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Wellness Amid a Pandemic

I think about wellness often and the unique aspects of being a physician that make preserving our wellbeing even more important. Of course, this COVID-19 pandemic has tested all of us and the things we turn to for wellness and our escape from medicine, may not be available to us right now. After work dinner and drinks, early morning group fitness classes, and young professional networking events have been replaced by Netlfix© and dine-in, home workouts, and Zoom “wine” downs. We all had to dig down deep inside to find new venues for wellness and if we were lucky, our institutions provided resources to help us during this crazy time. What this pandemic taught me was that there are things I still needed to work on to build my resilience even further- and I am totally okay with that. Working on ourselves to better ourselves should be a continuous goal- everyone has room for improvement.

As a single woman living in the city, my nights and weekends were always filled with social events. I felt very isolated and realized how much of my free time was being occupied by my friends and the events I attended as part of my wellness routines. I miss my morning classes at bootcamp and will never complain again when my alarm wakes me up at 4:25am to get to class- whenever that may be. Some of the things that have helped me are FaceTime and Houseparty dates with friends and family, walking outside on the few sunny days Boston has graced us with, trying to eat healthy when I can, in-home workouts which I am not a fan of to be completely honest, but most important, was being vulnerable with friends, family, colleagues, and even patients who asked how I was doing during our virtual visits. I met with a Wellness Coach provided through my institution and the lightbulb moment for me was when he reminded me to be kind to myself. I remember seeing posts all over social media about how we should be building businesses, getting in shape, writing grants, or checking off any other number of “goals” because we have “so much time” and feeling bad, but I got over that. In the middle of this crisis, all our lives have been disrupted, some much more so than others, and we are all doing the absolute best we can. I remind myself to be grateful and I started writing specific things down that I am grateful for each day.

May is Mental Health Awareness Month and as physicians, we shy away from talking about such things. It may be that we are supposed to be superheroes who are invincible, or it may be that if we did seek help and received a diagnosis we would have to declare it on some medical state licensing applications, or we may just be afraid. Mental health is one of the many aspects of overall wellbeing and there are many ways to reach out for help for those who need it. COVID-19 has had many casualties and we must guard our mental health during this pandemic. Find what works for you and do it. Reach out when you need to and remember that it is totally okay to not be okay. Protect your mind, body, and soul as these are key aspects of our overall wellbeing. I feel optimistic about our future. When we come out on the other side of this let us take all the lessons we learned and remember to never take things such as human contact for granted again.

Stay safe and stay healthy.

“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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Another (Louder) Call to Improve the Care We Provide Heart Failure Patients

I am always taken aback when I recommend a switch to sacubitril/valsartan in a patient with heart failure with reduced ejection fraction (HFrEF) and the response is “my patient feels fine”. This is a common response and certainly not a good enough reason to not optimize guideline directed medical therapy (GDMT) in patients with HFrEF. Optimization of GDMT in HFrEF, known to improve morbidity and mortality (1,2), is dismal. The Change the Management of Patients with Heart Failure (CHAMP-HF) registry included patients in the United States with chronic HFrEF receiving at least one oral medication for management of HF and showed >25% of eligible patients are not prescribed angiotensin converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor, >33% are not prescribed a beta blocker, >50% are not prescribed a mineralocorticoid receptor antagonist. Remarkably, even among those receiving GDMT fewer than 25% are prescribed target doses and only 1% of eligible patients are simultaneously on target doses of all 3 classes of GDMT (3,4).

The mechanisms for suboptimal prescription of GDMT in HFrEF are complex and undertreatment is even more evident among women, minority patient populations, and patients from economically disadvantaged backgrounds, among others. Cost is certainly an issue, especially with more novel HF therapies and co-pay assistance programs are not always available to our most vulnerable patients. There are not enough HF cardiologists to take care of the continuously increasing population of HF patients and therefore, optimization of GDMT needs to be done by general cardiologists and primary care clinicians as well. We should also become creative and use telemedicine to optimize GDMT more efficiently. We do our patients a disservice by not optimizing GDMT that improves HF morbidity and mortality.

And just as optimization of GDMT is not ideal, neither is our evaluation of etiology of HF. Optimization of GDMT and determination of etiology of HF whose management may change disease trajectory should be undertaken in all patients with new-onset HF. This begins with a fundamental understanding of the various etiologies of HF, the laboratory and imaging testing needed, and the best treatment strategy for the underlying etiology discovered- if any (cue, “idiopathic” cardiomyopathy). O’Connor and colleagues’ observational cohort study from the Get With The Guidelines- Heart Failure (GWTG-HF) registry demonstrates the need to improve the testing we perform to exclude coronary artery disease (CAD) as the underlying etiology of new-onset HF.4

Why is this important? Well, of course for treatment, which involves deciding whether medical therapy (aspirin, statins) or revascularization (surgical or percutaneous) is a more optimal strategy. And most important to improve disease trajectory as continued ischemia will lead to worsening HF. O’Connor and colleagues found that the majority of  17,185 patients hospitalized for new-onset HF did not receive testing for CAD either during the hospitalization or in the 90 days before and after, despite data demonstrating that 60% (!!!) of HF patients have concomitant significant CAD.4 And consistent with disparities I mentioned earlier regarding the undertreatment of women with GDMT, men were more likely to be tested for CAD.

Diagnosing and treating CAD provides an opportunity to discuss risk factor modification with patients such as smoking cessation, diabetes control, exercise, healthy diets etc.… to further mitigate future risk. The importance of optimization of GDMT in patients with HFrEF cannot be understated and analogous to this, is the importance of examining the underlying etiology of HF in patients with new-onset HF with preserved, borderline, or reduced EF to improve disease trajectory. Furthermore, inequities in both aspects of the care of HF patients in terms of identification of etiology and optimization of GDMT, must be addressed on a national level. We have plenty of data illustrating suboptimal optimization of GDMT in those with established HFrEF and suboptimal testing for CAD in those with new-onset HF. The next steps are understanding the mechanisms and implementing strategies to improve care. The need for this is critical to reduce morbidity and mortality in all HF patients.

References

  1. Yancy CW, Jessup M, Bozkurt B et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation 2017;137.
  2. Yancy CW, Januzzi JL, Allen LA et al. 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction. Journal of the American College of Cardiology 2017.
  3. Greene SJ, Butler J, Albert NM et al. Contemporary Utilization and Dosing of Guideline-Directed Medical Therapy for Heart Failure with Reduced Ejection Fraction: From the CHAMP-HF Registry. Journal of the American College of Cardiology 2018.
  4. O’Connor, Kyle D., et al. “Testing for Coronary Artery Disease in Older Patients With New-Onset Heart Failure.” Circulation: Heart Failure, vol. 13, no. 4, 2020, doi:10.1161/circheartfailure.120.006963.

“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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Dear Kobe

 

Dear Kobe,

Thank you for inspiring all of us in medicine too.

Sincerely,

The future of medicine.

From Los Angeles to Manila, sports fans and people that know nothing about sports were shattered by the deaths of Alyssa, John, and Keri Altobelli, Gianna and Kobe Bryant, Payton and Sarah Chester, Christina Mauser, and Ara Zobayan aboard that helicopter on Sunday January 26, 2020 in Calabasas, California. We all knew exactly what we were doing when OJ was found not guilty, when we realized Prince would never perform Purple Rain again, when Whitney was found in her bathtub, and when we found out Robin Williams would never star in a Broadway play of Patch Adams. Kobe’s death will be no different. I was sitting on my couch watching reruns of a show on BET with one of my best friends. We sat there stunned for several hours hoping this was some sort of sick joke, but as every news outlet and social media platform picked up the tragedy, I felt sick.

Death is inevitable. It’s the only thing we know for sure is going to happen to every single one of us. But like I said in my previous blog about being on heart donor call, when the deaths are unexpected and take young people, they are shocking, they are life altering, they are gut wrenching. They remind you that life is fragile and our time here is limited.

Kobe’s legacy will live on forever through the magic he shared with people he knew directly and with people he never met, like myself, who grew up watching him, sometimes hating him because he was destroying your team. His work ethic was unmatched, and his love of the game surpassed every athlete’s of our generation.

What did and can we, as clinicians, scientists, and educators, learn from the Black Mamba?

  • To show up in every single thing we do, every single time
  • To love our family and friends and make them a priority despite how busy we may be
  • To leave the world a better place for future generations coming behind us
  • To inspire those around us to be the very best human beings they can possibly be
  • To inspire people to live their life’s purpose
  • To inspire people to live each day like it’s their very last
  • To bring grit and passion to everything we do
  • To find that fire inside and keep it ignited
  • To set monstrous goals, crush them, and then set even bigger goals
  • To find the things we love doing outside of medicine and do them with our whole heart. I mean, you won an Oscar, Kobe
  • To love deeply
  • To never take no for an answer
  • To bring heart to everything we do
  • To know when it’s time to leave the stage
  • That without obstacles there is no growth
  • That we can be fierce AND kind
  • That there are no ceilings
  • That records are made to be broken
  • That one human being can indeed have a profound impact on the entire world
  • That when we feel like quitting, we should ask, what would Kobe do?

May you, your daughter, and all the passengers aboard that helicopter RIP. Your legacy will live on through all of those you touched. There are no words to express how grateful we are to have been touched by your magic.

So, what legacy are you going to leave behind?

 

“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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How My Heart Failure/Transplant Fellowship Changed Me

When I started my Advanced Heart Failure/Transplant fellowship, my program director told me this year would change my life. I thought, “Yeah okay, whatever.” Boy, did that year change my life. The way I looked at the world changed entirely. Transplant is one of the most incredible medical therapies available to patients with end-stage heart, kidney, and liver disease, amongst others. Because of the generosity of the donor and the donor’s family, someone else is given a second chance at life. I always tell my heart transplant patients that they should now be celebrating 2 birthdays every year- to commemorate the gift of life given to them a second time over.

When I say that year changed my life, it truly did, and that change is lasting. When we’re on heart donor call and we’re evaluating hearts for suitability for our recipients, they’re usually younger hearts and cause of death is almost always unexpected. The stories are tragic- suicides, car accidents, freak accidents, and unintended drug overdoses, amongst other causes of death. As I sit in my pajamas (donor heart evaluations happen in the middle of the night a lot) on my laptop making sure I look through all personal and medical details available to me, I can’t help but create an image in my mind of who this donor is, what they may have looked like, where they worked, how much pain they must have been in if their death was intentional, and most gut-wrenching is all the people they left behind. Death is never easy, but when the donors are young, when the deaths are intentional, when the deaths are completely unexpected, it makes me realize how grateful we should be for this life we are living.

That year completely changed how I look at the world. No longer was I going to “sweat the small stuff” whether they were work related or personal. Every donor call reminds me that we sometimes spend so much time, energy, and emotions on things that, in the grand scheme of life, are truly insignificant. I became a happier and more content person. This year taught me that human connections are the most important thing in this world. My family, the friends I consider family, my friends at work, my patients, and all the people I cross paths with that have an impact on my life.

And on the other side of death, after I have pictured this life lost and the family and friends they’ve left behind, I get to tell one of our patients with end-stage heart failure that a heart “has become available” to them and now their life is going to change. I can’t imagine how they feel but I’ve heard all kinds of the emotions on the other end of that phone- tears, shock, anxious smiles that can be heard through the phone, and more tears. My patients tell me it’s a very emotional experience from the time they’re listing. Some have said it feels weird to be “waiting for someone to die” so that they can live. Some have noted guilt. Some of my patients have developed relationships with their donor’s families and I can only imagine how surreal that must feel.

What I do know is that I couldn’t imagine myself doing anything else and that being a Transplant Cardiologist has truly changed my life. I am grateful to the patients who have allowed me to play a small role in their journey and forever grateful to the donors and their families for this incredible gift of life.

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AHA19 Was the Juice I Didn’t Realize I Needed

I left Scientific Sessions 2019 (AHA19) feeling so refreshed, empowered, motivated, and ready to rock it when I got home to Boston. I’ve been told this a lot, but I really felt it this time – that conferences serve more than just to educate and provide a venue for networking; they rejuvenate you. We all exist in our silos within our various institutions, but when we’re at AHA’s scientific conferences, we’re surrounded by people from all over the world, sharing science, friendship, and most important, hope for the future of medicine. AHA19 was particularly diverse in my eyes, I saw more people of color than I have seen at any scientific session, both attending and sharing their science.

When I’m at my institution, I sometimes forget about the world outside of it. You get caught up in the things going on at your institution and the work your research team is doing. You forget that there’s an entire world out there doing brilliant work too and that we’re all in this together – to better medicine and to open doors for the generations we will be passing the baton to. Attending conferences is one of the best ways to exit that bubble.

During the AHA President’s address, when several students from all over Philadelphia were on the stage sharing their stories as part of their ant-vaping campaign – #QuitLying Big Vape – I was assured that the future of medicine is so, so, so bright. The diversity of the students on that stage made me so proud and made me even more determined to work so hard in order to have the ability to create opportunities for the underrepresented women and men who will be our next generation’s healthcare leaders. It’s moments like these that you remember your life’s purpose.

My life’s purpose in medicine is 2-fold. 1) To make sure underserved, underrepresented, and disadvantaged patients receive world-class healthcare. Meaning, if you’re a Google executive or a school environmental services employee- you have the exact same access to healthcare, including organ transplantation. And 2) To make it to the top so that I can create opportunities for historically underrepresented women and men in medicine too. Get to the table and bring all of my friends, and by friends, I mean the women and men missed for opportunities because of the color of their skin, their religious preference or lack thereof, their sexual orientation, the way they wear their hair, their socioeconomic status, their disabilities, or any number of superficial factors that contribute to inequities in medicine.

When you identify your life’s purpose and keep it at the center of every decision you make, I can’t imagine not succeeding. We’ve been given a gift – we are scientists, academics, teachers, advocates, activists, and most important, we are healers. It’s our responsibility to pay that gift forward. Especially to those who don’t have a voice and haven’t made it through those doors yet.

I came home from AHA19 ready to crush more goals and added new ones to my list. AHA19 was literally the juice I didn’t realize I needed. I’m looking forward to AHA20 already.

 

 

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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Public Service Announcement: Guidelines Are NOT Merely Suggestions

We are doing a pretty poor job of getting our patients with heart failure with reduced ejection fraction (HFrEF) on the appropriate guideline-directed medical therapies (GDMT). It is the talk of the town (and by town, I mean Twitter- and if you are not following Gregg Fonarow, MD @gcfmd on there, you need to because he Tweets almost daily science-backed sermons about how bad we are at this).

It is time; it has been time.

We are doing our patients a huge disservice by not optimizing GDMT to reduce morbidity and mortality for a complex disease with an enormous societal burden. I say this all the time, GDMT are low hanging fruit with significant impact. We are not talking about cracking chests open and implanting mechanical pumps or new hearts; we are talking about medications that in some cases cost patients nothing. I am keenly aware that co-pays can be unaffordable, but the reasons for non-adherence to GDMT are not always financial in nature and include complex patient, physician, and systems issues including therapeutic inertia.

The data is clear, we have so much work to do. The Change the Management of Patients with Heart Failure (CHAMP-HF) registry included outpatients in the US with chronic HFrEF receiving at least one oral medication for management of HF and told us just how bad we are. Over 1/4 of eligible patients are not prescribed an angiotensin converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor (ARNI); over 1/3 are not prescribed a beta blocker; and over 1/2 are not prescribed a mineralocorticoid receptor antagonist. Additionally, less than 1/4 are on target doses of GDMT and sadly, only 1%, ONE PERCENT, are simultaneously on target doses of all 3 classes.

It is time to implement the guidelines for our patients’ sake. Let us get comfortable with the 3-class approach now because as The Godfather of Heart Failure himself, Clyde Yancy, MD @NMHheartdoc, suggested at his provocative talk at AHA.19, sodium-glucose cotransporter-2 inhibitors in non-diabetics and de novo ARNI may just make an appearance on the 2021 HF guideline update. Brace yourselves.

And if we are not putting our HFrEF patients on the appropriate GDMT, we need a really good reason why. And the excuse, “well, my patient feels fine”, is not good enough, because we have more than enough data to tell us we are reducing long term bad outcomes with GDMT and “feeling fine” does not tell us who will die of sudden cardiac death and who will not.

As we go into the new year, let us make a commitment to optimize our HFrEF patients on GDMT. We owe it to them to provide the best care available to them. Be creative- technology, remote monitoring devices that keep getting better, phone calls, emails, telehealth, and HF nurses are all our friends. A navigator-led remote optimization of GDMT program like the one presented by Akshay Desai, MD at AHA.19 give me hope that creativity can improve adherence.

This is a team effort that will certainly pay off.

#GDMTWorks

 

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.