Should interventional cardiologists perform thrombectomy?

“Sutor, ne ultra crepidam” a Latin expression for shoemakers not beyond the shoe, a common saying to warn people to avoid passing a judgment beyond their expertise.

With mechanical thrombectomy changing the management of stroke and becoming the standard of care for patients with large vessel occlusion (LVO), a new challenge has emerged, adequate access for care.

A recent cross-sectional study by Aldstadt et al.1 aimed to determine the percentage of the US population with 60 min (ground or air) to a designated or non-designated endovascular capable stroke center, or percentage of non-designated endovascular centers that were 30 min from an endovascular capable center.  They reported that overall a 49.6% of the US population is within 60 min of an endovascular capable stroke center, while 37% of the US population lacked access to endovascular capable centers within 60 min. For the non-endovascular stroke centers, 84% have access within 60 min, and 45.4% are within 30 min drive from an endovascular capable stroke center.

Since time is the brain, increasing the access to care is of paramount importance and increasing the number of well-trained physicians equipped to perform and treat stroke holistically.  Since there are approximately 10 times more interventional cardiologists, radiologists, and vascular surgeons than neuro interventionalist in the USA (10.000 vs. 800-1000)2, some non-endovascular capable hospitals have explored the option of incorporating some of this workforce to contribute to patient care.

Some retrospective studies3 with low sample sizes have described that their interventional cardiologist team was able to perform a thrombectomy safely, with the guidance of a stroke neurologist. Nonetheless, they are not clear on the prior training these cardiologists have had regarding neurovasculature, the nuances of the procedure, critical care, and stroke neurology.

Endovascular Neurosurgery and Interventional Neuroradiology is a field shared by physicians with different backgrounds in training, such as neurosurgeons, neurologists, and interventional radiologists. Regardless of their background or training, they are all required to complete an additional 1-2 years of training exclusively for neurointervention. Endovascular physicians trained rigorously per ACGME4 requirements were most of the physicians involved in the clinical trials (ESCAPE and DAWN) and maintained a high caseload volume of thrombectomy. The cumulative case volume is crucial since it has been associated independently for obtaining good recanalization and outcomes.5

Even if the technical aspects have various similarities between the endovascular fields, shoemakers not beyond the shoe, cannot be translated from one field to another without proper training. To adduce that interventionalist cardiologist can inherently treat intracranial diseases would be, in my opinion, not in benefit of the care of the patient, even if they are the only option nearby where no endovascular treating center can be reached, the patient outcome of patients is directly correlated with the expertise of the treating physician.

Nonetheless, interventional cardiologists should only be allowed to perform thrombectomies if they complete a full endovascular fellowship with the requirements established by the ACGME and as the other specialties go through (interventional radiology, neurosurgery, and neurology). This formal training could contribute to those rural areas where there is no possibility to access an endovascular center. More efforts should be made to increase access to endovascular capable stroke centers, to continue training neurosurgeons, radiologists, and neurologists to meet patients’ demands requiring this life-saving treatment.  But I don’t consider converting specialists in treating myocardial infarctions to stroke being a priority in the US.


  1. Aldstadt J, Waqas M, Yasumiishi M, et al. Mapping access to endovascular stroke care in the USA and implications for transport models. Journal of NeuroInterventional Surgery. 2021:neurintsurg-2020-016942.
  2. Hopkins LN, Holmes DR. Public Health Urgency Created by the Success of Mechanical Thrombectomy Studies in Stroke. Circulation. 2017;135(13):1188-1190.
  3. Hornung M, Bertog SC, Grunwald I, et al. Acute Stroke Interventions Performed by Cardiologists: Initial Experience in a Single Center. JACC Cardiovasc Interv. 2019;12(17):1703-1710.
  4. Hussain S, Fiorella D, Mocco J, et al. In defense of our patients. J Neurointerv Surg. 2017;9(6):525-526.
  5. Kim BM, Baek J-H, Heo JH, Kim DJ, Nam HS, Kim YD. Effect of Cumulative Case Volume on Procedural and Clinical Outcomes in Endovascular Thrombectomy. Stroke. 2019;50(5):1178-1183.

“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.”


The Great Terror of Oral Anticoagulant Use: Intracerebral hemorrhage

I am pleased to summarize a recent paper published by Dr. Xian Et.al on the clinical characteristics and outcomes associated with oral anticoagulants (OAC) use among patients hospitalized with intracerebral hemorrhage (ICH)1.

Major question addressed in the paper: 

What is the association between prior oral anticoagulant use (FXa inhibitor, Warfarin or none) and in-hospital outcomes among patients with nontraumatic ICH?


The investigators used the American Heart Association Stroke Association Get with The Guidelines-Stroke (GWTG-Stroke) registry to evaluate patients between October 2013 and May 2018, that had experience non-traumatic ICH with preceding use of FXa inhibitor compared with warfarin or none.  Patients with subarachnoid hemorrhage, subdural hematoma, or taking dabigatran were excluded. Included patients were defined by documentation ICH and use for at least 7 days of OAC, in three different groups: FXa inhibitor (rivaroxaban, apixaban, edoxaban); warfarin, or no use of OAC prior to hospital arrival and ICH.

Main outcomes and measures:

  • Primary outcome: In-hospital mortality
  • Secondary outcome: Composite of in-hospital mortality or discharge to hospice, discharge home, independent ambulation, and modified Rankin Scale (mRS) score at discharge.



  • Of 219,701 patients in the study, 104,940 were women (47.8%), 189,069 were not taking any OAC prior to ICH (86%), 9202 were taking FXa Inhibitors (4.2%), and 21,430 (9.8%) were taking warfarin.
  • One third of patients were taking concomitant antiplatelet therapy. This was more prevalent amongst patients taking FXa inhibitor (27%) and warfarin (30.1%) than those without taking OAC (24.8%).
  • NIHSS median score was 9 amongst the three groups. Patients taking warfarin had a higher mean NIHSS (12.5 {SD:11.3}).

Major results

  • FXa inhibitors (aOR: 1.27; p<0.001) and warfarin (aOR: 1.67; p<0.001) were associated with greater odds of in-hospital mortality compared with no OAC.
  • FXa inhibitors (aOR: 1.19; p<0.001) and warfarin (aOR: 1.50; p<0.001) were associated with greater odds of death or discharge to hospice compared with no OAC.
  • Patients with FXa were less likely to die (aOR 0.76; p<0.001) or be discharged to hospice (0.79; p<0.001) compared to those taking Warfarin.
  • Patients taking FXa were more likely to be discharged at home (aOR1.18; p<0.001) and have better mRS scores at discharge (aOR 1.24; p<0.001).
  • No statistical difference was found amongst the three groups regarding rates of discharge home, independent ambulation, or mRS score.
  • The use of single or dual antiplatelet, in patients taking warfarin was associated with higher odds of in-hospital mortality (aOR 2.07; p<0.001), and dead or discharge to hospice (aOR 1.86; p<0.001).

Major study limitations:

  1. The use of OAC use was defined as patients taking them 7 days prior to ICH, however the timing of the last doses of the OAC was not document, and it is possible that some patients might have not taken it or received a lower dose.
  2. Data regarding platelet transfusion was not recorded on the registry, and this might have influenced outcomes.

Key take-home message:

One of the most devastating complications of the use of FXa inhibitors is ICH, and although its prevalence is low (<0.5%), the in-hospital mortality can be as high as 27% as it was found on this study.  Although its high, when compared with prior use of warfarin, taking FXa inhibitors has a lower risk of mortality and dead or discharge to a hospice in the setting of ICH.

Potential future research:

  • Develop prospective studies that compare the available treatments for spontaneous ICH bleeding, four-factor prothrombin complexes concentrate vs. reverse factor Xa inhibitors (Andexanet). An underpowered retrospective study by Ammar et. Al,2 found no difference between these treatments due to the low number of patients analyzed in this study. Due to the burden of this complication we must find the most adequate treatment for non-traumatic ICH in the setting of FXa inhibitor use.



  1. Xian Y, Zhang S, Inohara T, et al. Clinical Characteristics and Outcomes Associated With Oral Anticoagulant Use Among Patients Hospitalized With Intracerebral Hemorrhage. JAMA Network Open. 2021;4(2):e2037438-e2037438.
  2. Ammar AA, Ammar MA, Owusu KA, et al. Andexanet Alfa Versus 4-Factor Prothrombin Complex Concentrate for Reversal of Factor Xa Inhibitors in Intracranial Hemorrhage. Neurocrit Care. 2021.

“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.”


Interview with Dr. Shlee S. Song, Director, Comprehensive Stroke Center at Cedars-Sinai

Almost one year since COVID19 was deemed a pandemic, we are nowhere close to get it under control. Although it has affected the healthcare system in innumerable ways, stroke management has been particularly impacted. Not only by the disease itself, but also by the multidisciplinary and strictly protocols for its diagnosis and treatment that have been difficult to maintain for the past year. To understand the impact of COVID19 on stroke management, Dr. Shlee S. Song, the Director of the Comprehensive Stroke Center at Cedars-Sinai shared with me her experiences, and learnings through these unprecedented times.

Dr. Shlee S. Song, Director of is a board-certified vascular neurologist who completed her clinical and research fellowship at the National Institutes of Health. She has worked on steering committees and served as PI on multiple national and international multicenter stroke clinical trials.  She serves as Medical Director of Stroke Programs at Cedars Sinai, Torrance Memorial, and Marina del Rey hospital, affiliate sites of Cedars-Sinai, and has developed a telemedicine network that delivers acute stroke care, oversees stroke quality improvement, and clinical trials enrollment across network hospitals. As the previous program director for the vascular neurology fellowship program at Cedars-Sinai, she has trained many stroke neurologists that practice across the country.

MDQC: Dr. Song, what is the association between COVID19 and Stroke?

Dr. Song: So far, we know that COVID has been associated with an inflammatory state and hypercoagulable state. Patients with more severe COVID symptoms also develop cloths in both lungs and other end organs. When we had our initial surge in the spring months in 2020, we had avoided what our NY colleagues have seen, like large vessel occlusion (LVO) in young patients. However, we did see a surge since the end of November. We have had a case series of patients where they were young, without many comorbidities, but had large cloths in large vessels like the ICA and carotid.

MDQC: So, is there an association between COVID severity and stroke?

SS: Right, what I have seen so far is that patients may have one risk factor or a couple, whether it is on birth control, having hypertension, or diabetes, even if they are managing their risk factors well, a COVID infection tips the scale toward clotting. Maybe a 2 or 3 hit hypothesis, where if you have the individual risk factors you are not in an inflammatory state, you can manage them, but when the infection occurs, the other diseases set off this cascade of injury that we see.

MDQC: Has the standard of care for management for patients with stroke has changed during the pandemic?

SS: We have seen that during the pandemic, that we have to be flexible. With the demand so high for stabilization, the surge in patients to the ICU, and hospital systems being stressed, our usual stroke pathways are not available. The patients are spread out all over the hospital because the beds are hard to come by. We have to be able to train a lot of our other service line team members to be able to deliver emergency care and monitoring.

For example, sometimes, the patients cannot go to the Neuro ICU, our usual pathway. Sometimes they are going to the PACU, where the personnel might not have received that training to get the NIH stroke scale done. However, we are focusing on the things we can monitor in more severe COVID. ICU patients that require high ventilation settings have to be paralyzed, so it doesn’t make sense to do no an usual neuromonitoring ( antigravitational strength, speech, etc.), but we can do other things like checking the pupils. We have had to shift our thinking and pivot to tailor to our situation.

Right now, we are in the “stabilization mode.” We are no trying to plan a 3-6 12 follow-up because, before the pandemic, we were able to stabilize our patients quickly. However, right now, it takes longer to stabilize these patients because of the injury to their lungs. We are just trying to get patients through to the first one or two weeks and then talk about lipid-lowering and secondary prevention that can be addressed later on. Right now, we want them to survive this cascade and storm that is going on.

MDQC: Would you consider changing the mindset of strict diagnostic and treatment protocols for stroke has been the most significant challenge during the pandemic?

SS: I think there is an acknowledgment from our specialist, that are in the frontline, that we have to be flexible because we are all operating in the dark, but we are realizing collectively that we are dealing with such limited data, this is so new in terms of what we are experiencing.

Acknowledging that there is limited data allows us to focus right now on acute stabilization and realize that somethings can be done down the road. We are working on that standardized protocol to promote this mindset to streamline the process, so during night calls, there would be some guidance focused on stabilizing the patients when there is a limited team.

MDQC: Since stroke is an acute event, what has the hospital done to procure the healthcare personnel’s safety when a patient comes to the ER with an acute stroke regarding their COVID19 status?

SS: We are minimizing the amount of exposure to our team members. Since we are a small team, we want to preserve everyone’s safety. We have incorporated our telestroke robot in our emergency department (ED). Our stroke team nurses’ expertise is well-versed in maneuvering and is quick at getting their images done and answering the inclusion/exclusion criteria for thrombolytic criteria. We can see the ER with the robot’s camera. Although we agree that is this is not equivalent to see the patient at the bedside, we are aware that we oversee a system where our stroke neurologist covers multiple hospitals, not only Cedars-Sinai.

Everyone has the personal protective equipment (PPE) ready in their backpacks, our gown, N95 masks. In the setting of a stroke code, anything can happen, sometimes the patients’ airway gets compromised or has a seizure; while this happens, we can quickly gear up since we have it with us. Our pharmacies will now have 24-hour coverage as an additional help to stabilize these patients.

The rapid COVID19 test is available. We try to do it as early during the code if we suspect an LVO, so that information can be available to the IR colleagues who can be prepared. They are also assuming that many of our patients are COVID positive. However, suppose we don’t have the test results. In that case, we don’t delay the emergency recanalization procedure, if the patient is eligible, so we assume they are positive or suspected for Covid, and we gear up properly.

MDQC: What is the impact telestroke has had in managing stroke during the pandemic? And how do you think It will evolve in the years to come?

SS: Telemedicine and telestroke are here to stay. It has been around for decades. We started our program of telestroke in 2016 for covering Torrance Memorial Hospital, and the demand keeps growing. Every minute counts in the setting of a stroke code. It doesn’t make sense for someone to start driving to a hospital when we have a camera that can quickly help guide our ER or ICU colleagues.

Dr. Song, pictured on the monitor, practices treating a stroke patient remotely with other members of the care team.

The technology has been around for a while. It continues to improve, like being able to see the imaging, PAC access, able to quickly document assessments, and write the recommendations that can be seen by the team members that are accepting patients in the ICU. The technology is being improved regularly, the software, and hardware, such as upgrading the camera or reducing background noise.

One thing that I have seen during the pandemic in telestroke where I would like to see some improvement in our non-speaking English patients. Especially with the pandemic and the no-visitor policy of many hospitals, out of a concern for community spread. It’s been challenging to get accurate clinical history from our patients. We rely on witnesses from the family and relatives to determine their medication, clinical history, and bleeding risk. All of that information is difficult to get, especially if we don’t get translators in the room. If Telemedicine could get paired with translator services, so they could be available during the stroke codes, I think that would help move things along from us.

MDQC: This is especially problematic given that the Latinx population has been affected disproportionally.

SS: Yes, we saw that in our data as well. We have a paper submitted right now (REFERENCE), looking at the nine-stroke comprehensive centers in Los Angeles. We saw a disproportional amount of Latinx community affected with LVO going to our colleague hospitals, and they have noticed a sharp increase in their thrombectomy volume during the pandemic.

MDQC: Why is the Latinx community disproportionally affected?

SS: We are trying to figure out what the patient profile looks like for that cohort. We don’t know exactly; however, some theories, such as having type 2 diabetes, maybe factor in the clotting cascade in patients with COVID. Additionally, the situation with multigenerational housing and the high prevalence of essential workers within this community don’t allow them to shelter at home because they still need to go to work. These factors have been considered to contribute to stroke, but there is no known causal relationship to date.

MDQC: Nonetheless, the social determinants play a massive role in the LatinX community.

SS: Yes, and we have been seen this in feedback from our patients. For many patients getting their health maintenance evaluation is hard since they have not had their medication for HTA, DM, etc. Chronic diseases are not being controlled. Some of them haven’t seen their doctors since most clinical visits have moved to Telemedicine, which is contingent on having a computer and Wi-Fi.

In a community with many living in multigenerational households, the computers and internet might be limited resources. Sometimes they only have one computer that must be shared, for example, with kids, for distance learning, and they don’t have other devices to schedule their appointments. COVID has highlighted the gaps between the patients with more resources and those lacking them.

MDQC: We assume that everyone has a computer and good internet access, and unfortunately, that is not the reality. A pillar of medicine is the hands-on training for medical students, residents, fellows. What changes have occurred to guarantee appropriate learning during the pandemic?

SS: We have taken this opportunity to push our trainees’ telemedicine skills in the neurology residency program. Before the pandemic, we had separated telestroke training only for the fellow because we wanted the residence to have that bedside experience first before going to the telemedicine platform. We quickly realize that this skill set needed to be incorporated into the curriculum.

We wrote a paper about that and published it in Neurology, with Dr. Alicia Zha from the University of Texas and colleagues from the University of Utah.1 We have incorporated Telemedicine for the residency program. Using the telemedicine robot, our residents are directing the camera and maneuvering the robot. We also have the capability called multi presence where the attending and fellow can see what the resident is doing, so we can all see what the host resident is doing, and we can easily take over if we need to. Having this tool has been helpful and flexible. It allows the trainee to develop these skillsets for this technology that is here to stay. Other things that have improved since the pandemic are reimbursement since now Medicare allows the Telemedicine encounters to be equivalent to the side delivery of care. It has been helpful to continue to implement Telemedicine in our practice.

MDQC: So, is this being implemented just for acute stroke?

SS: The residents are using Telemedicine for the clinical encounters since we realize the virtual space is safer for both our patients and the provider. We moved much clinical evaluation to the iPad or evaluated with the desktop computer. It is also good to identify the gaps with Telemedicine, such as the subtle things with weakness and coordination we might not be able to pick up, which is very hard over the camera. Our residents are finding with their experience that things like visual fields cannot be done well with the equipment that we have right now. It’s important to know where our current gaps are so that this generation helps to problem-solve these issues to create apps or more tools to develop better telecare.

MDQC: Another colossal problem regarding stroke is the increase of the delay from symptom onset to arrival to the hospital. What has been your experience at Cedars-Sinai regarding this phenomenon?

SS: On the study with the nine-stroke comprehensive centers, we have seen that. Collectively we all had a decrease in our thrombolytic treatment patients, and IV tPA numbers have gone down, mostly the mild symptomatic patients. I think many patients and their family members are fearful. They have heard the system is currently overloaded and might think that their symptoms are very mild and not worth going to the hospital or are afraid of getting exposed to the virus. We have worked together with the AHA, Stroke association, and Los Angeles County to diffuse the message to tell people that if you have an emergency, a condition like a stroke, call 911.

Understanding patients and famile’ fear, we are trying to get patients home as soon as possible. In that streamlined workup, we intend to get patients out of this hospital as soon as possible. Suppose some things can be done outside of the hospital in the outpatient setting, then that is what we would like to do to reserve the hospital setting for the severe cases.

Some of our patients with mild symptoms when they get evaluated may have resolved their symptoms. We do urgent things for these high-risk TIA patients, such as the vessel evaluation of the carotids. However, maybe the Eco can be done in an outpatient setting, so we send the patient home with the Zio pad, telemonitoring, and have a home visit in 48-72 hours. We are more flexible in the way we deliver health. Not everything has to be delivered at the hospital, understanding patients’ fear and wanting to get home as soon as possible.

MDQC: Burning out syndrome has been a pressing issue in healthcare personnel even before the pandemic, how are you doing Dr. Song? and how are you and your peers coping with the stress this pandemic has caused?

SS: In terms of how we are manning with this crisis scenario is leaning on each other more. We have weekly check-ins, we called it our “stroke team huddles”, we have always had it because we have a very stressful job. We deal with patients and family members in a moment of crisis, are life and death situation during many of those codes, and now we are seen a lot more death.

Now there are lot more patients sicker, and we are seen more distress because they can’t have at the bedside their loved ones. How we have been dealing with ourselves? is giving each other the space to share that level of stress, so it is not something they are holding on to, but a shared collective, living process.

We have noticed that everyone has their highs and lows at different times, so we take advantage of that. The person who is doing well that day, really reaching out to say, “hey, unload a little bit, let me hear what is going on,” and for the person who is having a tougher day. Another really helpful thing has been laughter and sharing when we see something very funny; it has been really helpful to get us through. Sometimes we have to say what we are going through is so ridiculous, and just calling it out has relieved the tension when you share it, and I see it in the body language. It seems to lift from a burden and seems more relaxed.

We have counselors on checking areas, we have resources from Cedars, and if I see that something is helpful, I share it. I have been very open on how I’m getting through this crisis, either with therapy, with zoom check in with girlfriends, who are also experiencing high stress levels at home and work. All those coping mechanisms help and just check in with the clinic patients.

I have been writing letters and have encouraged residents and nurses to write letters to the patients and check in on them, especially those at higher risk because they live alone. You reach out to them, and they also give back to you and often ask how we are doing to the doctors, nurses. We are taking care of each other through this; the key is that we have each other, and we have a team approach.

MDQC: As the last question Dr. Song, what lesson have you learned from ongoing this pandemic?

SS: Lots of lessons. It has helped to solidify for me that we are doing meaningful work. In our team members, we are focusing more on what’s important and letting go of what is not. Our energy stores are getting depleted faster. We are learning to let go easier, focused on important things, and getting rid of the noise that doesn’t allow us to do so. Now we are getting more efficient in our work.

Also, we have all collectively seen that we need to do better, especially for our community areas where resources are lacking. There is a lot of goodwill and recognition in the stroke community. When it comes to leadership, we have to improve healthcare disparities. We are so grateful to the essential workers working delivering packages, in groceries, and getting us through the pandemic. They are the mail carriers, cashiers, all the people that have helped society keep moving during this pandemic. We need to give back to them.


Dr. Shlee Song shared that the pandemic has highlighted the consequences of an unequal healthcare system. We must strive to address this pressing issue as vehemently as finding new interventions or drugs. That flexibility and adaptation have been paramount to get through the pandemic. However, most important of all is teamwork, to rely on each other to provide the best care to patients and take care of each other.



  1. Zha AM, Chung LS, Song SS, Majersik JJ, Jagolino-Cole AL. Training in Neurology: Adoption of resident teleneurology training in the wake of COVID-19: Telemedicine crash course. Neurology. 2020;95(9):404-407.

“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.”


The Inequity of the COVID19 Vaccine Distribution: The rich countries hoard vaccines while the poor countries struggle to get them

Last week at Cedars-Sinai, we received an email asking its employees interested in getting the vaccine against COVID19. I was very excited about this since it means a lot of things at once. The development of safe mRNA vaccines in a short period shows how much technology has advanced and highlights the importance of working together as the companies that manufactured the vaccines were not in a race against each other but against the virus. On the other hand, getting a notification that I was soon going to get vaccinated against this virus that has changed our world was pure joy, that sadly faded away.

As I told my friends and family the excitement that I was having because I would be vaccinated soon, all they did was ask me, but when are we going to get the vaccination for us? For our healthcare workers, grandparents, and grandmothers? We have heard in the USA with optimism how the government has secured millions of doses for its people, and it only makes sense that a government wants to put their citizens first but, at what cost? Where does the solidarity with other nations reside? These questions made me dig deeper into an issue that gets shadow by the hype of us getting vaccinated.

The People Vaccine Alliance, an international watchdog that includes Amnesty International, has warned that some countries have bought enough COVID vaccine to immunize their populations more than once. It highlights Canada as the top country on this matter that has reported over 400.000 cases of COVID19 has secured enough vaccinations to immunize its population at least five times. In contrast, poorer countries will only be able to vaccinate one in ten people. The Alliance data also showed that the deals that have been done between the governments and the eight leading vaccine candidates’ risk of leaving behind middle-low and low-income countries, as rich nations hoard on vaccine deals.1

A clear example of the disparity between the rich and the poor has been the Moderna and Pfizer vaccines’ inequitable deals, which have shown on their preliminary data to have the highest efficacy rate. Due to their promising results, the vaccine lots have been bought in a staggering 96% for Pfizer and 100% for Moderna by rich nations. With those impressive figures, the gap between the have and the have nots will stretch even further. The Director-General of the World Health Organization, Tedros Adhanom, warned during a press conference “Every government rightly wants to do everything to protect its people, but there is now a real risk that the poorest and most vulnerable will be trampled in the stampede for vaccines”.2

Nonetheless, international efforts have been made to achieve global vaccination, such as COVAX. This compact, composed of 189 countries, amongst which the USA and Russia resonate for their absence, has high and middle-income countries committing to provide funding to ensure access to vaccination and equitably manufacturing them. In contrast, poorer countries have signed to secure vaccines for their population. This effort will also be backed up by agencies such as the Bill and Melinda Gates Foundation.3 Efforts by the Oxford/Aztreneca are also of great importance to allow developing nations to get the vaccine, as they have pledged to five more than half of its doses to developing nations. Unfortunately, this would only reach 18% of the world’s population.4

I concur with Melinda Gates’s denomination of this phenomenon as vaccine nationalism, with the populist premise of “our citizens first,” that suffice its purpose of improving the polls for political gains. However, these actions go against one of the most powerful lessons this pandemic has taught us, the sense of community and working towards the benefit of all.

I firmly believe that vaccine allocation for a health crisis like this should prioritize global immunization for healthcare workers and elderly patients, rather than prioritizing country of residence or origin. It is not acceptable to have an effective vaccine, not reaching healthcare providers on the frontlines of developing countries fighting this virus without this indispensable weapon. In contrast, rich countries rely on an excess of vaccines and immunize low-risk citizens first.

This pandemic has shown us how fragile humanity. Now more than ever, the rich countries and their economic capacity must set an example of global leadership and outline a sensible policy that focuses on a global perspective rather than an exclusive, nationalistic one because this crisis won’t be over until everyone gets vaccinated.



  1. International. A and https://www.amnesty.org/en/latest/news/2020/12/campaigners-warn-that-9-out-of-10-people-in-poor-countries-are-set-to-miss-out-on-covid-19-vaccine-next-year/. 2021.
  2. https://abcnews.go.com/Health/rich-countries-hoarding-vaccine-report/story?id=74623521 A.
  3. https://www.cnn.com/2020/12/13/world/coronavirus-vaccine-developing-world-intl/index.html C.
  4. https://www.bbc.com/news/health-55229894 B.

“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.”


The Era of Misinformation: A Constant War of Science vs. Fiction

“Covid19 is a hoax”, “vaccines poison your body”, “the earth is flat.” Various conspiracy theories and misinformation statements have existed throughout history. Though some might seem absurd and often put into the spotlight to ridicule them as they are improbable to be accurate, like the earth being flat, this comedian aspect shifts to a sinister black connotation when the conspiracy theories, and misinformation infect the medical field.

As the first doctor of my family, it is not uncommon to get questions about a new drug that was promoted on TV, or regarding a bold scientific claim, such as someone curing cancer. However, during this year, amid the Covid19 pandemic, the spread of misinformation has been almost as incontrollable as Covid19 cases in the United States of America. With great concern, I saw that several acquaintances, friends, and family, most of them with higher education degrees, shared and contributed to spread false information on the treatment of Covid19, its origin, or questioning if this was part of a bigger plot to control humanity.

The spread of misinformation has contributed to mistrust towards medical healthcare personnel, to the point of being violent towards them,1  not following their advices, or falsely claiming overdiagnosis of Covid19 with the sole purpose of getting “more money,” claim that unfortunately gets backed up by the Highest Office in the Land.2

However, this problem isn’t new in the medical community, as Dr. Anne Marie Navar stated in her conference during the Scientific Sessions lecture “How Misinformation Steers Patients off Course.” She mentions that the Covid19 pandemic highlighted and made more evident the dire problem misinformation has brought to medical compliance with treatments. She focuses on the misinformation campaigns that have been occurring around statins, were social media personalities with doubtful medical claims such as the questionable Dr. Joseph Mercola, and unscrupulous social medial like Infowars pretend to scare and deter patients from taking statins, while promoting their products such as diets, supplements (Omega-3), that are commercialized with misleading labels, and lies about the efficacy of their products.

But how likely are statements made by doubtful doctors or non-healthcare providers likely to affect patient compliance? Would patients believe more something they read or see on social media than following the physician’s recommendations to whom they trust their health?  Unfortunately, it is quite likely. Dr. Navar highlights a prospective cohort study from Denmark that included 674.900 individuals > 40 years old, that were on statin therapy ( a drug used for patients with high cholesterol levels) from 1995-2010, and followed until December 31 of 2011, to test the hypothesis if statin-related news were associated with early statin discontinuation.3

This prospective cohort showed that early statin discontinuation increased with negative-statin related news, and early discontinuation was associated with increased risk of myocardial infarction and death from cardiovascular diseases (fig 1). Also, a sensitivity analysis showed that  negative statin-related news stories were associated with an odds ratio of 1.15 (CI: 1.09-1.21) for early discontinuation of antihypertensive medication (fig 2).3

Fig 1. Early statin discontinuation vs. continued use and cumulative incidence of myocardial infarction (top panel) and death from cardiovascular disease (bottom panel).

Fig 2. Statin-related news stories and early discontinuation of statin, antihypertensive medication, and use of insulin among statin users.

It is worrisome that patients’ very own life might be at stake due to misleading propaganda that feeds from the fear of exaggerating adverse events for specific treatments (drugs, vaccines, etc.). To have these very own propaganda makers, in an ungracious second act, pretending to be messiahs, to promise patients the “healthiest” option available for their disease, thus creating widely successful businesses by selling non-effective products at the expense of putting the populations’ health at risk.

But this misinformation phenomenon has been more impactful and dreadful during the pandemic since we are dealing with a highly transmissible disease, where the cost of disinformation results in more people getting infected with Covid19 ,or dying because of Covid19.

But what can we do as healthcare professionals?  As scientists? The first thing to do is to speak up. We must not be silent as false and misleading information spreads. The truth tends not to be soothing, hopeful, nor easy to process, and during this cumbersome year, this might become a more challenging task when coming to terms with “the new normal.” The evidence does not change because of our feelings, thus making it imperative to face the facts. Our role as physicians, healthcare workers, and scientists is to be modern versions of Prometheus, and reside on the frontline to fight back misinformation by being leaders that defend the torch truth, and share it with the world.

Dr. Anthony Fauci is the perfect example of the leadership we all must show as bearers of the torch of truth, as his statements are based on hard facts and science.  Nonetheless, his remarks often failed to reassure people during these unprecedented times since he has been very cautious by avoiding making any premature conclusions regarding the effectiveness of a treatment or on the efficacy of a vaccine without proper evidence, as it should be.

However, this lack of reassurance opens a door for opportunistic scientists and medical doctors such as America’s Frontline Doctors, that earlier during the year claimed that Covid19 could be treated with hydroxychloroquine, widely tested as being not useful.4,5 This bold claimed amid the uncertainty lived in the beginning of the pandemic, unleashed an incontrollable confirmation bias, as people would feel reassure when “doctors” tell them there is a cure for this virus; despite the fact that the “doctors” making such claims were not infectious disease experts, nor did they have any real evidence to support those claims. This mere example highlights the importance of raising our voices to spread real facts to prevent landslides of false information spread.

We must be empathetic to those that are sharing or commenting on false information. When seen friends or family doing this, please give them the benefit of the doubt, as people share information thinking of their well-being and that of others and, most of the time, is not out of a primary motive to harm or do wrong. When I have encountered my family or friends doing this, I try to reach out to them and ask them what they learned from the information they are sharing and explain to them the inaccuracies of all the misleading content on the news they are spreading. At last, I tell them to send me privately all the videos, chats, news they get so we can discuss them before sharing them. By doing this, the fake news chain will break, and more people will start acquiring critical thinking before sharing news from a field that is unknown or unfamiliar to their area of expertise, in this case, medical and healthcare related news.

Finally, I would like to share a pamphlet on how to fight misinformation from Dr. Tim Caufield from the University of Alberta that outlies four main steps, help stop the spread, and craft a message to counter misinformation, promote a regulatory response, and debunking (fig 3).  Let us all unite our voices so they can be loud enough to bury misinformation.

Fig 3.  Fighting misinformation pamphlet (https://www.ualberta.ca/law/faculty-and-research/health-law-institute/fighting-misinformation.html)

I would like to thank Dr. Anne Marie Navar for her conference “How Misinformation Steers Patients off Course” As it encouraged me to write todays blog on this pressing issue. I encourage you all to see her conference on the Scintific Sessions website.


  1. Medellin. Personal médico del Hospital General fue agredido por caso de covid-19. El Tiempo. https://www.eltiempo.com/colombia/medellin/coronavirus-en-medellin-denuncian-agresion-a-personal-medico-del-hospital-general-de-medellin-527090. Published 2020. Accessed.
  2. Griffin J. Medical professionals push back after Trump says COVID-19 cases are inflated to ‘get more money’. Daily Herald 2020.
  3. Nielsen SF, Nordestgaard BG. Negative statin-related news stories decrease statin persistence and increase myocardial infarction and cardiovascular mortality: a nationwide prospective cohort study. Eur Heart J. 2016;37(11):908-916.
  4. Boulware DR, Pullen MF, Bangdiwala AS, et al. A Randomized Trial of Hydroxychloroquine as Postexposure Prophylaxis for Covid-19. New England Journal of Medicine. 2020;383(6):517-525.
  5. Effect of Hydroxychloroquine in Hospitalized Patients with Covid-19. New England Journal of Medicine. 2020.