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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.