Sheila Sahni, MD, FSCAI – The Early Career Voice

Let’s add Stress Reduction as the 8th step in the American Heart Association’s “Life’s Simple 7”

February 19, 2021February 16, 2021 Sheila Sahni, MD, FSCAI

February is Heart Month! An entire month dedicated to heart disease awareness in our community. During this month, we also educate the community on why heart disease is a women’s biggest threat. After all, heart disease takes more lives than all cancers combined. Globally, that equates to one woman dying every 80 seconds. More recently, research has revealed an emerging heart disease epidemic in young women resulting from uncontrolled risk factors such as obesity, blood pressure, elevated cholesterol and diabetes.

The good news is that 80% of heart disease can be prevented through risk factor management – this journey begins with a baseline assessment with a clinician. Starting this journey early is critical – research has demonstrated that if a woman can reach 50 without developing a major risk factor for heart disease, her lifetime risk for heart disease is only 8%. By contrast, women who have 2 or more risk factors for heart disease at 50 have a 50% risk of developing heart disease.

Heart month is a great time to start your journey to #knowyournumbers. The three most important numbers to check are:

Blood Pressure
Cholesterol
Blood Sugar (A1C)

It’s also a great time to review your diet and exercise plan with your physician.

Furthermore, in women, an increasingly important aspect of cardiovascular health is the presence of psychological, psychosocial, and emotional stress. Well-established epidemiological data has shown that psychological risk factors such as anxiety, depression, work-related exhaustion, or perceived home stress are significantly associated with heart attacks in women (1). Another large study of young women presenting with heart attacks revealed that women reported higher amounts of perceived stress before their heart attacks symptoms compared with men. Overall, women reported worse baseline physical and mental health before heart attacks compared with men (2). Therefore, an important assessment of a woman’s current emotional health status is imperative in my initial cardiac workup, particularly for women.

During the initial consultation and subsequent follow-up visits, I focus on learning details about my patients’ lifestyle habits including eating patterns, physical activity/exercise routine, sleep hygiene, and stress levels. The key is to begin the discussion to open the door to awareness of how one’s lifestyle could be setting them up for the greater cardiovascular risk. The American Heart Association (AHA) has created a campaign for workplace health called “Life’s Simple 7” which defines ideal cardiovascular health in terms of seven risk factors (Life’s Simple 7) that people can improve through lifestyle changes: smoking status, physical activity, weight, diet, blood glucose, cholesterol, and blood pressure. While I have leaned on AHAs “Life’s Simple 7”, I have added a very important 8^th step to reduce cardiovascular risk in my patients: Reduce Stress.

When it comes to my women patients, I have found that they are usually suffering from a compounded impact of accumulated stress from both families, interpersonal relationships, and/or work. To help improve mental health, I recommend practicing the 4-7-8 breathing technique, prioritizing self-compassion, and focusing on gratitude. These simple steps help to create the mindfulness that helps mitigate stress and its potential impact on the heart.

The 4-7-8 breathing technique popularized by Dr. Andrew Weil in the West is based on the ancient Indian yogic breathing technique called Pranayama. This technique can slow down the nervous system that controls the “stress response” and in turn enhance the relaxation response in the body and the heart. It is easily accessible for my “busy” women patients as it can be performed from any location without any equipment. The goal is to ensure your exhalation is twice as long as your inhalation.

While there are officially 8 total steps to use this technique, I often ask my patients to simply inhale for the count of 4 in the nose, hold for a count of 7, and exhale for a count of 8 through the mouth.

Self-compassion is another effective way to enhance well-being and reduce burnout. Self-compassion is the act of directing compassion towards oneself when dealing with a failure, a personal struggle, or negative thoughts about oneself. Self-compassion leads with kindness and understanding instead of self-criticism and self-judgment in response to personal shortcomings. Recent studies on self-compassion have revealed a direct relationship between self-compression and feelings of greater well-being.

Gratitude is another way to return kindness to one’s life. It is the quality of being thankful. The creation of a gratitude practice in one’s life may take many different forms: journaling, meditation, active daily reminders or even prayer. The common theme is opening the emotional heart to recognize and appreciate the simple pleasures in life which may be overlooked during times of stress. It is about cultivating a sense of thankfulness for what you have rather in your life no matter how small or simple.

Last year prior to a women’s heart disease awareness lecture series I delivered, I created a handout adapted from AHA’s “Life’s Simple 7” and added the additional 8^th step: Reduce Stress. [See caption below] The details of how to actually begin that journey of self-awareness of perceived stress as well as important stress reduction techniques can now be found in this blog and hopefully will find their way to our patients.

Reference:

Yusuf S, Hawken S, Ounpuu S et al. INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): a case-control study. Lancet. 2004; 364:937–952.
Xu X, Bao H, Strait K et al. Sex differences in perceived stress and early recovery in young and middle-aged patients with acute myocardial infarction. Circulation. 2015; 131:614–623.
Life’s Simple 7. https://heart.org/en/professional/workplace-health/lifes-simple-7. Accessed 2/14/2021

“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.”

Self-Compassion: A Potential Antidote for Physician Burnout

January 22, 2021January 22, 2021 Sheila Sahni, MD, FSCAI

Physicians have been facing a crisis for years: Burnout. As defined by the 11^th Revision of the International Classifications of Diseases (ICD-11), burnout is a syndrome of chronic occupational stress that is not managed successfully. It is further characterized by physical and emotional dimensions which include: 1) feelings of energy depletion or exhaustion; 2) increased feelings of isolation, “separateness”, negativism, or cynicism related towards one’s job; or 3) reduced professional efficacy. (1) A recent survey found that more than 1 in 3 cardiologists in the U.S. report experiencing burnout. Women and mid-career cardiologists experience even higher rates of burnout. The data tells a similar story for the broader healthcare professional community: 35-54% of U.S physicians and nurses and 45-60% of medical students and residents have been reported to experience burnout (2). Burnout creates a perpetual state of exhaustion truly impairing physician’s ability to care for others in a safe, effective, and efficient matter which heightens negativity that may already be pervasive in one’s life. This cycle opens the door to harsh self-judgment or self-criticism and feelings of low self-esteem as well as depression. We not only have to break the cycle of burnout but also need to address the deep struggle of a harsh inner critic. Self-compassion can serve as a potential antidote for physician burnout.

The Need for Self-Compassion as a Physician

Compassion is defined as a sympathetic concern for the suffering of others. (3) As physicians, we know compassion. Compassion, empathy, and altruism play a key role in the patient-physician relationship. It is the cornerstone of our communication. Burnout, with its characteristic loss of empathy, can challenge even the strongest presence of humanism in our patient-physician relationships. Despite the exhaustion, many physicians are able to push through burnout for the sake of patient well-being. However, we are often most challenged to treat ourselves with the same level of compassion as we treat our patients or others. Burnout can accelerate feelings of professional inadequacy that can lead to a state of deep suffering: negative thoughts about one’s self, one’s professions, and one’s workplace. Additionally, it can become isolating with a tendency to feel alone in our suffering. While physicians may not always be aware of their level of self-criticism, it is, in many cases, ubiquitous among physicians.

For many physicians, self-criticism can be a strong source of motivation. The trade-off, however, can be quite harmful. Self-criticism deepens the stress-induced threat-based system in our brain that actually directs the harmful stress response back to ourselves (the source of our criticism). Perpetual self-criticism is closely linked to chronic stress, burnout, and depression. Self-compassion can break the cycle of self-criticism. Recent studies on self-compassion have revealed a direct relationship between self-compression and feelings of greater well-being. Self-compassion is the act of directing compassion towards oneself when dealing with a failure, a personal struggle or negative thoughts about oneself. Self-compassion leads with kindness and understanding instead of self-criticism and self-judgment in response to personal shortcomings (4).

Defining Self-Compassion

Dr. Kristen Neff, a pioneer in the field of self-compassion research, defines self-compassion in three components:

Self-kindness – characterized by approaching oneself with warmth and understanding versus self-judgment, anger, or negative emotions when confronted with feelings of failure or inadequacies. Self-kindness sits at the core of self-compassion.
Common humanity – the understanding that when a mistake happens or something does not go our way, it is part of a shared human experience rather than a state of “isolation”. Often times we can feel as though we are the only ones experiencing negative outcomes overcome by an overwhelming sensation of “why me”. Self-compassion recognizes that these outcomes are a part of a shared human experience.
Mindfulness – the state of being aware of the present moment is an essential part of self-compassion. It steadies the mind to be present and helps curtail negative reactivity from one’s emotions. It is a non-judgmental state of mind where one can observe his or her emotions passively such that we avoid becoming “over-identified” by our emotions (4).

Self-compassion has been identified as an effective way to enhance well-being and reduce burnout for healthcare professionals (5). Ultimately, the practice of self-compassion is a skill. For physicians, it should be considered one of the essential skills for our personal and professional health. The more we practice self-compassion the more compassion we will have to give our patients. For more information about how you can incorporate self-compassion in your life check out the resources listed below.

References:

Burnout an “occupational phenomenon”: International Classification of Disease. World Health Organization. https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases Accessed: 1/10/2020
Mehta, LS et al. Practice factors affecting cardiology wellbeing: The American College of Cardiology 2019 Burnout Study. Presented March 28, 2020. ACC 2020.
Oxford Learner’s Dictionaries. https://www.oxfordlearnersdictionaries.com/us/definition/american_english/compassion Accessed: 1/10/2020
Neff, K. (2011) Self-Compassion: The Proven Power of Being Kind to Yourself. HarperCollins Publishers.
Neff, KD et al. Caring for others without losing yourself: An adaptation of the Mindful Self-Compassion program for healthcare communities. Journal of Clin Psychol. 2020;1-20.

Resources for physicians to learn more about self-compassion:

“Self-Compassion for Caregivers” by Kristen Neff https://www.youtube.com/watch?v=jJ9wGfwE-YE&feature=youtu.be
An Exercise to Change Your Critical Self-Talk by Kristen Neff https://self-compassion.org/exercise-5-changing-critical-self-talk/

Self-Compassion by Kristen Neff https://self-compassion.org/
Center for Mindful Self-Compassion. https://centerformsc.org/

The Adaptation of Virtual Learning Platforms for Scientific Sessions: A Change Worth Keeping!

December 31, 2020December 28, 2020 Sheila Sahni, MD, FSCAI

It was Sunday, February 23^rd when I boarded my first and last flights of 2020. It was one of those very rare trips where you’re roundtrip would be within 12 hours. Destination: Cardiovascular Research Technologies 2020 meeting in National Harbor, Maryland. Why only a one-day trip? It was all I could swing with my clinical schedule, professional and personal commitments. To be honest, I felt grateful that the requested speaking engagement was on a Sunday relief that saying “yes!” to a meeting wouldn’t disrupt my patient care schedule. Within the span of 7 hours that Sunday, I reviewed my presentation in the Speaker Ready Room, connected with the moderators and other interventional cardiologists on the panel, presented a lecture, reunited unexpectedly with colleagues and mentors, and sat for an interview about my participation. My last encounter was an impromptu meeting with a mentee which began in person and completed by phone as I rushed to catch my flight home to New Jersey just in time for the workweek to begin. The types of jaunts surely sound familiar to many of you. This was the way of many professional cardiologists committed to advancing science, spreading awareness of evidence-based therapies, creating forums for advocacy and networking across of the spectrum of cardiovascular societies and national meetings. This was a commitment we all embraced regardless of the sacrifices. And then, weeks later, the world fundamentally changed.

As coronavirus began to spread worldwide in March 2020, our nation changed dramatically with fear of an invisible enemy – the SARS-CoV-2 virus. The COVID-19 pandemic changed all of our lives as physicians, personally and professionally. Impressively, national societies adapted to an unprecedented time rapidly – the commitment to bridge practice-changing, ground-breaking science to physician offices globally remained its primary mission. Therein birthed the onset of virtual meetings with physicians worldwide participating and engaging in science virtually. As I reflect on my personal experience attending the virtual American Heart Association’s 2020 Scientific Sessions highlights was such a stark contrast to the moment I described earlier in February.

Going into this year’s scientific session, it was clear that this year would look and feel completely different. What was less obvious, however, was the positive impact a virtual meeting had on my learning, engagement, and participation. Despite many technological advancements to facilitate virtual learning, transitioning to this model to create a well-rounded experience necessitated thoughtful consideration of the right ways to optimize learning. While the experience of listening to lectures and symposiums may be easily replicated virtually, the essence of conferences is the moments to engage with colleagues and peers on late breaking research as well as discuss professional challenges. I was particularly impressed with how AHA facilitated fireside chats on Zoom alongside sessions both live and on-demand. The discussion was dynamics – covering a wide array of topics regarding social injustice in healthcare, imposter syndrome, early career advice, and debates in dual-antiplatelet therapy It enabled active participation, optimized learning, and allowed me to consume more content than ever before. A hybrid model can achieve clear cost savings, minimize travel while also maintaining an ideal learning environment to advance evidence-based medicine. By striking this balance, I am optimistic about a future that leverages a hybrid virtual and physical format.

An ALL-Woman Trial on MINOCA Takes a Seat in the Main Area as Late Breaking Science Addressing Challenges in Coronary Care

November 16, 2020November 17, 2020 Sheila Sahni, MD, FSCAI

As an interventional cardiologist who’s passionate about reducing the disparities in diagnosis and management in women with cardiovascular disease, I was captivated by the late-breaking science that took the main arena for Current Challenges in Coronary and Valve Disease at Scientific Sessions 2020. The Coronary OCT and Cardiac MRI (CMR) to Determine Underlying Cause of MINOCA (Myocardial Infarction with Nonobstructive Coronary Arteries) in Women Trial from the HARP (Women’s Heart Attack Research Program) investigators led by Dr. Reynolds and colleagues is truly groundbreaking for women patients with MINOCA (1). HARP-MINOCA was a multimodality imaging trial that included all women. Yes—that’s correct. An ALL Woman Trial. Why would a study enroll all women? Because MINOCA is a condition that disproportionately affects women (3). In women presenting with MI, the presence of MINOCA is 10.5% compared to 3.4% in men (4). MINOCA is a disease process that has largely been met with controversy such that clinicians have challenged the presence of a “true” myocardial infarction in the absence of coronary artery disease. Furthermore, the lack of an obstructive lesion on a coronary angiogram has misled women to believe that they’re “fine” just because their coronary arteries don’t require stenting. This is completely false. Patients with MINOCA have clinical outcomes similar to patients with obstructive CAD at the time of myocardial infarction (MI) (3). Our patients have suffered in this variability of treatment and assessment which ultimately impacts their care. The findings of this study area additive to the American Heart Association’s scientific statement on the contemporary diagnosis and management of MINOCA which sought to standardize the definition of MINOCA and create a clinically useful diagnostic framework and treatment algorithm (2). Thus, the HARP-MINOCA multimodality imaging findings deepen the roots of MINOCA as a true disease process that requires a proper diagnosis with multimodality imaging to optimize management for improved patient outcomes.

This prospective multicenter study enrolled women a total of 301 women with a clinical diagnosis of MI across 16 different sites of which 170 had MINOCA. Once invasive coronary angiography was performed and revealed <50% stenosis in all major arteries, multi-vessel optical coherence tomography (OCT) was performed, followed by CMR (cine imaging, late gadolinium enhancement, and T2-weighted imaging and/or T1 mapping). [Figure 1]

Figure 1

Dual imaging allowed for a thorough investigation of the following: 1) Vascular causes of MINOCA by OCT, 2) Myocardial abnormalities on CMR and 3) integration of the various underlying etiologies on OCT and CMR. The findings from OCT investigation revealed that a culprit lesion in 46% of cases included plaque rupture, thrombus without plaque rupture, intra-plaque cavity, layered plaque, dissection, or spasm. The CMR findings revealed infarction with late gadolinium enhancement 33% of cases, regional pattern of ischemic injury in 21% and 21% had non-ischemic pattern giving them an alternate diagnosis. The study did have a few limitations included a low rate of STEMI enrollment, regional myocarditis cannot be excluded from the CMR definition of ischemic injury (defined as a single coronary territory with myocardial edema) that was used, the contribution of coronary vasospasm to the presentation was not evaluated, and not all women underwent 3-vessel OCT and CMR leaving some diagnoses that may have been missed.

The integration of the dual-imaging findings revealed a specific cause for MINOCA in 85% of cases. When an OCT culprit lesion, there was CMR evidence of infarction or regional ischemic injury in 75% of cases. Multi-modality imaging was better than either imaging modality alone leading to an identified cause of MINOCA in 85% of cases. One of the cases shared during the trial presentation was eye-opening. Despite no evidence of an obstructive lesion in the LAD vessel on a coronary angiogram, OCT performed in the LAD revealed plaque rupture and subsequent CMR demonstrated a small, transmural infarction in the terminal segment of the LAD. [Figure 2]. The importance of establishing the diagnosis with additional multimodality imaging is the key findings here. MINOCA patients have pathophysiology hidden deep beyond the limitations of coronary angiography and without additional imaging, they could be subject to a missed diagnosis and ultimately poor long-term care and management.

Figure 2

The 2020 European Society of Cardiology for non-ST elevation MI gave the use of CMR a Class IB recommendation for MINOCA evaluation. Unfortunately, there are no such recommendations for the use of intracoronary imaging. As a community-based interventionalist who performs emergent percutaneous coronary interventions at ST-Elevation MI (STEMI) receiving centers without cardiothoracic surgical support, we have restrictions as operators when performing interventions such an intravascular imaging when no intervention is planned. The implications of this OCT relevant data would be practice-changing for interventional cardiologists practicing in my clinical setting. The feasibility of OCT may bring its own challenges with operator-experience, staff support, and contrast use. However, education regarding the important data noted from OCT in MINOCA patients is a very important first step to implement change in one’s cath lab.

This study presented here at sessions continues to advance the growing field of MINOCA science. Late-breaking science advancing the understanding of this heterogeneous population of MINOCA patients is incredibly exciting and I’m looking forward to the continuum of knowledge to transform the algorithm for diagnostic assessment and framework for MINOCA treatment.

References:

Reynolds et al. Coronary Optical Coherence Tomography and Cardiac Magnetic Resonance Imaging to Determine Underlying Causes of MINOCA in Women. Circulation 2020; Epub. 10.1161/CIRCULATIONAHA.120.052008
Tamis-Holland JE et al. Contemporary diagnosis and management of patients with myocardial Infarction in the absence of obstructive coronary artery disease: a scientific statement from the American Heart Association. Circulation. 2019;139(18):e891–908.
Safdar B et al. Presentation, clinical profile, and prognosis of young patients with myocardial infarction with nonobstructive coronary arteries (MINOCA): results from the VIRGO study. J Am Heart Assoc. 2018;7(13)
Smilowitz NR et al. Mortality of myocardial infarction by sex, age, and obstructive coronary artery disease status in the ACTION registry-GWTG (acute coronary treatment and intervention outcomes network registry-get with the guidelines). Circ Cardiovasc Qual Outcomes. 2017;10(12):e003443.