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“Paid Leave Regardless of Pregnancy Outcome? While New Zealand pioneers the future for women, the US continues to be left behind.”

As I approach the final weeks before delivering my second child in cardiology fellowship, my friends outside of medicine ask if I’ve started maternity leave. I answer, “No, I’m saving the 7 weeks of paid leave to start at the time of delivery.” Like most women physician mothers, I have a suspicion you can relate. We want to maximize our time with our newborns before returning to work. While every pregnancy varies, the last few weeks can be quite challenging, depending on the clinical and procedural duties required, all while balancing the responsibilities of “nesting” and mentally preparing for this new addition. While our preferences may differ on how much time we’d ideally spend on maternity leave, I feel it’s worth the few moments to reflect that maybe we would like the opportunity to have more time if we were granted it. That being said, there continues to be a lack of standardization of maternity leave across the country.

As we approach the end of #InternationalWomensMonth and celebrate women across the world and discuss #equalpay, the news of New Zealand’s approval of paid leave after miscarriage announced a few days ago in the NY Times is so fitting for a finale1. Ginny Anderson, the Labour member of Parliament who drafted this bill, stated.

“I felt that it would give women the confidence to be able to request that leave if it was required, as opposed to just being stoic and getting on with life, when they knew that they needed time, physically or psychologically, to get over the grief.”

I have been fortunate to not experience the immeasurable pain of losing a baby through miscarriage or stillbirth. As healthcare providers, we are all aware of the 10-20% of known pregnancies resulting in miscarriages, and with more women, in general, pursuing careers and getting married later in life, us “older mothers” are at increased risk of miscarriage and gestational complications. The jury continues to be out on whether the culture of medicine that embraces night shifts and working long hours contributes to physician miscarriages2. Regardless, the culture of appearing calloused immediately after such a devastating loss and carrying on as expected while mentally grappling with the physical and emotional trauma that lingers seems primitive.

As I hold growing belly during this final stretch, my hope is for all women who desire to be mothers to have the same opportunity to have the time and space to deal with whatever comes down the road. While the rise in pregnancy hormones may explain my emotional post today, the humility I feel and sensitivity to women who may be coping in isolation is not lost on me.

With a warm heart,

Kyla Lara-Breitinger, MD, MS

“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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Eating To Live Or Living To Eat? The Weight-Gain Struggle During a Pandemic

To my fellow physicians and patient providers, how many of your patients have gained weight and blamed it on the pandemic due to limited options for physical activity outside of the home?

Unsurprisingly, almost all of my patients I’ve seen over the past year have fallen victim to this, with good reason. They are protecting their health by avoiding exposure to COVID-19 but at the same time are unconsciously neglecting their health by not having the means or green light to engage in healthy behaviors such as going to the gym, walking in public spaces, and engaging in aerobic exercise and strength training. Our current restrictive environment combined with more time at home to eat and indulge is a fail-proof setup for adding on these harmful extra pounds.

So what can our patients control and how do we motivate them? This reminds me of my roommate in medical school who once told me that I “live to eat” because I would act immediately on a food craving and would also plan my next meal while actively eating a meal in front of me. I asked him if he also followed this same dogma of being an “emotional eater” and acted impulsively on energy-dense, nutritionally lacking foods. He responded with “I eat to live” because he only thinks about food when his body sends him the appropriate signals. I had to think about this. Yes, “stress-eating” is a habit that many of us are using as a coping mechanism during the COVID-19 pandemic.

Food culture is central in many cultures across the world. Food brings people together, establishes common ground amongst strangers, and provides satisfaction and emotional fulfillment while traveling, learning, and growing. We’re social creatures who naturally select to build connections that many times are centered around meals. But when the balance tips towards overindulgence and away from physical activity and healthy mindfulness is when chronic diseases such as coronary artery disease and its associated comorbidities arise.

For many of us, we understand what we should eat to become healthier, however, that does not mean we will actually follow this rationale to maintain a heart-healthy diet, especially during a pandemic when most of our day is spent sedentary in isolation at home. Despite having a master’s degree in Nutrition as part of my training, I can admit that I have invariably fell victim to the vices of food comfort at home. I was eating a lot of baked desserts after dinner but recently decided to replace this habit with a cup of hot chocolate made with soy milk and sugarless cocoa powder.

So how do we combat this? We know the right food prescriptions of diet to provide our patients and have all heard the saying of “you are what you eat.”

Let me quickly review the 4 strategies of motivational interviewing (OARS) and a few quick tips to help our patients (and ourselves) make gradual and achievable nutritional changes:

  • Open-ended questions- this allows your patient to explore and think more deeply about personal goals.
  • Affirmations- highlight your patient’s strengths and skills to support self-efficacy
  • Reflections– reflective listening and providing empathy deepens the trust with your patient; avoid making judgments as patients become may become defensive
  • Summaries- summarizing the above then allows you to move on to making a specific plan with your patient

Here are 5 tips to help your patients make healthier food choices during the pandemic:

  • Allow your patient to decide on 1-2 specific food goals per week (this can involve eliminating one food item they are able to identify that is unhealthy or decreasing the amount of this food item per day or week).
  • Empathize with the difficulty of being at home and that boredom by itself can cause overeating. Prior to eating, challenge them to take a few seconds to determine whether or not they are hungry or are deciding to eat because they are bored.
  • Make a goal of drinking at least 8 glasses of water a day- being underhydrated can in turn cause overeating of salt-laden foods.
  • “Eat your calories, don’t drink them.” Ensure that your patient is avoiding caloric beverages. If they enjoy fruit juices, ask that they try eating fruits as the fiber benefits are much more plentiful with less additive sugars.
  • Lastly, congratulate them on their decision to make a change and have a specific follow up plan to continue building on the changes they are making.

Be well,

Kyla Lara-Breitinger, MD, MS

References:

https://psycnet.apa.org/record/1998-04654-001

 

“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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To Vaccinate or Not Against COVID-19 During Pregnancy: A Pregnant Cardiology Fellow’s Humble Perspective

When news of the approval of the Pfizer vaccine surfaced, I felt a sense of anxiety. There was no data on pregnant women in the COVID-19 vaccine trials. As a medical professional, we have been trained to apply for evidenced-based medicine and baseline patient characteristics of trial participants to the patients we plan to treat. But what if your pregnancy status was not studied in the trial during a global pandemic? How might you weigh the unknown risks of the vaccine to your growing fetus with the risk of COVID-19 infection while pregnant?

Making the Decision

A few days passed when I received an email from Occupational Health that my cardiology fellowship program would be part of the Phase I distribution of the vaccine. The following day, my midwife conveyed to me that the OB department would align with the American College of Obstetrics and Gynecology (ACOG) Practice Advisory Statement:

“ACOG recommends that COVID-19 vaccines should not be withheld from pregnant individuals who meet criteria for vaccination based on ACIP-recommended priority groups.”

I felt a sense of relief that I would not be prohibited from getting the vaccine if I chose to do so yet also felt a sense of panic when I read the following:

“Vaccines currently available under Emergency Use Authorization (EUA) have not been tested in pregnant women. Therefore, there are no safety data specific to use in pregnancy.”

As a trained medical professional and protective mother, the overwhelming number of daily decisions we make to ensure the safety of our babies are overwhelming- no sushi, no wine, no retinoids or other harmful active ingredients found in our beloved skin care regimens, no hot tubs… I could go on.

However, the challenge of navigating the emotions of fear and uncertainty about the vaccine became incomparable to the following facts:

mRNA Does Not Alter Your DNA

These vaccines are not live virus vaccines and do not use an adjuvant to augment the efficacy of the vaccine. It does not enter the nucleus or alter human DNA.

Risk of Exposure

My job involves routinely interacting with patients and performing aerosolizing procedures, which places me at increased risk for exposure to COVID-19.

Symptomatic Pregnant Patients Infected With COVID-19 Are at Increased Risk of Severe Illness

This includes hospitalization in the intensive care unit (ICU), the need for intubation and mechanical ventilation, extracorporeal membrane oxygenation (ECMO), and death.

I decided that getting vaccinated was safer than getting COVID-19. I also consulted with my partner who is also my husband and the father to our developing fetus. Although ultimately it was my decision to make, I felt comforted knowing he was 100% on board with me proceeding with vaccination based on the above as well.

Getting Vaccinated and the Side Effects

I received both doses of the Pfizer vaccine, the first dose at 20 weeks and the second dose at 23 weeks gestation. With the first dose of the vaccine, I only experienced arm soreness that peaked on day two. With the second dose, I experienced a mild headache and mild bilateral upper extremity soreness but with two doses of acetaminophen, I continued to work at full capacity and performed intraoperative transesophageal echocardiograms without issues.

I am now 25 weeks pregnant and feel a sense of pride that I made this decision to protect myself and my unborn child. I have received many texts and messages inquiring about how I made my choice. Questions such as “would your decision change if you were in your first trimester before organogenesis was complete?” or “would you get vaccinated while trying to conceive?” were a few memorable ones. I firmly believe it is your right as a woman to make this difficult decision when there is no safety data available.  Personally, yes, I would have still made the decision to vaccinate.

Lastly, I will join many of the other scientists and advocates out there who demand that pregnant and lactating women be included in future vaccine research trials http://vax.pregnancyethics.org/prevent-guidance. Track records of vaccine safety should exist for expectant mothers to help guide and improve vaccination rates.  Here is to hoping for a better year that allows each and every one of us access to the COVID-19 vaccine no matter what country, gender, pregnancy status, lact

ation, status, or employment status we bear.

Stay safe and stay healthy,

Kyla Lara-Breitinger, MD, MS

References:

https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/12/vaccinating-pregnant-and-lactating-patients-against-covid-19

https://s3.amazonaws.com/cdn.smfm.org/media/2632/FDA_final.pdf

 

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

 

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A Reflection on Prevention: Can a Holistic Approach to Prevention Include a Polypill?

Does a polypill obviate the need for behavioral changes? Absolutely not. As a physician training in Cardiology, I spend a sizeable part of my time discussing achievable weekly nutritional goals with patients in addition to stressing the importance of medication adherence. I ask myself after watching the “Bending the Curve for CV Disease- Precision or Polypill,” would I recommend a pill that can treat both hypertension and hypercholesterolemia and decrease the risk for CV disease? Certainly, this would make medication adherence for our patients much simpler, especially with the combination of atenolol, ramipril, hydrochlorothiazide, and simvastatin into one pill.

The International Polycap Study (TIPS-3) presented by Drs. Prem Peis and Salim Yusuf was a double-blinded, randomized trial of more than 5,700 adult men and women at increased CV risk with an intervention of the once-daily polypill, aspirin, combination of both or placebo (see figure). Endpoints of CVD events included CV death, non-fatal stroke, non-fatal MI, heart failure, resuscitated cardiac arrest, or arterial revascularization.

To summarize the results, 5-year outcomes found that the polypill was superior to placebo in decreasing systolic blood pressure, LDL-C, and non-fatal CV events in mostly Southeast Asian participants.  Low-dose aspirin resulted in lower stroke risk and the additive effect of aspirin to the polypill had a higher reduction in nonfatal CV events when compared to the double placebo arm. The side effects of the intervention group included dizziness and hypotension.

 As I return back to clinical responsibilities, I reflect on the AHA Scientific Sessions with particular attention to this polypill. Would you recommend a pill that was cost-effective that decreased pill-burden in your patient? I think I would but not at the cost of leaving behind crucial behavior changes that are integral for health and well-being.

More importantly, the following slide resonated with me the most and I believe conceptualizes a comprehensive framework for prevention and precision medicine:

The takeaways here are that there is a continuum of care across a spectrum of healthy, at risk, and diseased patients we see on a daily basis. Each group in this spectrum requires an individualized, community, and health system approach to intervention and implementation of decreasing cardiovascular risk. The domains needing to be addressed are part of a long list but each important in their own right:

Health Literacy

Health System

Health Policy

Socio-Behavioral Sciences

Human Resource Training

Health Economics

Technological Innovations

Media and Communication

Monitoring and Evaluation

With this framework in mind, I challenge myself and you all to think more deeply about how we might integrate universal standards along with individually-tailored preventative interventions when managing our patients. Our day-to-day clinic experience can at times lull us into the feeling of an unchanging routine, however this presentation was a great reminder of future opportunities to probe further to apply novel universal approaches while also seeking to understand individual patients’ health behavior needs and pushing individualized medicine further in the domain of CV prevention. This will be accomplished through quality care projects, educational work, health equity advocacy, and investigative research.

Take care and be well.

References:

https://www.nejm.org/doi/full/10.1056/NEJMoa2028220

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

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A Career in Preventive Cardiology: It’s A Lot More Than Statins

I spent the finale of #AHA20 Tuesday evening at the “What You Need to Know for a Career in Preventive Cardiology” fireside chat hosted by the lovely Dr. Anum Saeed with experts Drs. Ann Marie Navar, Andrew DeFillips, Seth Martin, Michael Shapiro, and Martha Gulati. The panel discussed the following topics:

Exploring the field of prevention when your program may or may not have a prevention program 

Certainly, one month of exposure is not enough to truly get a taste of the multiple flavors within this field which includes exercise, cardiac rehab, hypertension, advanced lipidology, multimodality imaging and risk scoring, diabetes, and obesity. That being said, it’s important to find a way to get involved even if your program doesn’t have a prevention program. Request to spend elective time in other specialties including Endocrinology where SGLT2 inhibitors are routinely prescribed, clinics where weight-loss medications are frequently used, and other areas in medicine that may intersect within prevention. If you do spend time in cardiac rehab, don’t just spend time with the physicians but also hang out with the exercise physiologists on the floor who engage with cardiac patients- there’s a lot to be learned from them.

Finding an academic position in prevention

Unfortunately, the current reality is that reimbursement for preventive services does not pay the bills for a cardiology division. This means that it’s extremely important for you to find a niche or expertise within cardiology that gets you paid. This can include an imaging modality, interventions (yes, there are interventionalists who practice as preventive cardiologists!), quality improvement care, research, healthcare delivery, technology, and clinical care.  The hope is that in the not-too-distant future, we will transition to more of a value-based care model.

Another very insightful pearl from the panel: when you ask for your position, know what you need early on and ask for what you want. DEFINE WHAT YOU NEED UPFRONT and where you need that time to develop a program, work on research, or start an initiative that will be productive for your department.

A day in the life of an academic preventive cardiologist

This varies widely depending on the unique interests and expertise of the individual. This can range from spending 2 week blocks caring for patients in the cardiac intensive care unit to then being off for 2 weeks followed by an outpatient clinic and research time. If you are primarily research, this may mean having a clinic one day a week with 70% of the time focusing on writing/research and attending national meetings, and collaborating with preventive groups across the world.

The future of prevention

“We’re more than giving statins.” The exciting areas of prevention and late-breaking science that were highlighted during #AHA20 speak for themselves. SLGT2 inhibitors, the promise of Inclisiran, and the polypill are just the tip of the iceberg within the field of prevention. With artificial intelligence and machine learning, polygenetics, implementation science, health equity, and digital technology, the field of prevention will be pivotal in improving outcomes such as myocardial infarction, for example, by tailoring therapy based on individual risk rather than covering everything with all available treatments. Lastly, if there is a silver lining of this #COVID-19 pandemic, it is that the cardiovascular risk factors and health disparities that have come to the surface are now being prioritized as the path for future research trials and public health movements.

I’ll leave you with a Chinese proverb one of our panelists shared: “A superior doctor prevents sickness; A mediocre doctor attends to impending sickness; An inferior doctor treats sickness.”

Stay well, be well, and be safe. And wear a mask.

 

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

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A Possible Link Between That “Gut Feeling” and Heart Disease

Let’s face it- this #COVID19 pandemic has found us seesawing between embracing extra workouts and healthier homemade meals to lamenting over those extra pounds from those sourdough starters. Many of us can use a jump start to reclaim our #hearthealthy goals. #AHA20 has provided us a captivating session on the link between diet, the gut microbiome, and cardiovascular disease.

Drs. Katherine Tucker, Wilson Tang, and Caroline Genko presented the basics of how the quality of our diet affects the diversity of bacteria and level of systemic inflammation in the body, the role of the TMAO pathway in atherosclerosis, and how oral pathogens can affect both atherosclerosis and the gut microbiome:

SCIENCE: Epigenetics alter the transcription of genes through modification (DNA methylation, histone modification, and miRNAs). These processes can be affected by stress, diet, and the microbiome.

TAKEAWAY: We have some control over the expression of our genes if we adhere to healthy lifestyle changes that improve our stress, sleep, diet, and physical activity.

SCIENCE: Gut bacteria metabolize indigestible fibers into short-chain fatty acids (SCFAs) which have been associated with the prevention of chronic disease and are also important for muscle function.

TAKEAWAY: Continue eating more plants and whole grains to prevent heart disease and other chronic diseases.

SCIENCE: Animal-based diets increase bile-tolerant microorganisms that are responsible for pro-inflammatory pathways.

TAKEAWAY: Limit animal meat (especially red meat) to decrease the amount of inflammation in your body. Inflammation = heart disease!

SCIENCE: The more highly processed the diet is, the higher the risk of CV disease even after multivariable adjustment.

TAKEAWAY: Limit the middle aisles of your grocery store and go rogue on the perimeter aisles, which should be abundant in perishables (fruits and vegetables) and freshly baked whole grains.

SCIENCE: Increased TMAO levels are associated with atherosclerosis and are only one of the many pathways involved in the link between the gut and CV disease. Red meat is associated with elevated TMAO levels. There is also unique crosstalk between organs, with reduced excretion of TMAO by the kidneys with increased consumption of red meat. Lastly, caloric restriction and intermittent fasting have been associated with decreased levels of TMAO.

TAKEAWAY: As above, another reason to limit or avoid red meat!

SCIENCE: Animal studies showed those fed a Western diet and infected with P. gingivalis (oral pathogenic bacteria) had accelerated atherosclerosis. The gut microbiome composition was also affected by P. gingivalis infection.

TAKEAWAY: Be sure to take care of your oral health and see your dentist regularly for cleanings to help prevent cardiovascular disease.

After reading this, I hope you all reconsider how you think about going with your “gut” when deciding on your next meal.

Eat well, be well, and be safe. And keep posting #PetsofAHA20.

 

 

“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.”