William Aitken, MD – The Early Career Voice

Housing and Health Equity in Cardiovascular Disease

July 24, 2020July 27, 2020 William Aitken, MD

So far, 2020 has been a year of public health crises. By early spring, it was apparent that people living in socio-economically disadvantaged areas were being hit hardest by Covid-19 [1]. In these same areas, people across the United States took to the streets protesting the murder of George Floyd, an unarmed Black man – in police custody [2]. In the words of James Baldwin, “It demands great spiritual resilience not to hate the hater whose foot is on your neck, and an even greater miracle of perception and charity not to teach your child to hate.”, and we as a country are still looking for this resilience [3]. Among the many consequences of this year’s events, these tragedies have really prompted a long, hard look at our healthcare system. One recently published article that was particularly heartening to read was the American Heart Association’s Council on Epidemiology and Prevention and Council on Quality of Care and Outcomes Research Scientific Statement on “Importance of Housing and Cardiovascular Health and Well-Being”. It outlines how housing stability, quality, affordability, and neighborhood environment are linked to cardiovascular disease. The statement doesn’t shy away from evidence of how increased psychosocial stress in the Black community and other social determinants of health are associated with cardiovascular health disparities.

The world has changed profoundly over the past year and while we continue to strive to show charity to others in our everyday encounters, I look forward to reading more research that will help inform how we as a community can better address health inequity.

References:

Chowkwanyun M, Reed AL Jr. Racial Health Disparities and Covid-19 – Caution and Context. N Engl J Med. 2020;383(3):201-203. doi:10.1056/NEJMp2012910 (https://www.nejm.org/doi/full/10.1056/NEJMp2012910)
Taylor, Derrick Bryson. “George Floyd Protests: A Timeline.” The New York Times, The New York Times, 30 May 2020, www.nytimes.com/article/george-floyd-protests-timeline.html. (https://www.nytimes.com/article/george-floyd-protests-timeline.html)

Baldwin, James, 1924-1987. The Fire next Time. New York: Dial Press, 1963. (https://www.newyorker.com/magazine/1962/11/17/letter-from-a-region-in-my-mind)
Sims M, Kershaw KN, Breathett K, Jackson EA, Lewis LM, Mujahid MS, Suglia SF; on behalf of the American Heart Association Council on Epidemiology and Prevention and Council on Quality of Care and Outcomes Research. Importance of housing and cardiovascular health and well-being: a scientific statement from the American Heart Association. Circ Cardiovasc Qual Outcomes. 2020;13:e000089. doi: 10.1161/HCQ.0000000000000089 (https://www.ahajournals.org/doi/10.1161/HCQ.0000000000000089)

“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.”

Scientific Sessions during the pandemic

May 28, 2020May 29, 2020 William Aitken, MD

I didn’t know what to expect when I logged in to the American Heart Association’s Quality of Care and Outcomes Research Scientific Sessions earlier this month but having attended I’m definitely a fan of this new virtual format. As a trainee, the largest barriers to attending conferences are usually finding the funding and arranging the time off from work. Not having to worry about missing work on Friday and the cost of a roundtrip flight and hotel for the weekend was a huge positive.

In the couple of weeks since the conference, it’s also been great having access to sessions I missed. With so much going on during the live scientific session, it’s easy to miss a lot of really interesting new research being presented. Being able to go back a couple of weeks later and look through the content has made it much more digestible and eased any fear of missing out I had.

It did take me a little bit to get comfortable navigating the HeartHub (https://www.hearthubs.org/qcor), but then again I usually get turned around at in-person conferences too. Once I was in virtual sessions, I was surprised by how interactive the chats were and how relaxed they felt. Not sure why it felt less formal than an in-person conference but “attending” while having a coffee in my living room, rather than wearing a suit in a conference room sure didn’t add any stress.

Looking forward to #AHA20 online!

Tele-medicine and COVID-19

April 24, 2020April 24, 2020 William Aitken, MD

The coronavirus pandemic has changed the world profoundly over the past few months. Globally, millions of people have contracted COVID-19 and hundreds of thousands have died [1]. Millions more have had their lives up-ended with jobs ending, schools closing, family separations, and varying degrees of quarantine. We face uncertainty daily: Did someone I pass at the grocery store have COVID? How much longer should I stay home? Fortunately, people have been taking precautions to keep themselves and others healthy: washing their hands, covering their mouths, and avoiding unnecessary exposures.

One exposure that I didn’t expect we would be able to avoid here in the US has been visits to the doctor’s office. However, given recent Centers for Medicare & Medicaid Services (CMS) temporary expansions, more people than ever are using tele-health. In March, there was a 50% increase in tele-health visits across the country [2]. This expansion into tele-health has been aided specifically by the recent CMS 1135 waiver that has increased access to and reimbursements for tele-health [3].

That said, I’m left wondering how tele-medicine will affect caring for patients with heart disease and other high-risk groups in the future. Will adherence improve without the hassles of having to drive to the office? Will tele-physical exams be accurate enough to confidently make medication changes? Only time will tell. Certainly something I’ll be looking out for.

[4]

References:

https://coronavirus.jhu.edu/
https://www.cnbc.com/2020/04/03/telehealth-visits-could-top-1-billion-in-2020-amid-the-coronavirus-crisis.html
https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
Author: Intel Free Press
- License: https://creativecommons.org/licenses/by-sa/2.0/legalcode
- No changes made.

Social distancing in the time of COVID-19

March 26, 2020March 26, 2020 William Aitken, MD

I was just getting to work when I received a text from one of my chiefs, “can you call me?”. Not usually the start of a conversation you want to have. A person I had been exposed to had tested positive for SARS-CoV-2 and they suggested I put a facemask on and head home to self-quarantine and monitor for symptoms. Walking to my car, I realized I couldn’t stop at a friend’s apartment or my parent’s house for coffee or to decompress. The social distance hit me.

At home we had already been staying in, washing our hands, and seeing the “flatten the curve” graphs floating around twitter and online. But going to work still provided a sense of normalcy, and my social distancing felt more like a choice than an obligation. Over the next few days, keeping in touch with friends, family, and co-workers via iMessage, Whatsapp, or Zoom really helped close that social gap I felt as I was driving home. Keeping my social distance from others has given me a new found respect for what our global community is really doing to fight this thing.

[1]

This past week I’ve been amazed not only at how empty the roads have been, but by how many more people I’ve seen out walking their dogs, jogging, or riding bicycles. When I get back into the clinic, I’m looking forward to talking to patients about how they’re incorporating physical activity among the other AHA Life’s Simple 7 lifestyle changes into their new routines [2]. Unfortunately, in many places around the world curves aren’t flattening yet. All the more reason to stay home and give our healthcare workers and their patients a fighting chance.

References:

Attribution: Siouxsie Wiles and Toby Morris, This file is licensed under the Creative Commons Attribution-Share Alike 4.0 International license https://commons.wikimedia.org/wiki/File:Covid-19-curves-graphic-social-v3.gif
The American Heart Association’s “Life’s Simple 7” cardiovascular health risk factors that people can improve though lifestyle changes https://www.heart.org/en/professional/workplace-health/lifes-simple-7

#HeartMonth and Healthy choices

February 18, 2020February 18, 2020 William Aitken, MD

See what’s on Netflix or go for a run? We’re more than half-way through #HeartMonth and I’m still picking the next episode of Netflix nine times out of ten. That said, with the Heart Month hashtags flooding my twitter feed I have been inspired to start “prescribing” exercise to patients who are having trouble making healthy exercise choices. Thanks to #cardiotwitter I also have a couple of interesting studies to show patients on the benefits of running.

One observational study at the London Marathon found an approximately 4-year reduction in vascular age associated with training for and completing the race among first-time runners. Most of these people ran 6 to 13 miles per week for the 4-5 months leading up to the race. [1] A separate, outcomes-focused meta-analysis published in 2019 analyzed data from 14 studies and found a 27% risk reduction of all-cause mortality associated with running. The authors concluded that mortality risk reduction was seen with running even just once per week. [2]

Heart disease is the nation’s leading cause of death, but it doesn’t have to be. February is American #HeartMonth to reminds us that we can fight back by making healthy choices: being active, eating healthier, and going for that occasional run.

My son and I after his first Turkey Trot last year

References:

Bhuva A, D’Silva A, Torlasco C, et al. Training for a First-Time Marathon Reverses Age-Related Aortic Stiffening. J Am Coll Cardiol. 2020 Jan 7;75(1):60-71. doi: 10.1016/j.jacc.2019.10.045.(https://www.ncbi.nlm.nih.gov/pubmed/31918835)
Pedisic Z, Shrestha N, Kovalchik S, et al. Is running associated with a lower risk of all-cause, cardiovascular and cancer mortality, and is the more the better? A systematic review and meta-analysis. Br J Sports Med 2019; 0:1-9. doi:10.1136/bjsports-2018-100493 (https://www.ncbi.nlm.nih.gov/pubmed/31685526)

What Does Tobacco 21 Mean for Adolescent Tobacco Use?

January 21, 2020January 21, 2020 William Aitken, MD

We’ve come a long way from the Joe Camel commercials I remember watching as a kid on TV. As a culture, we’ve become a lot less tobacco friendly. Indoor smoking bans, stricter advertising restrictions (meaning no more cartoon characters advertising cigarettes), and other policies have been enacted to curb tobacco use across the country. Despite these changes, teen smoking is still a big problem.

In 2015, the Institute of Medicine reported that raising the legal age for using tobacco products from 18 years to 21 years would significantly decrease, delay, or differ adolescent tobacco use ^[1]. Just last month Congress decided to test this prediction by passing House Resolution 1865 – Further Consolidated Appropriations Act, 2020 which was subsequently signed into law by President Trump. This spending package includes an amendment to the Federal Food, Drug, and Cosmetic Act, raising the minimum age for purchase of tobacco products to 21 years ^[2]. This certainly signals a bipartisan effort to curb adolescent tobacco use, but only time will tell the lasting impact of this and other new policies.

Despite laws existing to restrict tobacco sales to adults, there is limited evidence of interventions able to achieve high levels of adherence with these laws ^[3]. In fact, a majority of smokers endorse first using tobacco products before being of age. While the is ample evidence that exposure to tobacco advertising is related to youth picking up smoking, there are no randomized clinical trials (RCTs) that assess the effectiveness of different advertising restrictions or bans on adolescent tobacco use ^[4]. What percentage of potential under-age smokers are deterred by age restrictions? What effect would increasing the tobacco tax have on youth sales? What effect could flavor restrictions have on youth smoking? One approach to better understand the health effects of possible tobacco legislation could be to incorporate RCTs into this new law’s implementation.

Last year the Nobel Memorial Prize in Economics was awarded to three researcher who used RCTs to better understand the effects of economic policies on people’s lives ^[5]. This approach to policy interventions has allowed developmental economists inform legislation aimed at alleviating poverty and its negative externalities. Using these same standards to assess the efficacy of policies aimed at preventing youth tobacco use could have a lasting impact on the health of our nation.

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.

References:

Committee on the Public Health Implications of Raising the Minimum Age for Purchasing Tobacco Products; Board on Population Health and Public Health Practice; Institute of Medicine; Bonnie RJ, Stratton K, Kwan LY, editors. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington (DC): National Academies Press (US); 2015 Jul. https://www.ncbi.nlm.nih.gov/pubmed/26269869
R.1865 – Further Consolidated Appropriations Act, 2020 (Subtitle E, Section 603: Minimum age of sale of tobacco products) https://www.congress.gov/bill/116th-congress/house-bill/1865/text#toc-H1CB3CAE840AA412285E15A86531C8446
Stead LF, Lancaster T. Interventions for preventing tobacco sales to minors. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD001497. DOI: 10.1002/14651858.CD001497.pub2. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001497.pub2/information
Lovato C, Watts A, Stead LF. Impact of tobacco advertising and promotion on increasing adolescent smoking behaviours. Cochrane Database of Systematic Reviews 2011, Issue 10. Art. No.: CD003439. DOI: 10.1002/14651858.CD003439.pub2. (Page 1, 12) https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003439.pub2/abstract
The Prize in Economic Sciences 2019. https://www.nobelprize.org/prizes/economic-sciences/2019/press-release/

Environmental and Neighborhood Influences on Health at #AHA19

November 29, 2019November 29, 2019 William Aitken, MD

Where we live and work shapes us in many ways. Whether growing up in an urban, suburban, or rural community, our neighborhoods can have an outsized impact our hobbies, lifestyle, and health. It was inspiring to see so many investigators presenting findings on this topic today at the American Heart Association (AHA) 2019 Scientific Sessions during the “Environmental and Neighborhood Influences on Health” poster session.

W. Wyatt Wilson and colleagues at the University of Chicago presented “Spatiotemporal Association Between Violent Crime And Ambulatory Elevations In Systolic Blood Pressure”, an innovative analysis of 133,024 geo-coded violent crimes reported by the City of Chicago and home addresses of patients with blood pressure readings from 232,488 unique outpatient appointments. They found that longer duration of exposure to violent crime within 500 meters of patients’ home addresses was associated with increased systolic blood pressure (approximately 0.27 mmHg per crime) [Figure 1]¹. These results echo findings from the Jackson Heart Study published earlier this year by Tanya M. Spruill and colleagues on chronic stress and incident hypertension among black adults². This analysis followed 1,829 adults without hypertension over a median of 7 years and recorded their blood pressure and self-reported stress. After multi-variable adjustment, they found moderate or high perceived stress was associated with higher risk of developing hypertension. The chronic health effects of stress resulting from living in a neighborhood with violent crime is a newly identified and very significant externality of these crimes.

Figure 1:

Daniel W. Riggs and colleagues at the University of Louisville presented findings on the interaction between neighborhood greenness, air pollution, and arterial stiffness³. This cross-sectional study of 63 adults measured: neighborhood greenness (satellite-derived normalized difference vegetation [NDVI] index), air pollution (particulate matter [PM] 2.5 levels and ozone levels), and arterial stiffness (augmentation pressure, pulse pressure, and aortic systolic pressure in mmHg). They found among participants living in low greenness areas that air pollution was positively correlated with arterial stiffness. Further, Zachary Rhinehart and colleagues at the University of Pittsburgh presented their poster “Association of Particulate Matter and Incident Stroke in Atrial Fibrillation” which was a retrospective study of 31,414 patients at their academic medical center⁴. They found that among patients diagnosed with atrial fibrillation, living in neighborhoods with high levels of air pollution (highest quartile compared to lowest quartile) was associated with an increased risk of stroke (HR 1.50; CI 1.30 – 1.72) [Figure 2]. Given such consistent findings between air pollution and cardiovascular disease, I wonder if built environment interventions such as increased vegetation might help mediate neighborhood factors that contribute to cardiovascular disease long-term.

Figure 2:

Attending scientific sessions this year was a phenomenal experience. I came away with new insights for clinic from the late breaking trial sessions, met some incredibly smart and gifted people, and as evidenced by this specific session came away with a renewed enthusiasm to research some questions I was left with. Looking forward to #AHA20!

References:

W. Wilson et. al. Spatiotemporal Association Between Violent Crime And Ambulatory Elevations In Systolic Blood Pressure. Poster Presentation, American Heart Association 2019 Scientific Sessions, Philadelphia, PA, November 18, 2019 https://www.ahajournals.org/doi/10.1161/circ.140.suppl_1.17139
J Am Heart Assoc. 2019;8:e012139. DOI: 10.1161/JAHA.119.012139.
W. Riggs et. al. Effect Modification of Neighborhood Greenness on the Relationship Between Ambient Air Pollution and Arterial Stiffness. Poster Presentation, American Heart Association 2019 Scientific Sessions, Philadelphia, PA, November 18, 2019 https://www.ahajournals.org/doi/10.1161/circ.140.suppl_1.15881
Rhinehart et. al. Association of Particulate Matter and Incident Stroke in Atrial Fibrillation. Poster Presentation, American Heart Association 2019 Scientific Sessions, Philadelphia, PA, November 18, 2019 https://www.ahajournals.org/doi/10.1161/circ.140.suppl_1.16440

Psychological and Social Influences on Cardiovascular Disease at #AHA19

November 17, 2019November 26, 2019 William Aitken, MD

Better understanding how depression, social isolation, and other psychosocial determinates of health interact with cardiovascular disease is a rapidly growing field of research. Unpacking the relationship between brain function, cardiovascular physiology, and health outcomes is no simple feat. A number of new studies presented on Saturday, November 16^th at the “Depression and Psychosocial Influences on Cardiovascular Disease” poster session during this year’s American Heart Association Scientific Sessions shed new light on this topic.

Crystal Cene and her team at the University of North Carolina presented findings from the Womens Health Initiative Study (WHI) showing a correlation between social isolation and heart failure. In their analysis, they found that socially isolated woman had a 19% higher risk (HR of 1.19; CI 1.03 – 1.39) of developing heart failure over a median follow-up of 15 years¹. These findings complement work published earlier this year by Anne Vingaard Christensen and colleagues at Copenhagen University Hospital². Among 13,442 patients with ischemic heart disease, arrhythmia, valvular disease, or heart failure, loneliness predicated all-cause mortality in men (HR 2.14; CI 1.43 – 3.22) and women (HR2.92, CI 1.55 – 5.49). Given that we now have evidence that loneliness or social isolation puts patients at risk for heart failure and puts patients with heart failure at risk of all-cause mortality, there is all the more need to better understand this relationship.

simple 7 Two other groups of researchers presented similar findings with depression and heart failure. An analysis of The Atherosclerosis Risk in Communities Study (ARIC) presented by Katja Vu from Brigham and Women’s Hospital found a relationship between depression and incidence of heart failure with preserved ejection fraction (HR 1.07; CI 1.02 – 1.13) among older adults (mean age 75 years) of both sexes³. However, there was no such relationship with incidence of heart failure with reduced ejection fraction [Figure 1]. Yosef Khan from the American Heart Association presented National Health and Nutritional Examination Survey (NHANES) data suggesting that depression increases risk of heart failure, coronary disease, or cerebrovascular disease even after adjusting for Life’s Simple 7: physical exercise, heart healthy diet, weight, blood pressure, cholesterol, blood sugar, and tobacco use⁴.

Call to action:

These provocative findings leave us with many questions: What mechanisms are responsible for poor outcomes among patients with social isolation or depression? Does access to care or medication adherence mediate these effects? Would interventions to reduce social isolation or depression improve cardiovascular outcomes in the long-run? There is a lot left to discover in this bio-psychosocial model, but I for one am looking forward to future work in the field.

References:

CW Cene et. al. Social Isolation Independently Predicts Incident Heart Failure Among Older Women: Findings From the Womens Health Initiative Study. Poster Presentation, American Heart Association 2019 Scientific Sessions, Philadelphia, PA, November 16-18, 2019 (https://www.abstractsonline.com/pp8/#!/7891/presentation/29740)
Christensen AV, et al. Heart 2019;0:1–7. doi:10.1136/heartjnl-2019-315460
K Vu et. al. Depressive Symptoms, Cardiac Function, and Risk of Heart Failure With Preserved or Reduced Ejection Fraction in Late Life: The Atherosclerosis Risk in Communities (ARIC) Study. Poster Presentation, American Heart Association 2019 Scientific Sessions, Philadelphia, PA, November 16-18, 2019 (https://www.abstractsonline.com/pp8/#!/7891/presentation/29738)
Y Khan et. al. Depression and Non Fatal Cardiovascular Diseases Among Adults in the United States. Poster Presentation, American Heart Association 2019 Scientific Sessions, Philadelphia, PA, November 16-18, 2019 (https://www.abstractsonline.com/pp8/#!/7891/presentation/29739)