community-based participatory research.

The experts highlighted the issue of representativeness in the conduct of research and presented diversity as a solution. Diversity in research means that people of different ages, different racial and ethnic groups and both men and women participate in research studies. The lack of diversity in participants of research impedes the ability to generalize study results and make medical advancements of effective therapies. It may further prevent some populations from experiencing the benefits of research innovations and receipt of high-quality care.2

In the context of clinical trial enrollment, the speakers emphasized the importance of having a diverse sample.  They also discussed the need for inclusivity of minority groups during the enrollment period. They also highlighted the importance of informed consent forms available in other languages to facilitate the diversity of the sample during enrollment. They also suggested the approval of translated informed consent forms in an expedited fashion to avoid delays in the consenting process for ethnic minority groups.  Another very important factor was the importance of having the infrastructure to support diversity and inclusion in the stroke science workforce. Factors such as the hiring of clinicians and research personnel that may resemble the target population of interest are vital to facilitate the recruitment of ethnic minority groups much needed in these studies.3

As academicians and researchers, we should advocate for diversity as it drives excellence and enhances innovation in the biomedical sciences, leading to novel findings and treatment of diverse populations.3 Diverse and inclusive scientific teams can generate new research questions, develop methodical and analytical approaches to better understand study populations, and offer approaches to problem-solving from multiple and different perspectives.  Moreover, the promotion of diverse groups presents opportunities for the inclusion of individuals with different perspectives who can complement each other and inform of new approaches.3  This may further strengthen the approach of the research team through the various phases of the research process, especially when their diversity and inclusion match the racial and ethnic minority group under study.

One of the experts, Dr. Michelle Evans highlighted the importance of community-based participatory engagement in research, especially in ethnic minorities.  Another speaker, Dr. Trudy Gaillard discussed the opportunity to engage members in the community, stakeholders, and utilize this as a venue to engage study participants through community-based participatory research (CBPR).  Engaging in active reflection and adopting promising partnering practices are important for CBPR partnerships working to improve health equity.4

The roundtable presentation aligns with current National Institutes of Health (NIH) strategies to support diversity and inclusion in the science community. A program called UNITE was launched in 2020 to tackle the problem of racism and discrimination in science while developing methods to promote diversity and inclusion across the biomedical enterprise. Some of its functions include understanding stakeholder experiences through listening and learning, pursuing research on health disparities, minority health, and health equity, improving the NIH culture and structure for equity, inclusion and excellence, transparency, communication, and accountability with internal and external stakeholders, changing policy, culture, and structure to promote workforce diversity (NIH, 2021).5

In addition to NIH, the National Institute of Neurological Disorders and Stroke (NINDS) (2021) is committing to diversity, equity, and inclusion in the neuroscience community as both an employer and funding agency, addressing the stark differences in neurological health outcomes related to where one lives, has access to care, their race/ethnicity, and socioeconomic status.6  In the process of implementation of these initiatives, it will be important to note that implementation science can exacerbate health disparities if its use is biased toward entities that already have the highest capacities for delivering evidence-based interventions.

There is a call for making efficient use of existing data by applying epidemiologic and simulation modeling to understand what drives disparities and how these can be overcome.  There is also a need for designing new research studies that include populations experiencing disparities in cardiovascular disease, neurological disease, and stroke.7  It will be interesting to observe in the next coming months, the implementation of some of these strategies to promote diversity and inclusion in stroke science. Much remains to be done to bridge the gap and reduce healthcare-related disparities in racial-ethnic minority groups, especially in the context of stroke science. In the meantime, it is up to us to continue the work of raising awareness, promoting diversity and inclusion in our academic circles, in the science field, and in our communities.

For additional information on the efforts American Heart Association to support diversity and inclusion in heart science, please be sure to check out https://www.heart.org/en/about-us/diversity-inclusion.

References:

  1. Towfighi A, Benson RT, Tagge R, Moy CS, Wright CB, Ovbiagele B. Inaugural Health Equity and Actionable Disparities in Stroke: Understanding and Problem-Solving Symposium. Stroke. 2020;51(11):3382-3391. doi:10.1161/STROKEAHA.120.030423
  2. University of Maryland. Health Equity Project. (2021). Top five reasons why diversity is important in research. Retrieved from https://buildingtrustumd.org/unit/importance-of-research/importance-of-diversity#:~:text=Diversity%20in%20research%20means%20that%20people%20of%20different,specific%20reasons%20why%20diversity%20in%20research%20is%20important.
  3. Swartz TH, Palermo AS, Masur SK, Aberg JA. The Science and Value of Diversity: Closing the Gaps in Our Understanding of Inclusion and Diversity. J Infect Dis. 2019;220(220 Suppl 2):S33-S41. doi:10.1093/infdis/jiz174
  4. Dickson E, Magarati M, Boursaw B, et al. Characteristics and Practices Within Research Partnerships for Health and Social Equity. Nurs Res. 2020;69(1):51-61. doi:10.1097/NNR.0000000000000399
  5. National Institutes of Health. (NIH). (2021). Ending Structural Racism. Retrieved from https://www.nih.gov/ending-structural-racism/unite on 4/2/21.
  6. National NINDS (2021). NINDS is committed to ending structural racism. Retrieved from https://www.ninds.nih.gov/News-Events/Directors-Messages/All-Directors-Messages/NINDS-committed-ending-structural-racism
  7. McNulty M, Smith JD, Villamar J, et al. Implementation Research Methodologies for Achieving Scientific Equity and Health Equity. Ethn Dis. 2019;29(Suppl 1):83-92. Published 2019 Feb 21. doi:10.18865/ed.29.S1.83

 

“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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Transformation of the GWTG – Stroke Patient Registry to into a National Representative Database of Acute Ischemic Strokes (AIS) in the U.S.

Stroke remains a leading cause of death and disability in the United States.1  Approximately 800,000 people in the United States have a stroke every year.1  Eighty percent of all strokes can be prevented by screening for and treating known risk factors (hypertension, tobacco smoking, and atrial fibrillation).2 Recurrent strokes can also be prevented with proper management of these risk factors.3 Disease surveillance is crucial to the prevention of stroke, particularly in high-risk groups. Blacks and Hispanics report increasing stroke rates.4  Deprived populations within high-income countries are less likely to receive good-quality acute hospital and rehabilitation care than people with higher socioeconomic status.5  Findings from robust surveillance systems can be useful as healthcare providers can make informed decisions in the better medical management of strokes. Policymakers can work towards the development of aggressive campaigns to decrease the incidence of strokes in our communities and associated disparities in ethnic minorities and low-income groups.4,6  We can further estimate progress made towards the reduction and elimination of common risk factors of stroke.

Previously, the Institutes of Medicine recommended the development of surveillance systems in efforts to monitor the incidence and associated disabling burden from cardiovascular disease and strokes.7-8 The CDC’s Division for Heart Disease and Stroke Prevention (DHDSP) supports state, local, and tribal efforts to prevent, manage, and reduce risk factors related to stroke. The CDC has supported the implementation of stroke programs through cooperative agreements at these levels (CDC, 2020).9 However, due to the voluntary nature of these agreements, stroke surveillance data has been limited to only participant states. Therefore, it has been difficult to estimate the burden of a stroke at the national level.

A recent study by Ziaeian and colleagues presented the transformation of The Get With The Guidelines (GWTG) Stroke Patient Registry into a nationally representative database.10  This is the first study that has transformed a patient registry using post-stratification weights to represent a larger population of interest. The ability to translate observations from large registries to a national scale fills a considerable gap in the surveillance of the clinical characteristics, quality of care, and outcomes for Acute Ischemic Strokes (AIS) hospitalizations nationally.10  An acute stroke quality registry that is integrated with a guideline-based support tool can be a powerful tool for measuring and improving the quality of stroke care.11  Here we provide a summary of this recent study.10

Study population: The target population for the post-stratification weighting procedure is the total AIS presenting to U.S. hospitals by year. The NIS defines the AIS burden nationally stratified between the years of 2012 and 2014 and the nine U.S. Census regions – preserving the smallest sampling unit recommended by the NIS sponsors.  The National Inpatient Sample (NIS) is a weighted structured random sample of U.S. hospitalizations to represent national hospital utilization. However, the database does not include detailed clinical data such as stroke severity, laboratory data, medical treatments received, and patient-reported outcomes. The NIS is sponsored by the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project.

GWTG Stroke Patient Registry History: The GWTG – Stroke Patient Registry is a voluntary registry and continuous quality improvement initiative that collects data on patient characteristics, hospital adherence to guidelines and inpatient outcomes.  It was developed as part of a strategic goal of the American Heart Association (AHA) to reduce stroke and its associated risks, and Healthy People 2010 (HP2010) established national goals for stroke prevention and management.  The implementation of the GWTG Stroke registry has led to the implementation of evidence-based care and improved patient outcomes in many hospitals, acute care, and long-term care settings.6

GWTG hospitals comprise a mix of Joint Commission-certified stroke centers, PCNASR hospitals and small and large hospitals in urban and rural settings across the USA and Puerto Rico. Based on previous studies, the population of patients enrolled in GWTG is similar in age and racial makeup to the US population according to the U.S. census 2000.  Medicare beneficiaries linked to the GWTG registry are similar in demographics, comorbidities, and in-hospital outcomes compared with Medicare beneficiaries who are not linked.6,10

Methods: Ziaeian and colleagues integrated two data sources, The National Inpatient Sample (NIS), a structured random sample of U.S. hospitalizations weighted to represent national hospital utilization.10 The AHA-sponsored Get With The Guidelines Program (GWTG) program includes rich clinical data for quality improvement and research analyses.  They transformed these non-representative databases into a representative one with the use of post-stratification weights to rebalance over and underrepresented segments of the U.S. acute ischemic stroke (AIS) population. The approach described in the present paper is a far more robust estimation of the characteristics of stroke presentation and the quality of hospital care nationally.

The NIS lacks detailed clinical data such as stroke severity, laboratory data, medical treatments received, and patient-reported outcomes. It is not nationally representative and inadequate to measure stroke burden and quality of care nationally.  The GWTG-Stroke patient registry captures 58% of all strokes nationally. The GWTG program registries with volunteer hospitals are not proportionally representative of the entire nation.10  Ziaeian and colleagues used the GWTG-Stroke registry from 2012 to 2014 to evaluate post-stratification weighting procedures to represent the entire US AIS population.10

To determine the total number of AIS hospitalizations in the U.S. and marginal population characteristics for post-stratification weights, the investigators used target population counts from the NIS database. The NIS sampled 20% of the administrative discharge records from all participating hospitals (approximately 4300 hospitals) covering 95% of the U.S. population and 94% of all community hospital discharges from 2010 to 2014.  Raking and Bayesian interpolation, two parallel methods to estimate post-stratification survey weights, were used and their distribution was analyzed with histograms and treemaps to provide a perspective on the skewed representation of the GWTG-Stroke raw sample.

Results:  There were an estimated 1,388,296 AIS hospitalizations between 2012 to 2014 in the U.S. For the raking method, anchored characteristics in the weighted GWTG-Stroke sample matched the exact population totals estimated from the NIS. On admission, 49.2% of stroke patients nationally were using antiplatelet medications, 15.5% anticoagulants, 69.1% antihypertensives, 43.6% cholesterol-lowering medications, and 27.4% used diabetic medications. Approximately 48% of patients were discharged home, 40.2% to transitional care facilities, and 4.6% with hospice-related services.

Conclusions and Implications:  This research demonstrated the integration of two valuable data systems to make better population wide clinical estimates of acute ischemic stroke in the U.S., the GWTG Stroke Patient Registry and the NIS.  Their work demonstrates that methods exist to marry existing databases to make more reliable statistical inferences of population health and health services utilization. Understanding the effectiveness of hospital systems at a national and regional level is critical to insure consistency and timeliness in the receipt of evidence-based care. With the expansion of patient registries, the inclusion of clinical outcomes in these registries, and advanced statistical methods are available to transform non-random samples into representative population estimates.

References:

  1. Centers for Disease Control and Prevention. Underlying Cause of Death, 1999–2018. CDC WONDER Online Database. Atlanta, GA: Centers for Disease Control and Prevention; 2018. Accessed March 5, 2020.
  2. George MG, Fischer L, Koroshetz W, et al. CDC Grand Rounds: Public Health Strategies to Prevent and Treat Strokes. MMWR Morb Mortal Wkly Rep 2017;66:479–481. DOI: http://dx.doi.org/10.15585/mmwr.mm6618a5external icon.
  3. Caprio FZ, Sorond FA. Cerebrovascular Disease: Primary and Secondary Stroke Prevention. Med Clin North Am. 2019;103(2):295-308. doi:10.1016/j.mcna.2018.10.001
  4. Skolarus LE, Sharrief A, Gardener H, Jenkins C, Boden-Albala B. Considerations in Addressing Social Determinants of Health to Reduce Racial/Ethnic Disparities in Stroke Outcomes in the United States. Stroke. 2020;51(11):3433-3439. doi:10.1161/STROKEAHA.120.030426
  5. Marshall IJ, Wang Y, Crichton S, McKevitt C, Rudd AG, Wolfe CD. The effects of socioeconomic status on stroke risk and outcomes. Lancet Neurol. 2015;14(12):1206-1218. doi:10.1016/S1474-4422(15)00200-8.
  6. Ormseth CH, Sheth KN, Saver JL, Fonarow GC, Schwamm LH. The American Heart Association’s Get With the Guidelines (GWTG)-Stroke development and impact on stroke care. Stroke Vasc Neurol. 2017;2(2):94-105. Published 2017 May 29. doi:10.1136/svn-2017-000092
  7. Committee on a National Surveillance System for Cardiovascular and Select Chronic Diseases; Institute of Medicine, IOM (Institute of Medicine). A Nationwide Framework for Surveillance of Cardiovascular and Chronic Lung Diseases. Washington: National Academies Press; 2011. 201 p. Available from: http://www.nap.edu/catalog/13145
  8. Sidney S, Rosamond WD, Howard VJ, Luepker RV. The “Heart Disease and Stroke Statistics–2013 Update” and the Need for a National Cardiovascular Surveillance System. Circulation. 2013;127(1):21–3 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23239838.
  9. Centers for Disease Control and Prevention. Division for Heart Disease and Stroke Prevention. About the State, Local, and Tribal Programs. Atlanta, GA: Centers for Disease Control and Prevention; 2020. Accessed March 5, 2020. Available from: https://www.cdc.gov/dhdsp/programs/spha/overview.htm
  10. Ziaeian B, Xu H, Matsouaka RA, et al. National surveillance of stroke quality of care and outcomes by applying post-stratification survey weights on the Get With The Guidelines-Stroke patient registry. BMC Med Res Methodol. 2021;21(1):23. Published 2021 Feb 4. doi:10.1186/s12874-021-01214-z
  11. Shahraki AD, Ghabaee M, Shahmoradi L, Malak JS, Jazani MR, Safdari R. Smart Acute Stroke Quality Registry Design-Data Elements Identification. J Registry Manag. 2018;45(1):43-47.

“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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Can Vitamin C Prevent COVID-19?

The outbreak of COVID-19 has created a global public health crisis. Our knowledge continues to be limited about the protective factors of this infection. Therefore, preventive health measures that can reduce the risk of infection, and halt the progression and severity of symptoms and complications related to COVID-19 are desperately needed. In the midst of the COVID-19 pandemic, health promotion measures, such as proper nutrition, physical activity, rest, and stress reduction measures have been advocated.  More recently, attention has been shifted to vitamin supplementation as a means to keep American’s health and immune system in optimal status.

Source: https://www.heart.org/en/healthy-living/healthy-eating/add-color

Adequate intake of micronutrients is critical for optimal health, growth and development, and healthy aging. However,  the Dietary Guidelines for Americans 2015–2020 highlight low-consumption of important nutrients including vitamins A, C, D and E, calcium, magnesium, iron, potassium, choline and fiber, with variations by age groups.1   Vitamin C has recently gained attention as a potential micronutrient in the prevention of COVID-19.  Vitamin C has been known for promoting the oxidant scavenging activity of the skin, potentially protecting against environmental oxidative stress, enhancing chemotaxis, phagocytosis, and microbial killing.2

Based on previous evidence, oral vitamin C (2-8 g/day) may reduce the incidence and duration of respiratory infections and intravenous vitamin C (6-24 g/day) has been shown to reduce mortality, hospital length of stay, and time on mechanical ventilation for severe respiratory infections3-4

Given the favorable safety profile and low cost of vitamin C, and the frequency of vitamin C deficiency in respiratory infections, trials are currently underway to determine its effect in hospitalized patients with COVID-19.4-5  Although there are currently no published results of these clinical trials due to the novelty of SARS-CoV-2 infection, there is pathophysiologic rationale for exploring the use of vitamins such as Vitamin C in this global pandemic.6

Source: https://www.heart.org/en/news/2019/07/01/low-vitamin-d-in-babies-predicts-blood-pressure-problems-for-older-kids

While we await for results from these trials, we need to continue being vigilant, and adhere to a varied and balanced diet with an abundance of fruits and vegetables and the essential nutrients known to contribute to the normal immune system functioning.  Vitamin C supplementation could present a safe and inexpensive approach to prevention of respiratory diseases, and perhaps aid in COVID-19.7

Avoidance of deficiencies and identification of suboptimal intakes of these micronutrients in targeted groups of patients and in distinct and highly sensitive populations could help to strengthen the resilience of people to the COVID-19 pandemic. It will be also important to highlight evidence-based public health messages, to prevent false and misleading claims about the benefits of vitamin supplements. It will also be important to communicate the exploratory state of research on micronutrients and COVID-19 infection and that no diet will prevent or cure COVID-19 infection. Frequent handwashing and social distancing will continue to be critical to reduce transmission during this pandemic.8

 

References:

  1. Blumberg JB, Frei B, Fulgoni VL, Weaver CM, Zeisel SH. Contribution of Dietary Supplements to Nutritional Adequacy in Various Adult Age Groups. Nutrients. 2017;9(12):1325. Published 2017 Dec 6. doi:10.3390/nu9121325
  2. U.S. Department of Health and Human Services. U.S. Department of Agriculture [(accessed on 15 March 2017)];2015–2020 Dietary Guidelines for Americans. (8th ed.). 2015 Available online: http://health.gov/dietaryguidelines/2015/guidelines/
  3. Holford P, Carr AC, Jovic TH, et al. Vitamin C-An Adjunctive Therapy for Respiratory Infection, Sepsis and COVID-19. Nutrients. 2020;12(12):3760. Published 2020 Dec 7. doi:10.3390/nu12123760
  4. Carr AC. A new clinical trial to test high-dose vitamin C in patients with COVID-19. Crit Care. 2020;24(1):133. Published 2020 Apr 7. doi:10.1186/s13054-020-02851-4
  5. Zhang J, Rao X, Li Y, et al. Pilot trial of high-dose vitamin C in critically ill COVID-19 patients. Ann Intensive Care. 2021;11(1):5. Published 2021 Jan 9. doi:10.1186/s13613-020-00792-3
  6. Jovic TH, Ali SR, Ibrahim N, et al. Could Vitamins Help in the Fight Against COVID-19?. Nutrients. 2020;12(9):2550. Published 2020 Aug 23. doi:10.3390/nu12092550
  7. Allegra A, Tonacci A, Pioggia G, Musolino C, Gangemi S. Vitamin deficiency as risk factor for SARS-CoV-2 infection: correlation with susceptibility and prognosis. Eur Rev Med Pharmacol Sci. 2020;24(18):9721-9738. doi:10.26355/eurrev_202009_23064
  8. Richardson DP, Lovegrove JA. Nutritional status of micronutrients as a possible and modifiable risk factor for COVID-19: a UK perspective [published online ahead of print, 2020 Aug 20]. Br J Nutr. 2020;1-7. doi:10.1017/S000711452000330X

“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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Exercise: New Year Resolutions in the Midst of the COVID Pandemic

New Year. New Resolutions. With the start of the New Year, many of us make commitments to improve our health. Some of us take on a new routine or hobby, give up or change old habits.  As the holidays go, many of us take on the resolution to engage in more exercise and lose the extra pounds gained through the indulgence during the holidays.  As we embark on the new journey to better health at the start of a new year, it is important to know that we are not alone. There are many around us that are also trying to engage in a healthy resolution to be fit. And there are many resources available to increase our physical activity and remain fit throughout the year.

It has been well established that physical activity contributes to many health benefits. Those who engage in regular exercise benefit from better sleep, growth, development, mood, and overall health.1 On the contrary, the lack of exercise and an increase in sedentary behaviors may contribute to overweight and obesity. Overweight and obesity have deleterious effects in adults, including increased risk of cardiovascular disease, cancer, metabolic syndrome, depression, poor quality of life, and decreased life span.

As the global COVID‐19 pandemic unfolded in year 2020, over 90% of U.S. adult residents found themselves confined to their homes, with restaurants, shops, schools, and workplaces shut down to prevent the disease from spread.2 For some, it meant additional changes, including working remotely, homeschooling children, and personal changes in lifestyle behaviors. Some of these, unfortunately, have led to increased sedentary activity and decreased physical activity, known risk factors associated with overweight and obesity.

For some groups, the transition to lockdown and social distancing has resulted in increased physical activity, especially for bodyweight training, and higher adherence to a healthier diet. Some individuals have engaged in higher consumption of farmers’ produce or purchasing of organic fruits and vegetables, resulting in lower body mass index.3   However, this has not been the norm. More studies report adults experiencing five-to-ten pound increases in weight as a result of increased eating in the home environment. The increased levels of stress, combined with the lack of dietary restraint, snacking after meals, reduced physical activity, and inadequate sleep has further aggravated the risk of overweight and obesity in our population.4   Some groups report less frequent consumption of vegetables, fruit, and legumes during the quarantine, and higher adherence to meat, dairy, and fast-foods.5   Anxiety, depression, self-reported boredom, and solitude have worsened the consumption of snacks, unhealthy foods, cereals, and sweets. These have correlated with higher weight gain for many.6

Being overweight not only increases the risk of infection and complications for those categorized as obese. Recent studies also suggest that the large prevalence of obese individuals within the population might increase the chance of appearance of the more virulent viral strain, and prolong the virus shedding throughout the total population. This may further increase the overall mortality rate as a result of COVID-19. A study on previous influenza pandemics suggests losing weight with a mild caloric restriction, including AMPK activators and PPAR gamma activators in the drug treatment for obesity-associated diabetes. Practicing mild-to-moderate physical exercise may further improve our immune response. Regular physical exercise enhances levels of cytokine production mediated via TLR (toll-like receptor) signaling pathways during microbial infection, improving host resistance to pathogen invasion.7 Regular physical activity may then serve as a cornerstone measure to improve our defenses against influenza viral infection, cardiometabolic diseases, and COVID-19.

Physical activity remains one of the seven modifiable health behaviors and an important metric of The American Heart Association (AHA) Life’s Simple 7 (LS7), associated with improved cardiovascular disease survival and reduced healthcare costs.8   As we battle the restrictions imposed by the pandemic, we have to also think that these circumstances present opportunities to engage our communities in healthy lifestyle practices. Practice aimed to increase our physical activity, may contribute to improving overall health status in the midst of the COVID pandemic.

Here are some ideas on how to meet the New Year resolution to exercise and increase our levels of physical activity:

  • Move More
    • Set up a timer or alarm to move at least once every hour.
    • A good starting goal is to engage in physical activity at least 150 minutes a week. This represents three 50-minute sessions or five 30-minute sessions a week.
    • Start slowly. Gradually build up to at least 30 minutes of activity on most or all days of the week.
    • Check with your healthcare provider before beginning a physical activity program and follow their recommendations.
  • Establish a routine
    • Start with small changes.
    • Make the time.
    • Try to engage in exercising consistently at the same time every day and every week.
    • Stick to the new routine for at least a month.
    • Find a convenient time and place to do activities.
    • Be flexible. If you miss an exercise opportunity, get back on track.
    • Work physical activity or exercise session into your day in another way.
    • Keep reasonable expectations of yourself and your physical activity or exercise routines.
    • Reward or praise yourself for sticking to the changes.
    • Use non-food items to reward yourself.
  • Get support
    • Find buddies or friends who are also making the same commitment to be fit and engage in physical activity.
    • Invite others to join you on your journey.
    • It becomes more fun when you exercise or move in a company.

Start the New Year with a commitment to better health by increasing activity and engaging in regular exercise. Engage others in exercise while keeping social distancing guidelines. Celebrate the small changes. Make a commitment to a Better You!

References:

  1. Centers for Disease Control (CDC). Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion. Physical Activity Basics. Reviewed 2020 Nov 18. Accessed 2021 Jan 13. https://www.cdc.gov/physicalactivity/basics/index.htm
  2. Bhutani S, Cooper JA. COVID-19-Related Home Confinement in Adults: Weight Gain Risks and Opportunities. Obesity (Silver Spring). 2020;28(9):1576-1577. doi:10.1002/oby.22904
  3. Di Renzo L, Gualtieri P, Pivari F, et al. Eating habits and lifestyle changes during COVID-19 lockdown: an Italian survey. J Transl Med. 2020;18(1):229. Published 2020 Jun 8. doi:10.1186/s12967-020-02399-5
  4. Zachary Z, Brianna F, Brianna L, et al. Self-quarantine and weight gain related risk factors during the COVID-19 pandemic. Obes Res Clin Pract. 2020;14(3):210-216. doi:10.1016/j.orcp.2020.05.004
  5. Sidor A, Rzymski P. Dietary Choices and Habits during COVID-19 Lockdown: Experience from Poland. Nutrients. 2020;12(6):1657. Published 2020 Jun 3. doi:10.3390/nu12061657
  6. Pellegrini M, Ponzo V, Rosato R, et al. Changes in Weight and Nutritional Habits in Adults with Obesity during the “Lockdown” Period Caused by the COVID-19 Virus Emergency. Nutrients. 2020;12(7):2016. Published 2020 Jul 7. doi:10.3390/nu12072016
  7. Luzi L, Radaelli MG. Influenza and obesity: its odd relationship and the lessons for COVID-19 pandemic. Acta Diabetol. 2020;57(6):759-764. doi:10.1007/s00592-020-01522-8
  8. Garg PK, O’Neal WT, Mok Y, Heiss G, Coresh J, Matsushita K. Life’s Simple 7 and Peripheral Artery Disease Risk: The Atherosclerosis Risk in Communities Study. Am J Prev Med. 2018;55(5):642-649. doi:10.1016/j.amepre.2018.06.021

“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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#AHA20: Reflections from 2020 AHA Scientific Sessions

As an American Heart Association Early Career Professional, attending the #2020 AHA Scientific Sessions will be an unforgettable experience. The virtual modality of the conference provided an alternative to the social distancing challenges presented by COVID-19. There was creativity in the programming to allow opportunity to engage through the various forums and live chats for those interested in live participation; and this added to the unique experience of online networking and learning. Participants also had the opportunity to join the on-demand sessions, learning at their own pace, within the comfort of their home or work setting.

From the early morning health and wellness sessions to late-breaking science, technology application to support better patient outcomes in the treatment of cardiovascular disease, and COVID-19 topics, the conference programming was comprehensive, diverse, and appealing to the interest of the participants. It was also in tune with the current state of global health and social issues, addressing ongoing debates in cardiovascular disease management.

The wide range of topics presented at the sessions truly reminds us of the AHA’s mission to be a relentless force for a world of longer, healthier lives.

Highlights of the #AHA 2020 Scientific Sessions included the following:

  1. Focus on Fitness and Health. Participants had the opportunity to join the morning fitness and dance breaks, as well as and on-demand exercise sessions. Attendees who could not join the early scheduled meetings had the opportunity to join the on-demand model.
  2. Discussion on racism in Medicine. The opening session featured a fireside chat with two legends in the education and treatment of cardiovascular disease, Dr. Eugene Braunwald and Dr. Nanette Wenger. This was followed by a robust discussion of racism as a public health crisis at various sessions delivered over the course of the five days. They also presented a call to support and embrace diversity, equity, and inclusion in the delivery of care to our growing racial and ethnically diverse population.
  3. Late-Breaking Science. Recent findings from clinical trials were presented during the sessions on precision or polypill with TIPS and TIPS+ASA, the STRENGTH and OMEMI trials, the GALACTIC-HF and VITAL Rhythm trial.
  4. Women Professional Development. Session topics ranged from discussions on leadership, self-care during COVID-19, and management of cardiovascular disease risk among women across the lifespan.
  5. Latest Insight on COVID-19 and Cardiovascular Disease. The session addressed a wide range of topics from diagnostics and treatment, to the management of complications as a result of COVID-19. Discussion on complications such as thrombosis and myocardial involvement was presented and provided a fresh view of the latest treatment guidelines and the need for monitoring for cardiovascular complications.

These sessions will be available on-demand until January 4th, 2020, and AHA Partners have FREE access to Scientific Sessions 2020 OnDemand Extended Access through 2021. Please check these out to learn about the latest evidence.

“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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Fish Oils versus Statins?

Hypercholesterolemia remains a significant risk factor for cardiovascular disease. Management of hypercholesterolemia has entailed the use of statins and non-statins, such as omega-3 fatty acid supplements. Common side effects related to fish oil supplements have included reports of gastrointestinal upset and difficulty in swallowing the fish capsules. Common side effects of statin therapy have included reports of muscle aches, abdominal pain, dizziness, leading to non-adherence and termination of therapy.

The debate on the use of omega-3 fatty acids over statins in the management of blood cholesterol continues, calling for more studies.1  Day 3 of this year’s AHA Scientific Conference highlighted results from recent trials on the use of non-statins and statins in the reduction of cardiovascular events. Here are some takeaways from three studies: the STRENGTH Trial, the OMENI study, and the SAMSON study.

The STRENGTH (Outcomes Study to Assess STatin Residual Risk Reduction With EpaNova in HiGh CV Risk Patients With Hypertriglyceridemia) trial – This phase III international study evaluated the use of a medication derived from fish oil, containing the omega-3 fatty acids EPA and DHA, more than 13,000 people who had existing heart disease or who were at high risk of heart disease due to other medical conditions.2

  • The medication did not reduce the risk of cardiac events compared to a corn oil-based placebo.
  • Atrial fibrillation, an abnormal heart rhythm, occurred more frequently in participants taking the omega-3 CA medication.

The OMENI (OMega-3 fatty acids in Elderly patients with Myocardial Infarction) trial – a study of more than 1,000 patients in Norway investigated whether adding 1.8 grams of omega-3 fatty acids to standard treatment prevented further cardiovascular events among elderly participants with recent heart attacks.

  • When compared to placebo, omega-3 fatty acids supplement in addition to statin therapy and/or a blood thinner did not reduce the number of cardiac events in the participants.

The SAMSON (The Self-Assessment Method for Statin Side-effects Or Nocebo) Trial – The study, conducted in London, enrolled adults who had previously taken one or more statins but stopped taking them due to side effects. The participants had self-reported symptoms measured throughout a 12-month period of randomly alternating months of statin use, placebo, and no medications.

  • The participants who reported side effects from statins also reported the same side effects when they unknowingly took placebo pills.
  • The side effects appeared to be mostly due to psychological rather than pharmacological effects of statins since the reported symptoms were consistent when taking the placebo.

In the discussion led by Dr. Karol E. Watson, statins remain the mainstay in the reduction of Low-Density Lipoprotein (LDL) and Atherosclerotic cardiovascular disease (ASCVD) risk.  As also recommended in the 2018 AHA/ACC/ AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol, non-statin therapies should be considered in high-risk patients with LDL above thresholds.  Heart-healthy lifestyle changes should be also considered as important measures in the reduction of LDL and triglycerides in patients at risk for ASCVD. The heart-healthy lifestyle should include diet, weight control, and physical activity.4  It will be important to observe the outcome of future studies including the combined effects of heart-healthy lifestyle interventions and non-statin/statin therapy among those considered to be at high risk for ASCVD. Future discussions should also center on intervention studies to address patients’ perceptions of statin/non-statin therapies.

 

 

References

  1. Tummala R, Ghosh RK, Jain V, Devanabanda AR, Bandyopadhyay D, Deedwania P, Aronow WS. Fish Oil and Cardiometabolic Diseases: Recent Updates and Controversies. Am J Med. 2019 Oct;132(10):1153-1159. doi: 10.1016/j.amjmed.2019.04.027. Epub 2019 May 8. PMID: 31077653.
  2. Nicholls SJ, Lincoff AM, Bash D, Ballantyne CM, Barter PJ, Davidson MH, Kastelein JJP, Koenig W, McGuire DK, Mozaffarian D, Pedersen TR, Ridker PM, Ray K, Karlson BW, Lundström T, Wolski K, Nissen SE. Assessment of omega-3 carboxylic acids in statin-treated patients with high levels of triglycerides and low levels of high-density lipoprotein cholesterol: Rationale and design of the STRENGTH trial. Clin Cardiol. 2018 Oct;41(10):1281-1288. doi: 10.1002/clc.23055. Epub 2018 Sep 28. PMID: 30125052; PMCID: PMC6489732.
  3. Kalstad AA, Myhre PL, Laake K, Tveit SH, Schmidt EB, Smith P, Trygve Nilsen DW, Tveit A, … Effects of n-3 Fatty Acid Supplements in Elderly Patients after Myocardial Infarction: A Randomized Controlled Trial. Circulation. 2020 Nov. https://doi.org/10.1161/CIRCULATION AHA.120.052209Circulation.
  4. Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, Braun LT, de Ferranti S, Faiella-Tommasino J, Forman DE, Goldberg R, Heidenreich PA, Hlatky MA, Jones DW, Lloyd-Jones D, Lopez-Pajares N, Ndumele CE, Orringer CE, Peralta CA, Saseen JJ, Smith SC Jr, Sperling L, Virani SS, Yeboah J. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/ AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2019 Jun 25;73(24):e285-e350. doi: 10.1016/j.jacc.2018.11.003. Epub 2018 Nov 10. Erratum in: J Am Coll Cardiol. 2019 Jun 25;73(24):3237-3241. PMID: 30423393.

 

“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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Reducing Disparities in Access to Cardiovascular Disease Prevention with the Polypill

This year’s AHA 2020 Scientific Session is taking place using combined modalities, including live, simulive, and on-demand sessions. Despite the change from the traditional in-person modality to the virtual approach, listening to the opening session and findings from emerging science reminded me of the mission of the American Heart Association to be a relentless force for a world of longer, healthier lives. This year’s scientific sessions also align with a wide range of events we all have experienced this year, ranging from the COVID-19 pandemic, to racial/ethnic, gender, and income disparities leading to health inequity in our society. These further present a call to action in order to address these very same societal issues that are likely to impact on health equity for the most vulnerable groups.

The cardiovascular polypill, or combined aspirin, cholesterol, and blood-pressure-lowering agents into a single pill has been proposed for nearly a decade as a complementary option in the prevention of cardiovascular diseases in intermediate- and high-risk patient populations.1 Yet there have been previous limitations in understanding its efficacy and relative safety in developing countries.2  The findings of the International Polycap Study (TIPS)-3 presented by Dr. Salim Yusuf during the late-breaking science session bring a ray of hope to the global disparities in cardiovascular disease prevention.3 The study resulted in a 30% reduction in cardiovascular risk with a combined regimen composed of Aspirin and a polypill (atenolol, ramipril, hydrochlorothiazide, and a statin).3  Based on the TIPS-3 study, the polypill approach presents a safe and cost-effective strategy with the potential for satisfactory medication adherence.

While these findings are promising for developing countries, the polypill may present a viable solution to underserved, low-income minority groups in developed countries.4  Another important takeaway from this study was the inclusion of women, who represented 53% of the sample.  Their inclusion in global studies such as this one also highlights the move into health equity and awareness of women’s health globally at a time when cardiovascular disease continue to present women’s greatest health threat. Traditionally, the enrollment of women in clinical trials has been limited. This has resulted in a limited understanding of risk factors and benefits from treatment regimens for cardiovascular disease-specific to women.5

As we observe the benefits related to polypill, it is also important to keep in mind that it may not align with the medical trend in developed countries for precision medicine, leading to individualized, targeted therapy.6  With cardiovascular disease remaining the leading cause of mortality and morbidity in developed and developing countries, and low-income, ethnic minorities affected by it, the question remains on long-term, best preventive strategies in the reduction of cardiovascular risk factors for all. It will also be important to measure long-term outcomes related to polypill strategies in future studies.

 

References:

  1. Lafeber M, Spiering W, Singh K, Guggilla RK, Patil V, Webster R; SPACE collaboration. The cardiovascular polypill in high-risk patients. Eur J Prev Cardiol. 2012 Dec;19(6):1234-42. doi: 10.1177/1741826711428066. Epub 2011 Oct 21. PMID: 22019908.
  2. Nguyen C, Cheng-Lai A. The polypill: a potential global solution to cardiovascular disease. Cardiol Rev. 2013 Jan-Feb;21(1):49-54. doi: 10.1097/CRD.0b013e3182755429. PMID: 23018668.
  3. Joseph P, Pais P, Dans AL, Bosch J, Xavier D, Lopez-Jaramillo P, Yusoff K, Santoso A, Talukder S, Gamra H, Yeates K, Lopez PC, Tyrwhitt J, Gao P, Teo K, Yusuf S; TIPS-3 Investigators. The International Polycap Study-3 (TIPS-3): Design, baseline characteristics and challenges in conduct. Am Heart J. 2018 Dec;206:72-79. doi: 10.1016/j.ahj.2018.07.012. Epub 2018 Aug 2. PMID: 30342297; PMCID: PMC6299262.
  4. Muñoz D, Uzoije P, Reynolds C, Miller R, Walkley D, Pappalardo S, Tousey P, Munro H, Gonzales H, Song W, White C, Blot WJ, Wang TJ. Polypill for Cardiovascular Disease Prevention in an Underserved Population. N Engl J Med. 2019 Sep 19;381(12):1114-1123. doi: 10.1056/NEJMoa1815359. PMID: 31532959; PMCID: PMC6938029.
  5. Saeed A, Kampangkaew J, Nambi V. Prevention of Cardiovascular Disease in Women. Methodist Debakey Cardiovasc J. 2017 Oct-Dec;13(4):185-192. doi: 10.14797/mdcj-13-4-185. PMID: 29744010; PMCID: PMC5935277.
  6. Psaty BM, Dekkers OM, Cooper RS. Comparison of 2 Treatment Models: Precision Medicine and Preventive Medicine. JAMA. 2018 Aug 28;320(8):751-752. doi: 10.1001/jama.2018.8377. PMID: 30054607.

 

“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.”