Devesh Rai, MD – The Early Career Voice

Polycystic Ovary Syndrome was found to be associated with increased cardiovascular complications at the time of delivery

July 19, 2022July 13, 2022 Devesh Rai, MD

A new study published in the Journal of the American Heart Association shows that women of reproductive age with Polycystic Ovary Syndrome (PCOS) are at increased risk of cardiovascular events (peripartum cardiomyopathy, heart failure, cardiac arrhythmias, venous thromboembolism, and acute kidney injury) at the time of delivery admissions.¹ PCOS is a common endocrine disorder affecting 5-13% of women in the United States. Previously PCOS was known to be associated with long-term cardiovascular complications. However, the current study has shown that women with PCOS can even develop acute CV complications during labor and delivery admissions.

The current study analyzes a national inpatient sample evaluating the data spanning 17 years from 2002 to 2019 and shows an exponential increase in cardiometabolic risk factors such as PCOS and obesity among reproductive age group women in the U.S. The results were notable for women with PCOS to be comparatively older, with higher comorbidities such as diabetes, obesity, and hyperlipidemia. For instance, PCOS prevalence increased from 569 to 15,348 per 100,000 deliveries. Similarly, obesity showed an exponential increase from 5.7% to 28.2%. This suggests poor cardiometabolic health among pregnant women in the U.S has significant public health implications. It is also noteworthy that patients with PCOS were found to have higher rates of pre-eclampsia, peripartum cardiomyopathy, and heart failure. The authors also reported the PCOS group to have longer hospital length of stay and higher cost of hospitalization.

The researchers also examined socioeconomic disparities and found that minority ethnic groups such as African American women and lower-income class groups are at the highest risk of developing cardiac complications. Hence an intervention aimed at this vulnerable population group may be most helpful in preventing future complications. “We want to stress the importance of optimizing the cardiovascular health of women with PCOS with prevention efforts, especially Black women and lower socioeconomic groups because we believe that those are the most vulnerable populations and will benefit most from intervention,” says Salman Zahid, M.D., a resident physician in the Rochester General Hospital Internal Medicine Residency program in Rochester, New York, and lead author of the study.

The author’s work in this area is commendable as the results of this study help in identifying necessary complications of PCOS and also shine a light on socioeconomic disparities. The results of this study can help in making important policy changes and also provide the framework to be more vigilant of the potential complications in PCOS patients.

In summary, the current work uncovers a worsening cardiometabolic health profile of reproductive age women in the U.S. Urgent public health interventions are needed to better screen and prevent cardiac disease with particular attention to at-risk groups. This work has tremendous implications for reducing the rising maternal mortality rate in the U.S.

Prominent researcher, cardiologist, and mentor of this important study, Dr. Michos comments “Polycystic ovary syndrome (PCOS) is the most common endocrine abnormality of women of reproductive age. PCOS is associated with a number of cardiometabolic abnormalities such as hyperandrogenism, insulin resistance, dyslipidemia, elevated blood pressure, and elevated body mass index. Recent studies have shown that PCOS is associated with future risk of cardiovascular (CV) disease, although whether this is directly causal or mediated through those underlying cardiometabolic and endocrine abnormalities has been debated. Either way, it is important for women with PCOS to be screened for CVD risk factors, treated if risk factors are present, and implement healthy lifestyle changes. Although prior work has focused on longer-term CV complications from PCOS, our current analysis examined acute peripartum CV complications at the time of pregnancy delivery. PCOS is associated with infertility, but our analysis using a large nationally representative U.S. sample showed even after these women become pregnant, they are still at heightened risk of adverse CV complications, including peripartum cardiomyopathy, acute heart failure, and venous thromboembolism. This association of PCOS with these acute cardiovascular complications was independent of preeclampsia/eclampsia risk. Our study stresses on the importance of optimizing the cardiovascular health of women with PCOS before, during, and after pregnancy to prevent adverse cardiovascular complications. We also showed that both PCOS and obesity prevalence was rising over this 17-year period (2002-2019), reflecting other national trends of the declining cardiovascular health of young adults, including reproductive age women. So much work needs to be done to revamp prevention efforts in the U.S. including at the individual, healthcare, societal, and policy levels to reverse these very worrisome trends.”

References:

Trends, Predictors, and Outcomes of Cardiovascular Complications Associated With Polycystic Ovary Syndrome During Delivery Hospitalizations: A National Inpatient Sample Analysis (2002–2019) Salman Zahid MD , Muhammad Zia Khan MD, MS , Smitha Gowda MD , Nadeen N. Faza MD , Michael C. Honigberg MD, MPP , Arthur (Jason) Vaught MD , Carolyn Guan BA , Anum S. Minhas MD, MHS , and Erin D. Michos MD, MHS [email protected]

“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.”

Gender Disparity in the Guideline Authorship, More Work Needs to Be Done on the International Level

March 25, 2022March 22, 2022 Devesh Rai, MD

Women have been widely underrepresented in cardiology over the past decades. Lately, over the last decade, the American College of Cardiology/American Heart Association (ACC/AHA) has made active efforts to bridge this gap. Other international societies such as the European Society of Cardiology (ESC) and the Canadian Cardiovascular Society (CCS) have also made similar efforts. However, the fruition of these efforts remains questionable. Although there is closure parity in the number of men and women entering medical school, the percentage of women continues to decrease as they advance in their career from medical school to residency and further to fellowship. This phenomenon has been called a “leaky pipeline,” which continues to drop down further going into academics and progressing to leadership.¹

As per recent original research published in the Journal of American Heart Association, there is persistent disparity in including women in the guideline authorships from the ACC/AHA, ESC, and CCS guidelines from 2006-2020.² The authors extracted all published guidelines from 2006-2020, reporting 80 ACC/AHA (1288 authors, 28% women), 64 CCS (988 authors, 26% women), 59 ESC (1157 authors, 16% women) guidelines suggesting vast underrepresentation of women in the leadership. There is a positive trend towards inclusion of women in the ACC/AHA guidelines, from11 (12.6%) in 2006 to 63 (42.6%) in 2020 (average annual percentage change, 6.6% [2.3% to 11.1%];P=0.005).² There was a similar increase in the inclusion of women in the ESC guidelines as well, from 1 (7.1%) in 2006 to 23 (25.8%) in 2020 (average annual percentage change, 6.6% [0.2% to 13.5%]; P=0.04). Interestingly, the inclusion of women in CCS guidelines remained similar over the years.

In recent years, there has been a comparatively higher inclusion of women in ACC/AHA than CCS and ESC. This could be reflective of earlier efforts initiated by ACC/AHA back in 1995 by setting up nationwide and statewide women in cardiology chapters to promote women in cardiology. The study reported a higher inclusion of women in the guideline writing group when a woman was a chair or at least one of the chairs was women in the ACC(48% versus 30% versus 21%; P<0.0001) and ESC (43% versus 34% versus 14%; P<0.0001) guidelines; however, a similar trend was not seen in the CCS guidelines. These results are intriguing, as guideline writing committees are chosen independently by the task force group without direct input from the chairs. These results suggest inherent bias in the selection of writing group members.²

The authors also report women authors’ inclusion in general cardiology and subspecialties, reporting a higher inclusion of women in pediatric cardiology and heart failure followed by general cardiology and lowest in interventional and electrophysiology guidelines. The lower inclusion of women in the intervention and electrophysiology guidelines is likely secondary to fewer women in these fields; this has been likely attributed to the procedure-oriented areas and women shying away from these fields due to potential radiation exposure. Currently, professional societies like Women as One SCAI have put special efforts to promote women in the procedure-oriented fields and decrease overall radiation exposure.^3-6

Another interesting aspect of this study was the repetition of the unique authors (the same authors being included in multiple guidelines) revealed 31.9% of women authors were repeat authors, which was similar to 32.9% of men authors. However, the highest frequency of inclusion of repeated men authors was higher than women. The authors propose limiting the number of times an author can be included on guidelines as a potential way to encourage more women in cardiology in the leadership.

It is important to achieve parity in the guideline authorship group as this group should reflect the population we serve. Prior studies have also supported that having a diverse physician group or patient treated by physicians of similar racial and ethnic backgrounds has better clinical outcomes. Thus, concerted efforts to plug the leaky pipeline at every step can help achieve gender parity in cardiology and promote leadership among women in cardiology.¹

Prominent researcher and senior author Dr. Martha Gulati says: “This work was led by fellow-in-training Dr. Devesh Rai. He was particularly interested in the need for the inclusion of women in cardiology. I was honored to serve as the senior author and mentor of Dr. Rai and am grateful that the upcoming generation of cardiologists, regardless of whether male or female, are interested in seeing a change in our cardiology community in terms of diversity, equity, and inclusion.

Our work demonstrated that there is a significant disparity in the inclusion of women on all national guideline committees within AHA/ACC, ESC, and the CCS. Additionally, women are less likely to serve as a chair of cardiology guidelines. Further advocacy is required to promote equity, diversity, and inclusion in our cardiology guidelines globally.”

Reference

Arnett DK. Plugging the Leaking Pipeline. Circulation: Cardiovascular Quality and Outcomes. 2015;8:S63-S64.
Rai D, Kumar A, Waheed SH, Pandey R, Guerriero M, Kapoor A, Tahir MW, Zahid S, Hajra A, Balmer‐Swain M, Castelletti S, Maas AHEM, Grapsa J, Mulvagh S, Zieroth S, Kalra A, Michos ED and Gulati M. Gender Differences in International Cardiology Guideline Authorship: A Comparison of the US, Canadian, and European Cardiology Guidelines From 2006 to 2020. Journal of the American Heart Association. 2022;11:e024249.
Cardiology ACo. Welcome to the Women in Cardiology (WIC) Member Section!
Cardiology ESo. EAPCI Women Committee.
Cardiology ESo. Women in Electrophysiology.
Interventions SoCA. Women in Innovations.

Mental stress may lead to poor cardiovascular outcomes

February 11, 2022February 4, 2022 Devesh Rai, MD

The presence of mental-stress-induced myocardial ischemia is associated with an increased risk of cardiovascular death and nonfatal myocardial infarction, as per an interesting study published in JAMA Network by researchers from Emory University.¹

Several studies have revealed the correlation between acute mental stress and the onset of myocardial ischemia seen on myocardial perfusion imaging, strengthening the concept of mental stress and coronary heart disease (CHD). These studies parallelly enrolled patients with stable CHD in the Mental Stress Ischemia Prognosis Study (MIPS) and Myocardial Infarction and Mental Stress Study 2(MIMS2). All participants underwent clinical and psychological assessment at baseline, standardized mental stress test, and myocardial perfusion imaging at rest, with mental stress and exercise or pharmacological stress test.

638 and 313 participants were enrolled in MIPS and MIMS2 study, respectively. Mental stress-induced ischemia was seen in 15%(MIPS) and 17%(MIMS2) participants. Over a medial follow up of 5 years, the pooled results of both studies revealed a higher event rate of cardiovascular death or myocardial infarction (6.9 per 100 patient-years) in positive mental stress-induced ischemia compared to those without ischemia (2.6 per 100 patient-years) (HR: 2.5, 95% CI: 1.8-3.5).¹ There was an even higher rate in patients with conventional and mental-stress-induced ischemia (8.1 events per 100 patient-years, HR:3.8, 95% CI: 2.6-5.6). Interestingly, participants with conventional stress ischemia did not have an increased risk of cardiovascular events. The study also revealed statistically significant higher heart failure incidence in patients with mental stress-induced ischemia. ¹

The Brain-Heart axis has been an active area of research over the last decade²; the current study further strengthens this correlation. This study differentiates between the ischemia incidence and outcomes based on mental and conventional stress, which has not been reported in prior studies. It is noteworthy that patients with mental stress-induced ischemia have a higher incidence than conventional ischemia. ere have been other studies in the past which have investigated the impact of acute mental stress leading to decline in cardiac function known as Takotsubo cardiomyopathy, or commonly known as broken-heart syndrome.³ Interestingly, a few smaller studies have shown that an ecstatic happiness state can also lead to Takotsubo cardiomyopathy.³ Nevertheless, the acute decline in these scenarios are mostly transient, but, as per the current study effect of mental stress induced ischemia my lead to prolonged adverse outcomes.

Further studies evaluating the screening for mental stress-induced ischemia and potential early interventions can pave the pathway for reducing CHD, thereby strengthening the concept of the Brain-Heart axis.

https://twitter.com/DrDavidKatz/status/1459574297601658883

https://twitter.com/andrebez/status/1479425795949056004

References.

Vaccarino V, Almuwaqqat Z, Kim JH, et al. Association of Mental Stress–Induced Myocardial Ischemia With Cardiovascular Events in Patients With Coronary Heart Disease. JAMA. 2021;326(18):1818-1828.
Tahsili-Fahadan P, Geocadin RG. Heart–Brain Axis. Circulation Research. 2017;120(3):559-572.
Lyon AR, Citro R, Schneider B, et al. Pathophysiology of Takotsubo Syndrome: JACC State-of-the-Art Review. J Am Coll Cardiol. 2021;77(7):902-921.

Equity, Diversity, and Inclusion: The Pillars of #AHA21

December 23, 2021December 17, 2021 Devesh Rai, MD

I was delighted to be selected as one of the American Heart Association (AHA) early career fellows in training bloggers for the year 2021-2022 during my first-year cardiology fellow. During 2019, the AHA conference was in Philadelphia and in-person. However, with the COVID-19 pandemic surge, we have learned how to attend virtual to hybrid conferences. Slowly, we have adapted to the new way of the virtual conference to be our harsh reality amidst an ongoing pandemic. The COVID-19 pandemic shed light on an essential aspect of healthcare. It brought forward the disparities in health care from enrollment of underrepresented patient populations in trials to the care of these patients.

The AHA has always emphasized equity, diversity, and inclusion (EDI) in the conferences and attempted to promote enrollment of the underrepresented population. The #AHA21 was a testament to these continued efforts visible in all sessions and specially planned sessions based on EDI. During the 3-day #AHA21, there were multiple exciting sessions.

Along with incredible live sessions regarding the ongoing groundbreaking research in the field of cardiology. There were multiple exciting on-demand sessions on EDI. Financial Toxicity and Cardiovascular Health Management and Outcomes by Dr. Krumholz from Yale School of Medicine was an incredible session raising important questions regarding the impact of the costly intervention on patients’ financial freedom, an aspect that is often ignored by the providers. Similarly, another session by Dr. Sharm from Johns Hopkins University discussed important concepts about monitoring of women with pregnancy complications or preterm deliveries discussed the important aspect of Cardio-Obstetrics, which has not been discussed much in the past.

With the pandemic, cardiac rehabilitation became challenging in the first place. However, with the evolution of the reach of virtual technology, Dr. Beaty from the University of California, San Franciso, discussed the innovative ways to encourage and involve patients in remote cardiac rehabilitation in older adults, women, and people of color as well. This kind of remote approach can potentially help in reaching all patient populations, thereby breaking the barriers of social determinants of health.

Not only #AHA21 provided a platform to practice with keeping social determinants of health. It also provided a platform for the fellows in training regarding how to navigate being a new parent in a special seminar. This was a heavily attended session with more than 100 participants where fellows shared their experiences of navigating through the challenges of being a parent during the fellowship. Everyone shared the nuances, tips, and tricks of being a parent during the fellowship, which was very powerful. These kinds of sessions can encourage more women to join cardiology and thereby close the leaking pipeline and bridge the gap.

The #AHA21 commitment towards motivating women in cardiology is also evident by the complete absence of MANELS in this 3-day conference and a testament to immediate past president Dr. Bob Harrington’s commitment towards #HeforShe campaign encouraging more women towards cardiology.

It’s heartwarming to see the success of #AHA21 and the fruition of EDI efforts of AHA extending from patient care, fellows in training to physicians.

“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.”

Early Intervention can Lead to Prevention Of Postoperative Atrial Fibrillation after Cardiac Surgery

November 14, 2021November 15, 2021 Devesh Rai, MD

Posterior left pericardiotomy can help reduce new-onset atrial fibrillation is suggested by a late-breaking science presented by prominent researchers and cardiothoracic surgeon Dr. Gaudino at American Heart Association 2021 virtual conference on November 14, 2021.

Atrial fibrillation(AF) is the most common complication after cardiac surgery, and the incidence ranges from 15-50%.¹ The incidence of postoperative AF has remained similar over the years. The researchers from the Posterior Left Pericardiotomy for the Prevention of Postoperative Atrial Fibrillation After Cardiac Surgery (PALACS) trial built upon the prior smaller studies suggesting posterior left pericardiotomy may decrease new-onset postoperative AF.² It is an adaptive, single-center, single-blind randomized controlled trial at New York-Presbyterian Hospital.

The trial included patients undergoing coronary artery bypass grafting (CABG), aortic valve and/or aortic surgery with no history of prior AF or other arrhythmias. These patients were started on beta blockers post-procedure. The trialists screened 3601 patients and included 420 patients for randomization with posterior left pericardiotomy vs. no additional intervention. The patients were followed only during the inpatient hospitalization for primary and secondary outcomes. Interestingly, the incidence of new-onset AF was remarkably lower in the intervention group (18% vs. 32%, Relative risk (0.55), p:<0.001) compared to the no intervention group. The authors also report that the need for postoperative antiarrhythmic medications and systematic anticoagulation was considerably lower in the intervention group. However, the length of hospitalization was similar in both groups. Similarly, there was no difference in mortality.²

The decrease in the incidence of postoperative AF can be attributed to lower postoperative pericardial effusion with the posterior left pericardiotomy. This small incision created a pathway for the drainage of the pericardial fluid to the pleural area, thereby inhibiting the inflammatory pathway and atrial remodeling, which could cause AF. Prior to this, many other therapeutic interventions with antiarrhythmic medications have been studied for the potential preventive strategy of AF. Nevertheless, this is a novel surgical technique with potential for future implications.

It is noteworthy, PALACS is a single-center trial with no hard clinical outcomes and comes with limitations. Evaluating the sample size, the mean age of the population was 61 years, and 24% of the participants were women. The mean CHA₂DS₂VASc score for the sample was 2. An important aspect of the trial is only the inpatient follow-up of the participants; there is a small subset of patients who may develop AF even after four weeks of discharge. The design of the trial is intuitive and aims for a proof of concept regarding the surgical technique.

Dr. Subodh Verma, a prominent researcher and cardiothoracic surgeon from the University of Toronto, says, “Congratulations to the authors and investigators, this well-conducted surgical trial provides convincing proof of concept that a simple, inexpensive, generalizable, surgical adjunctive procedure of pericardial drainage can safely reduce postoperative AF after cardiac surgery” at the AHA21 while discussing the study.

References:

Verma A, Bhatt DL, Verma S. Long-Term Outcomes of Post-Operative Atrial Fibrillation. Journal of the American College of Cardiology. 2018;71(7):749-751.
Gaudino M, Sanna T, Ballman KV, et al. Posterior left pericardiotomy for the prevention of atrial fibrillation after cardiac surgery: an adaptive, single-centre, single-blind, randomised, controlled trial. The Lancet.