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Peripartum Cardiomyopathy: Go Red & Recognize!

This one is dedicated to all women and their families who have been affected by Peripartum Cardiomyopathy (PPCM). Seldom detected, systolic heart failure can come as a surprise especially in young women. Developing heart failure during pregnancy, in the post-partum period or any other time throughout a subsequent pregnancy is not something any woman wants to worry about specially around the birth of their child.

The 2010 Heart Failure Association of the European Society of Cardiology Working Group defines PPCM to “an idiopathic cardiomyopathy presenting with Heart Failure (HF) secondary to Left Ventricular (LV) systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause of heart failure is found”1, hence a diagnosis of exclusion.

The annual incidence of PPCM continues to increase. Women present with wide range of HF symptoms. Although some have complete recovery with guideline directed medical treatment, others have persistent myocardial dysfunction, advance heart failure and death which subsequently leads to devastating consequences for an entire family.  Delays in diagnosis usually occur because the symptoms and signs of PPCM can mimic the normal findings of pregnancy.  Early recognition and treatment of PPCM could lead to improvements in maternal and fetal mortality and morbidity. Easier said than done.

By the time a patient with PPCM sees a cardiovascular specialist, they often have worsening symptoms of heart failure with moderate to severe depressed left ventricular systolic function which means it was later recognized by either a primary care physician and/or an obstetrician-gynecologist prior to referral.

Awareness is key in early detection of PPCM. If you see something, say something. Think PPCM in all pregnant women. Since we mentioned that survival and recovery are both improved by early diagnosis, there is a validated self-test that can help with discerning heart failure from pregnancy related symptoms from Fett et al2. (Table 1.)

 

  1. Self-Test for Early Diagnosis of Peripartum Cardiomyopathy
Symptoms 0 points 1 point 2 points
Orthopnea None Need to elevate head Need to elevated 45 degrees or more
Dyspnea None Climb 8 or more steps Walking on level
Unexplained cough None At night Day and night
Excessive weight gain during last month of pregnancy None 2-4 pounds per week Over 4 pounds per week
Lower extremity edema None Below the knee Above the knee
Palpitations None When Laying down at night Day and night or any position

  The present of 4 or more points should prompt additional investigation.

 

Fett’s self-test can be an essential tool for the PCP and OB-GYN to aid in early detection of PPCM. Think about PPCM and use the self-test on all patients at risk to help guide further next steps in the diagnosis and management. In support of awareness of heart disease in women, think PPCM in which case the battle is half way won.

 

References:

  1.  Sliwa K, Hilfiker-Kleiner D, Petrie MC, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur J Heart Fail 2010;12: 767–78.
  2. Fett, JD .Validation of a self-test for early diagnosis of heart failure in peripartum cardiomyopathy. Crit. Pathw. Cardiol. 10(1), 44–45 (2011).

 

“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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Heart Failure Management and the Challenge of Systems-Based Practice Implementation for Optimization of Guideline Directed Medical Therapy

As the population continues to age, along with the addition of lifesaving and prolonging medical therapies, the prevalence of HF will continue to increase. In this article, we will solely focus on Heart Failure with Reduced Ejection Fraction (HFrEF), and the potential solutions to the issues with the optimization of guideline directed medical therapy (GDMT) on a systems level.

Robust evidence has established a mortality benefit of GDMT for patients with left ventricular dysfunction. Although the known benefits of GDMT have continued to solidify, there remains a visible gap among patients with HFrEF and the efficacy of treatment.

The issues that exist are likely not based on the individual pharmaceutical therapies profile. Furthermore, medication intolerance and incomplete prescription data can only partially be blamed. Nevertheless, the problems are on a bigger scale, and they involve many different components of our care system.

Let’s discuss some of the barriers to the optimization of GDMT in patients with HFrEF: patient providers and the care system. Providers, including non-cardiologists, should be trained adequately to be able to initiate patients on appropriate medications for HFrEF. They should also know the threshold to discontinue the medications, their side effects, the major contraindications, and, most importantly, when to seek help. HF patients are often complex, and it is essential to know that the different providers involved in their care should be in constant communication when it comes to their medical regimen. It is not enough to start the medication. It’s of utmost importance to continue increasing the dosages as tolerated by the patient to at least the dosages used in the different studies where these medications have shown the most benefits. Education is a key aspect, and it should involve the patient, patient’s family, providers, and everybody in the care system responsible for the patient including nurses and pharmacists. I propose 2 points among many out there:

  1. Standardized education for everybody involved in the patient’s care
  2. Standardized methods of communication between the different providers involved in the patient’s care including the patient and their families.
Heart Failure Summit 2017 Overview: Improving care and outcomes in heart failure

Figure 1. Heart Failure Summit 2017 Overview: Improving care and outcomes in heart failure1.

The purpose of this article is not to re-invent the wheel. The American Heart Association Heart Failure Summit in 2017 identified opportunities to improve care and outcomes and reduce disparities for patients with HF.(Figure 1). The purpose of this article is to remind us that we should be focusing more on implementation strategies for GDMT. We already have the tools, and, as we speak, we are adding new ones. It’s not just the tools; it is how you make use of them that will be the difference.

In summary, establishing and implementing systems of care that can help increase the number of patients on GDMT with the focus on improving medication adherence will ultimately lead to better outcomes. What is certain is that we must continue to meet the challenges of the realities of GDMT and their barriers. Our patients with heart failure depend on it.

References

  1. Pamela N. Peterson. Circulation: Heart Failure. The American Heart Association Heart Failure Summit, Bethesda, April 12, 2017, Volume: 11, Issue: 10, DOI: (10.1161/CIRCHEARTFAILURE.118.004957)

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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My TOP 5 Moments of #AHA19 Scientific Sessions

Another successful scientific session in the books and I am already looking forward to the next one #AHA20, on to Dallas.  But first, from the City of brotherly love, these are some of the highlights.

Let the countdown begin.

 

5) Late breaking clinical trials

There is usually a lot of noise around these sessions. People eager to learn about the new trials that may or may not affect their clinical practice, inspire new research ideas and question prior data. In Philadelphia, it was about time the long awaiting ISCHEMIA trial results go public.  Practice changing or not? It’s coming out party was nail-biting and met all the expectations whether you think it will change your practice in the future or not. To quote Dr. Alice Jacobs in the New York Times, ISCHEMIA “certainly will challenge our clinical thinking”.  Bottom line, my take home point from the session is simply to “Get with the Guidelines”.  Adherence to GDMT is critical and presents a challenge for the best of us. Only time will tell the impact of the long-awaited ISCHEMIA results.

 

4) Presidential session

This year’s presidential session was mesmerizing, a bit longer understandingly so.  A lot of highlights within my top 4th moment. Started with a piece from Broadway’s hit musical “HAMILTON”. If you wanted to be in the room where it (#AHA19) happened, Pennsylvania Convention Center was the place to be. From Dr. Harrington’s incredible speech highlighting the incredible of work of the AHA in advancing clinical research and education, he reminded us “Evidence Matters”

What came after was stand up ovation worthy. Several students from the city of Philadelphia walked on stage to share their stories and stand up against Vaping. This is also a reminder to all of us to stand up for our patients not only in clinics and hospitals but where ever we can make a significant contribution to their health and well-being.

Finally, the presidential sessions weren’t without emotions. From Dr. Harrington’s emotional speech about his life story to CEO Nancy Brown’s remembering Bernard Tyson: “Through his words, actions and the way he made people feel, he left the world of health care – and the world at large – better than he found it”. This truly is exemplary of great leadership.

 

3) Vaping

Again, AHA not only talks the talk but also walks the walk. The American Heart Association is truly invested in fighting for the young and against the vaping epidemic on a multi-level nationwide platform. The future is bright and #AHA knows it as it is highlighted with their #QuitLying initiative that empowers kids in their schools and communities to call out different vaping companies on their lies.

#QuitLying

#QuitLying

 

2) Cardiomyopathy

[The “PechaKucha Potpourri”: The Key Things You Need to Know about Interesting Cardiomyopathies] session moderated by Dr. Sandra Chaparro was one of my favorites and highlighted key points regarding less common cardiomyopathies. Information covered was very concise and it was provided by the experts in their respective fields such as Sarcoidosis, Chagas Disease, Check Point inhibitors and Myocarditis, Hypertrophic Cardiomyopathy, Stress Cardiomyopathy, Recovered Cardiomyopathy and Peripartum Cardiomyopathy. #AHA20 needs to bring back “PechaKucha Potpourri’’.

 

1) Early Career Blogger
This was the first time, I attended AHA as an Early Career Blogger. This was truly a different perspective where I had a lot of fun enjoying the different sessions, twitting the different topics of interests, meeting new people and representing the #AHA19.

 

 

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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#HeartFailure: Remember the hashtag #GDMTworks

I have always been fascinated by the advances in heart failure specially with the mechanical circulatory support (MSC) devices. Cardiogenic shock is no longer simply cardiogenic shock but a syndrome with a wide array of different presentations as demonstrated by the SCAI Expert Consensus on the Classifications of Cardiogenic Shock (Figure 1) or better yet as one my colleagues, Dr. Anshul Srivastava calls it “The stages of cardiology fellow anxiety”

Figure 1.

figure 1

I got the chance to be part of the AHA’s Scientific Sessions 2019 for the first time as an AHA Early Career Blogger. The first session that I attended was titled “Mechanical Hemodynamic Support for Cardiogenic Shock in the Modern Era’’

It was a good one with the experts sharing the latest on the topic and future directions. MCS devices are exciting and at times, in a close to ideal scenario, a good “last minute” resort for our advance heart failure patients either as destination therapy, and/or bridge to transplant or to recovery. However, I came to the realization that we must not forget about GDMT (guideline directed medical therapy). GDMT for chronic heart failure with reduced ejection(HFrEF) works.

They are class I and II ACC/AHA guideline recommendations for a reason. As a new early career blogger for AHA, I wanted to take the opportunity to stress how the importance of GDMT and furthermore our role in assuring that our patients with cardiomyopathy are on the correct medications at the appropriate dosages. All of us, active on social media let’s make the hashtag “GDMTworks” trend. Let’s always remember, it works. Let us constantly remind ourselves and our colleagues that this is supported by evidence.

gdmt

After starting and optimizing the medications. We must be persistent. We must not give up. We must push. It does work. And if it’s not working, we must make sure that our patients are on the optimal medications and dosages before charting “Failed Medical Therapy’’. Having said that, I will quote Dr. Everett Koop1, “Drugs don’t work in patients who don’t take them’’.

Our options for medical therapy continue to grow.  With DAPA-HF, we are possibly witnessing the recruitment of another medication joining the “GDMT” crew. The possibilities are endless and it might just be the beginning for GDMT with “Quadruple therapy in heart failure2

I chose to talk about this topic because it is in my opinion that at times we are at fault for not been aggressive with GDMT in the treatment of chronic HFrEF.  We often throw in the towel early in the game forgetting that we have another quarter to play. You got this. It’s not over yet. Start the medications. Optimize the medications, educate your patient on how effective GDMT can be. If you don’t believe it works, how will you ever convince your patient otherwise.  Most importantly, spread the word and share your stories with the hashtag #GDMTworks .

 In conclusion, to highlight Dr. Robert Harrington take away message from the presidential session “Evidence matters”. Let’s make it count and reinforce the evidence for the sake of our patients.

 

References:
1. Cramer JA. Enhancing patient compliance in the elderly. Role of packaging aids and monitoring. Drugs Aging. 1998; 12:7–15.

2. G. Michael Felker. Building the Foundation for a New Era of Quadruple Therapy in Heart Failure. Circulation. Nov 2019.

 

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.