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

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 8th 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 8th 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:

  1. 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.
  2. 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.
  3. 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.”

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Conquering the K99 (Part 1)

Greetings postdocs! I wanted to share my experience with postdoc fellowships and grants for this month’s blog. As a postdoctoral researcher, I applied to over 15 grants and fellowships. Getting funding as a postdoc is difficult, and I did not receive most of the grants I applied to. However, my research proposal improved with each subsequent application, and I eventually found success first with an American Heart Association Postdoctoral Fellowship (thanks AHA!) and later with a K99 Pathway to Independence Award. Over the past two years, I have been a grant-writing coach and in the next few blogs wanted to share the many things I learned about applying for NIH funding.

What is the K99/R00?
The K99/R00 Pathway to Independence Award is an NIH career development award that supports up to five years of research. The five years consist of up to 2 years of mentored postdoctoral training (K99) and 3 years of independent support that funds your brand-new laboratory (R00).

Who is eligible to apply?
Unlike most NIH grants, both US citizens and non-US citizens (with a research or clinical doctoral degree) are encouraged to apply! Typically postdocs have four years (after degree conferral) to apply for a K99. However, postdocs can request extensions for numerous reasons, including medical issues, disability, family care responsibilities, and natural disasters. Recently, the NIH released two new notices that allow postdocs to apply for a one-year extension for childbirth (NOT-OD-20-011) and a two-receipt cycle extension for disruptions due to the COVID-19 pandemic (NOT-OD-20-158).

Should I apply? 

If you are eligible and have any inkling that you want to pursue a career in academics, then go for it! In my experience, postdocs often build a wall of concerns that delay their application process. Let me address a few of the most common concerns I have heard here:

  1. “I don’t have a chance at getting a K99 because I do not have a first-author postdoc publication yet.” You don’t have any chance of receiving a K99 if you never apply. While it is true that having multiple publications will likely strengthen your application and that some reviewers are overly critical of a lack of publications, I have met postdocs that received a K99 without a first-author publication. Do not disqualify yourself! It is better to apply without a first-author publication and address this issue in your resubmission instead of applying late and not giving yourself sufficient time to reapply.        
  2. “I don’t have enough preliminary data to write a K99.”
    The K99/R00 is unique in that it is a transition grant. The research you propose to do for your K99 must have a substantial training component that will elevate your science-self. Thus, while the science is important, the NIH is looking to fund people, not projects. The preliminary data’s sole purpose is to convince the reviewers that your project is feasible. Instead of worrying about gathering more preliminary data, refocus this energy towards building a strong team (aka. your scientific committee) that will function as the foundation of your training plan.
  3. “NIH success rates are low. I don’t think I’ll get it, and it’s not worth trying.”

Compared to other grants and fellowships, the K99 success rate is relatively high (~24% in 2019, with significant variability depending on the institute). Admittedly, preparing a K99 does take a lot of time. However, there are many benefits, even if you don’t get the award. First, it’s an excellent exercise in thinking deeply about your research. Second, it’s great practice for writing NIH grants. Lastly, in organizing your scientific committee, you have the potential to gain additional mentors and build real collaborations that can help you and your research succeed.

In my next blog, I will cover how to get started writing a K99, so stay tuned!

 

“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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From “Medicare for All” to “Health for All”

In the shadow of a global pandemic, national unemployment crisis, and ongoing presidential impeachment hearings, the debates surrounding Medicare for All that dominated news cycles through the summer and fall of 2019 may seem like a quaint and distant memory. However, as a newly minted Democratic-controlled legislative and executive branch elected on the promise of Medicare for All look to define policy priorities for the next four years, we in healthcare would be well served to consider how we might shape discussions of healthcare reform in the years to come, particularly given the unique spotlight the pandemic and race-related protests have placed on health disparities. There is no denying that public attitudes about healthcare reform have shifted dramatically over the past quarter-century, with 2017 marking the first year a majority of Americans supported government-instituted national health insurance coverage and 74% of Americans now reporting that they would like to see the government do more to provide care for all citizens.1 Yet, for all the political success of the Medicare for All campaign, universal healthcare coverage—even if achieved—in reality, represents not a panacea but one piece of the comprehensive healthcare reform needed to achieve improved health for all in the United States.

Identifying the other components and priorities of meaningful healthcare reform is no easy feat, but it is a necessary one. Doing so ultimately requires that we, as a society, achieve consensus on our healthcare values and begin to engage in discussions of costs and tradeoffs involved in the daily application of health policy. If achieving health equity ranks among these priorities as so many recent editorials and calls to action in the cardiovascular community demand, a reimagining of how we define healthcare quality is required. The American healthcare system has become notorious for its nearly singular focus on individual-level outcomes in measuring healthcare quality, but in doing so population-level performance, and in turn disparities in care, have been largely ignored at the system level. This is to the detriment of minority and underserved communities who experience ill-health in greater numbers, as well as the larger population, all of whom share in the downstream effects of rising healthcare costs driven by acute and tertiary care services. While providing universal coverage may lower or eliminate one barrier to care for underserved groups, unless paired with interventions to reach underserved populations, expand primary and preventive care resources, lower drug costs and expand access to preventive therapies, gains in health equity are unlikely to be achieved.

There are few better examples of this than in the case of cardiovascular disease, which affects more than 80 million people in the United States and is one of the largest single drivers of health expenditures, costing about $444 billion in direct healthcare costs and accounting for $1 of every $6 in health spending.2 Healthcare costs in cardiovascular care have continued to rise and are estimated to reach $818 billion in direct costs and $275 billion in lost productivity by 2030.3 This is, of course, largely preventable. Reductions in the prevalence of smoking and hyperlipidemia, improved recognition and control of high blood pressure, and expanded access to aspirin and statin therapy over the past four decades have driven substantial and consistent declines in cardiovascular mortality. However, disparities by gender, race, and geography remain unchanged in the same time period, demonstrating that while prevention is key in reducing the burden of cardiovascular diseases, unequal access to services and interventions and failure to engage systems of discrimination and racism will continue to hinder our progress toward improved cardiovascular health for all.

So how can we, as cardiologists, begin to reimagine an approach to prevention that meets the magnitude of the current demands for a better and more equitable healthcare system, while also not further ballooning spending? Doing so will require innovative thinking about how to deliver high-value care, a lesson we may well gain from studying the examples of resource-limited settings. Too often, we have seen the American healthcare system as incompatible with models of healthcare from low- and middle-income countries, but these countries and systems offer valuable lessons in how to reach vulnerable populations and provide high-quality care at low cost. This is not to say that any one country has fully achieved the vision of healthcare to which we strive, but rather to suggest that we may improve our own performance by broadening our approach to resource-limited care and embracing ideas with demonstrated efficacy. Over the course of this series which will roll out over the next 3 months, I’d like to explore some of these approaches and their respective strengths and weaknesses, starting with models of task-shifting, use of mobile health technologies, and polypills among others, specifically imagining how such interventions may apply to cardiovascular health in the U.S. and may act to reduce disparity and improve cardiovascular outcomes. These interventions are by no means comprehensive nor capture all of the intricacies of healthcare reform policy but may help us to identify tools at our disposal as we consider how healthcare may function to promote equity while improving health outcomes. By doing so, I hope we can begin to see how a vision for “Medicare for All” might eventually evolve to a vision for “Health for All”.

REFERENCE

  1. KFF. Public Opinion on Single-Payer, National Health Plans, and Expanding Access to Medicare Coverage. 2020; https://www.kff.org/slideshow/public-opinion-on-single-payer-national-health-plans-and-expanding-access-to-medicare-coverage/. Accessed February 11, 2021.
  2. Shaw LJ, Goyal A, Mehta C, et al. 10-Year Resource Utilization and Costs for Cardiovascular Care. J Am Coll Cardiol. 2018;71(10):1078-1089.
  3. Heart Disease and Stroke Cost America Nearly $1 Billion a Day in Medical Costs, Lost Productivity. 2015; https://www.cdcfoundation.org/pr/2015/heart-disease-and-stroke-cost-america-nearly-1-billion-day-medical-costs-lost-productivity#:~:text=Annually%2C%20about%20one%20in%20every,costs%20could%20exceed%20%24275%20billion. Accessed February, 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.”

 

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Equity & Inclusion in Medicine – Part II: Inclusion in Cardiology

In Part 1, I shared common experiences between myself and other BIPOC physicians in medicine and cardiology. In this piece, I will dive into the importance of why increasing diversity and inclusion in cardiology is so urgent. Cardiology is a coveted specialty and can incentivize a power dynamic that does not often include BIPOC. I would argue that for a progressive program, creating an inclusive workforce will help programs progress, be innovative, and positively impact patient care in the community. This change will be a win-win for all.

When reflecting on this topic, I am reminded of an African American woman who was crying on the cath table the other day, with a look of fear and helplessness. This was not long after a report of a physician of color, who was infected with COVID19, reported that her symptoms were dismissed, and later died. If a physician feels unheard, how can a woman of color who is not a physician feel safe? The cath team did a great job of comforting her, but it was hurtful to see her in such fear.

African Americans are significantly affected by heart disease risk factors; in fact, together these conditions contributed to >2.0 million years of life lost in the African American population between 1999 and 20101, with heart disease being the leading cause of mortality in African Americans. Unfortunately, there is a lack of African Americans in the physician workforce considering African Americans make up ~ 13% of the U.S population, but only 4% of U.S. doctors2. According to the Harvard Business Review, increasing the numbers may improve health outcomes. They described a study in Oakland that assigned African American male patients recruited from barbershops to African American and Non-African American physicians. What they found was that African American patients were more inclined to agree to more invasive and preventative services than those with non-African American doctors. This is not an argument for a segregated system, but certainly increasing the numbers and learning from colleagues can help BIPOC patient outcomes.

One historical change in medicine that impacts care in the African American community is likely rooted in the Abraham Flexner Report3. An African American medical student applying to medical school in 1900 had 10 choices which declined to approximately a quarter of that by 1920. The Flexner Report, which was meant to trim the medical workforce to only those with the greatest quality of training, decided that only two medical schools that trained African Americans (Howard University and Meharry Medical College) were worthy of staying open. His devastating comments terminated the rest4. My cousin, Dr. Hubert Eaton, wrote about this dilemma in his book Every Man Should Try5. He graduated from the University of Michigan School Medical School in 1942 and his father went to Leonard Medical School (see Table 14). He found his father’s exam scores and noted they matched his own. He was perplexed that Leonard was shut down and he wondered:  Who validated the Flexner report? Why was one individual able to create this modernity in medicine without any scrutiny?

By building diversity and increasing contact between those who have shared experiences, the field of cardiology could improve BIPOC patient trust and compliance as well as reduce cardiovascular disease outcomes. This change could lead to lower hospital admissions and increase prevention efforts. Many BIPOC is inspired by giving back to the community and being involved in community engagement. This community service is via BIPOC oriented organizations (e.g., The Divine 9 fraternity and sororities, the Boule, The Links, Incorporated, etc.) as well as the Black Churches.  As BIPOC cardiologists, we have the ability to teach important primary prevention to thousands of people and the message is stronger if that provider looks like the community they represent.

Cardiology is a prestigious field and as such should aim to set an example for leadership across the country. We know that inequities exist in all aspects of cardiovascular disease and one way to combat this issue is to build a diverse workforce. When we lost community physicians after the Flexner report, we lost the community itself; the field of cardiology has the resources to restore this relationship and improve heart disease outcomes.

References:

  1. Carnethon et al. Cardiovascular Health in African Americans: A Scientific Statement From the American Heart Association. Circulation 2017: 136(21)
  2. Research: Having a Black Doctor Led Black Men to Receive More-Effective Care by Nicole Torres. Harvard Business Review 2018
  3. Flexner A. Medical Education in the United States and Canada. Washington, DC: Science and Health Publications, Inc.; 1910.
  4. Savitt. Abraham Flexner and the Black Medical Schools.  Journal of the National Medical Association. 2006: 98 (9)
  5. Every Man Should Try by Dr. Hubert Eaton

 

“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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Can Vitamin C Prevent COVID-19?

The outbreak of COVID-19 has created a global public health crisis. Our knowledge continues to be limited about the protective factors of this infection. Therefore, preventive health measures that can reduce the risk of infection, and halt the progression and severity of symptoms and complications related to COVID-19 are desperately needed. In the midst of the COVID-19 pandemic, health promotion measures, such as proper nutrition, physical activity, rest, and stress reduction measures have been advocated.  More recently, attention has been shifted to vitamin supplementation as a means to keep American’s health and immune system in optimal status.

Source: https://www.heart.org/en/healthy-living/healthy-eating/add-color

Adequate intake of micronutrients is critical for optimal health, growth and development, and healthy aging. However,  the Dietary Guidelines for Americans 2015–2020 highlight low-consumption of important nutrients including vitamins A, C, D and E, calcium, magnesium, iron, potassium, choline and fiber, with variations by age groups.1   Vitamin C has recently gained attention as a potential micronutrient in the prevention of COVID-19.  Vitamin C has been known for promoting the oxidant scavenging activity of the skin, potentially protecting against environmental oxidative stress, enhancing chemotaxis, phagocytosis, and microbial killing.2

Based on previous evidence, oral vitamin C (2-8 g/day) may reduce the incidence and duration of respiratory infections and intravenous vitamin C (6-24 g/day) has been shown to reduce mortality, hospital length of stay, and time on mechanical ventilation for severe respiratory infections3-4

Given the favorable safety profile and low cost of vitamin C, and the frequency of vitamin C deficiency in respiratory infections, trials are currently underway to determine its effect in hospitalized patients with COVID-19.4-5  Although there are currently no published results of these clinical trials due to the novelty of SARS-CoV-2 infection, there is pathophysiologic rationale for exploring the use of vitamins such as Vitamin C in this global pandemic.6

Source: https://www.heart.org/en/news/2019/07/01/low-vitamin-d-in-babies-predicts-blood-pressure-problems-for-older-kids

While we await for results from these trials, we need to continue being vigilant, and adhere to a varied and balanced diet with an abundance of fruits and vegetables and the essential nutrients known to contribute to the normal immune system functioning.  Vitamin C supplementation could present a safe and inexpensive approach to prevention of respiratory diseases, and perhaps aid in COVID-19.7

Avoidance of deficiencies and identification of suboptimal intakes of these micronutrients in targeted groups of patients and in distinct and highly sensitive populations could help to strengthen the resilience of people to the COVID-19 pandemic. It will be also important to highlight evidence-based public health messages, to prevent false and misleading claims about the benefits of vitamin supplements. It will also be important to communicate the exploratory state of research on micronutrients and COVID-19 infection and that no diet will prevent or cure COVID-19 infection. Frequent handwashing and social distancing will continue to be critical to reduce transmission during this pandemic.8

 

References:

  1. Blumberg JB, Frei B, Fulgoni VL, Weaver CM, Zeisel SH. Contribution of Dietary Supplements to Nutritional Adequacy in Various Adult Age Groups. Nutrients. 2017;9(12):1325. Published 2017 Dec 6. doi:10.3390/nu9121325
  2. U.S. Department of Health and Human Services. U.S. Department of Agriculture [(accessed on 15 March 2017)];2015–2020 Dietary Guidelines for Americans. (8th ed.). 2015 Available online: http://health.gov/dietaryguidelines/2015/guidelines/
  3. Holford P, Carr AC, Jovic TH, et al. Vitamin C-An Adjunctive Therapy for Respiratory Infection, Sepsis and COVID-19. Nutrients. 2020;12(12):3760. Published 2020 Dec 7. doi:10.3390/nu12123760
  4. Carr AC. A new clinical trial to test high-dose vitamin C in patients with COVID-19. Crit Care. 2020;24(1):133. Published 2020 Apr 7. doi:10.1186/s13054-020-02851-4
  5. Zhang J, Rao X, Li Y, et al. Pilot trial of high-dose vitamin C in critically ill COVID-19 patients. Ann Intensive Care. 2021;11(1):5. Published 2021 Jan 9. doi:10.1186/s13613-020-00792-3
  6. Jovic TH, Ali SR, Ibrahim N, et al. Could Vitamins Help in the Fight Against COVID-19?. Nutrients. 2020;12(9):2550. Published 2020 Aug 23. doi:10.3390/nu12092550
  7. Allegra A, Tonacci A, Pioggia G, Musolino C, Gangemi S. Vitamin deficiency as risk factor for SARS-CoV-2 infection: correlation with susceptibility and prognosis. Eur Rev Med Pharmacol Sci. 2020;24(18):9721-9738. doi:10.26355/eurrev_202009_23064
  8. Richardson DP, Lovegrove JA. Nutritional status of micronutrients as a possible and modifiable risk factor for COVID-19: a UK perspective [published online ahead of print, 2020 Aug 20]. Br J Nutr. 2020;1-7. doi:10.1017/S000711452000330X

“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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It is February again!! The American Heart and Go Red for Women Month!!

 

It is February again of a new year of hope and progress!! Since it is the “The American Heart and Go Red for Women Month”, I would like to talk about the American Heart Association (AHA) GO RED initiative and discuss why heart disease in women is unique, urging my colleagues across the globe to work diligently to ensure optimal health and heart care for everyone, irrespective of their sex or gender.

 

What is the GO RED initiative and what does it mean?

The GO RED for Women initiative was launched in 2004 by the AHA with the aim to end heart disease and stroke in women worldwide; by increasing awareness of these diseases in women and removing barriers women face to achieve a healthy life.

Here is what GO RED means:

  • G: GET YOUR NUMBERS

Check your blood pressure and cholesterol level regularly, and early in life if there is a strong family history of heart disease or hypertension.

  • O: OWN YOUR LIFESTYLE

Encourage healthy lifestyle by stop smoking, losing weight, exercising, and eating healthy.

  • R: REALIZE YOUR RISK

Know your risk; heart disease is responsible for 1 in every 5 female deaths [1].

  • E: EDUCATE YOUR FAMILY

Educate your family members and make healthy food choices for you and your family.

  • D: DON’T BE SILENT

Spread the knowledge that heart disease is No. 1 killer in women [1]. It is also the No. 1 killer of pregnant women per Center for Disease Control and Prevention (CDC) data [2].

Why is heart disease unique in women?

Not only women tend to have atypical symptoms when they present with heart attacks, but also various diseases might behave differently in women potentially leading to differences in outcomes; highlighting the importance of vigilant clinicians in these cases. Women tend to have atypical symptoms when they present with heart attacks; so they tend to have nausea, vomiting, stomach pain, or atypical chest pain, in contrast to the typical exertional chest pain. Moreover, women have differences in their risk factor profile; a recent study has shown that women tend to have a different blood pressure trajectory; with blood pressure elevation starting as early as the third decade of life, and steeper increments of blood pressure over a lifetime compared to men [3]. In addition to the risk factors, there are certain heart conditions that mainly affect women, including spontaneous coronary artery dissections, which is one of the major causes of heart attacks especially in young and pregnant women [3], eclampsia/pre-eclampsia, and peripartum cardiomyopathy, which still carry significant morbidity and mortality [2].

The medical community is still learning about these diseases and the exact mechanism of each condition; urging the need for more research in this area, launching more initiatives to support these projects, similar to the “Research Goes Red” initiative by the AHA, and expanding related sub-specialties like “cardio-obstetrics”, which is a niche subspecialty focused on the care of pregnant women with heart disease.

Although February is the “American Heart and Go Red for Women Month”, we should celebrate women’s heart health every single day by doing our best in our daily clinical practice, increasing awareness of heart disease and risk factors among women, and by working relentlessly to understand the knowledge gaps we have in order to provide better and optimal care for all of our patients.

I would like to say a special thank you to my mom, Laila Abdullah, and my sisters, Rawan, Razan, and Raghad, for their help on this blog and for their continued support.

 

REFERENCES

[1] Women and Heart Disease: Center for Disease Control and Prevention (CDC): https://www.cdc.gov/heartdisease/women.htm

[2] Center for Disease Control and Prevention (CDC): https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillancesystem.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Freproductivehealth%2Fmaternalinfanthealth%2Fpregnancy-mortality-surveillance-system.htm

[3] Ji H, Kim A, Ebinger JE, Niiranen TJ, Claggett BL, Bairey Merz CN, Cheng S. Sex Differences in Blood Pressure Trajectories Over the Life Course. JAMA Cardiol. 2020 Mar 1;5(3):19-26. doi: 10.1001/jamacardio.2019.5306. Erratum in: JAMA Cardiol. 2020 Mar 1;5(3):364. PMID: 31940010; PMCID: PMC6990675.

[4] Hayes SN, Kim ESH, Saw J, Adlam D, Arslanian-Engoren C, Economy KE, Ganesh SK, Gulati R, Lindsay ME, Mieres JH, Naderi S, Shah S, Thaler DE, Tweet MS, Wood MJ; American Heart Association Council on Peripheral Vascular Disease; Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Genomic and Precision Medicine; and Stroke Council. Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association. Circulation. 2018 May 8;137(19):e523-e557. doi: 10.1161/CIR.0000000000000564. Epub 2018 Feb 22. PMID: 29472380; PMCID: PMC5957087.

“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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Optimal Management of Periprocedural Anticoagulation for Catheter Ablation of Atrial Fibrillation

Catheter ablation (CA) of atrial fibrillation (AF) is a safe procedure and the overall complication rates are low. Periprocedural thromboembolic events are one of the most feared complications of this procedure. A large systematic review of 192 studies showed the pooled complication rate of stroke or transient ischemic attacks was only  0.6%1. Despite the low rates of these thromboembolic complications, it is important to explore the factors that contribute to periprocedural thromboembolic events and more importantly ways to prevent them.

It turns out that the periprocedural anticoagulation (AC) strategy has a significant impact on the thromboembolic complications during CA of AF, and the peri-procedural management of AC has been continuously evolving. In the Vitamin K antagonist (VKA) era, the usual practice was to interrupt AC before ablation and then resume it after the procedure with the rationale of minimizing periprocedural bleeding. However, the pendulum moved rapidly after the landmark COMPARE trial. This study enrolled 1584 patients with CHADS2 score ≥1 and assigned them in 1:1 fashion to discontinue VKA or continue VKA during ablation and observed thromboembolic events in the 48 hours after ablation. The study showed that uninterrupted VKA use was associated with a reduction in periprocedural stroke and minor bleeding (odds ratio 13; 95% CI 3.1-55.6; p<0.001)2.

With the advent of direct oral anticoagulants (DOACS) and their improved efficacy in preventing thromboembolic events in patients with AF, an increasing number of patients in clinical practice are on DOACS when they present for CA. Multiple head-to-head trials have shown that uninterrupted DOACS are safe or even better as compared with uninterrupted VKA in preventing procedural thromboembolic events and current guidelines recommend uninterrupted or minimally interrupted DOACS for patients undergoing CA of AF3,4.

Currently, there is wide variability in clinical practice on whether to perform CA with completely uninterrupted DOAC or to omit a single dose or more than one dose? And is there any difference in procedural outcomes between these different strategies?

There is limited data on the comparison of procedural complications with different periprocedural AC strategies with DOACS. Data from randomized trials suggest that there is no difference in thromboembolic and bleeding outcomes whether uninterrupted, single-dose interruption, or more than one dose interruption strategy is used 5. One limitation to this data is that with the low rates of thromboembolic procedural complications in patients taking DOACS, it is hard to demonstrate that one strategy is better than the other. Silent cerebral ischemic lesions are increasingly recognized in patients undergoing CA and it is unclear if in the long term they are associated with dementia or cognitive impairment. An important finding from observational studies is that an uninterrupted DOAC strategy may be preventive against silent cerebral ischemic lesions, however, these results were not observed in randomized trials 6–8.

In summary, a strategy of uninterrupted or minimally interrupted DOACS appears to be safe in reducing periprocedural thromboembolic events for patients undergoing CA.

References

  1. Gupta Aakriti, Perera Tharani, Ganesan Anand, et al. Complications of Catheter Ablation of Atrial Fibrillation. Circ Arrhythm Electrophysiol. 2013;6(6):1082-1088. doi:10.1161/CIRCEP.113.000768
  2. Di Biase L, Burkhardt JD, Santangeli P, et al. Periprocedural stroke and bleeding complications in patients undergoing catheter ablation of atrial fibrillation with different anticoagulation management: results from the Role of Coumadin in Preventing Thromboembolism in Atrial Fibrillation (AF) Patients Undergoing Catheter Ablation (COMPARE) randomized trial. Circulation. 2014;129(25):2638-2644. doi:10.1161/CIRCULATIONAHA.113.006426
  3. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2019;74(1):104-132. doi:10.1016/j.jacc.2019.01.011
  4. Romero Jorge, Cerrud-Rodriguez Roberto C., Alviz Isabella, et al. Significant Benefit of Uninterrupted DOACs Versus VKA During Catheter Ablation of Atrial Fibrillation. JACC Clin Electrophysiol. 2019;5(12):1396-1405. doi:10.1016/j.jacep.2019.08.010
  5. Jafry Ali H, Akhtar Khawaja H, Chaudhary Amna M, et al. Abstract 13721: Is Single Dose Interruption of Direct Oral Anticoagulants Necessary Before Atrial Fibrillation Ablation? A Systematic Review and Meta-analysis. Circulation. 2020;142(Suppl_3):A13721-A13721. doi:10.1161/circ.142.suppl_3.13721
  6. Müller P, Halbfass P, Szöllösi A, et al. Impact of periprocedural anticoagulation strategy on the incidence of new-onset silent cerebral events after radiofrequency catheter ablation of atrial fibrillation. J Interv Card Electrophysiol Int J Arrhythm Pacing. 2016;46(3):203-211. doi:10.1007/s10840-016-0117-6
  7. Nakamura K, Naito S, Sasaki T, et al. Uninterrupted vs. interrupted periprocedural direct oral anticoagulants for catheter ablation of atrial fibrillation: a prospective randomized single-center study on post-ablation thrombo-embolic and hemorrhagic events. EP Eur. 2019;21(2):259-267. doi:10.1093/europace/euy148
  8. Nakamura R, Okishige K, Shigeta T, et al. Clinical comparative study regarding interrupted and uninterrupted dabigatran therapy during perioperative periods of cryoballoon ablation for paroxysmal atrial fibrillation. J Cardiol. 2019;74(2):150-155. doi:10.1016/j.jjcc.2019.02.003

“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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Legacy

Dr. Elijah Saunders was born in Baltimore City in 1934. As a young student he received a BS degree from Morgan State College in 1956 and he received his MD degree from the University of Maryland School of Medicine in 1960. During his medical studies, he was one of only four African-Americans in his class of 140 students and was instrumental in helping to desegregate the medical wards. He then went on to become the first African-American resident in internal medicine at the University of Maryland School of medicine and the first African-American cardiologist in the state of Maryland in 1965. 

Following fellowship, Dr. Saunders led a successful private practice for the first 20 years of his career before he returned to the University of Maryland as a professor in Cardiology, where he pursued research on hypertension among African Americans. For many years, he led the Hypertension Division in the Department of Medicine. His critical research illuminated that ethnicity may influence the response to certain types of antihypertensive medications. As a result of his research and lobbying, it is now standard for trials to require African Americans to be included in research. Over his career, he published more than 50 peer-reviewed articles and eight books.

Beyond his many achievements, including increasing African American representation in cardiovascular drug trials, being a founding member of the Association of Black Cardiologists, and co-founder of Heart House of the American College of Cardiology; Dr. Saunders was known for his positive demeanor, caring disposition, and gentle spirit. As a young black man growing up in Maryland with an interest in cardiology, Dr. Saunders was someone who I always admired. During my fourth year of medical school I spent an away rotation at the University of Maryland in hopes of training under Dr. Saunders, but was saddened to hear of his untimely passing prior to my arrival. However, I eagerly listened to his patient’s detailed stories regarding his intellect, compassion, dedication to health equity, and desire to bring healthcare to non-traditional spaces to reach the most at-risk populations. This experience quickly reaffirmed that Dr. Saunders was the type of cardiologist I hoped to emulate: clinically skilled, empathetic, and a leader in healthcare innovation. 

Despite improvements in health distribution inequalities, African-American communities are continuously  plagued with cardiovascular disease at an alarming rate. Some of the main contributors to the high burden of disease are the persistent and increasing degrees of limited access to healthy food, low socioeconomic status, and poor nutritional awareness.  To address this, Dr. Saunders advocated for community screening and outreach in barbershops and churches in order to engage the black community in non-traditional spaces. In 2006, he developed the Hair, Heart and Health program, an innovative program that trained barbers and hairstylists to pre-screen customers for hypertension and then make referrals for medical care.  

I believe as medical professionals we have two profound responsibilities. The first is to be an effective clinician. It is our obligation to treat and heal patients to the best of our abilities, while cultivating and promoting prevention. The second, and perhaps more important, is to go beyond the hospital walls and become an innovator in healthcare. We must identify roadblocks that may impede healthy practices, and provide sustainable solutions for these challenges. I hope that we can all mimic Dr. Saunders’s spirit for innovation and love of patient care. 

“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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10 Questions with 2 Legends

Stories That Ignite Movements

 

I had the honor of interviewing two legends who I admire very much. Dr. Cleve Francis, the first Black cardiologist at the Inova Health System, a Country Music Singer signed by Capitol Records and featured in the African American Museum of history (!!), and an entire movement in and of himself and Dr. , the Coach K of cardiology, a man with an unmatched vision, a true ally, and a queen and kingmaker as many of his mentees call him. I wanted to know how hearing Dr. Fancis’s story of challenges and triumph impacted the way Dr. O’Connor leads Inova Heart and Vascular and the Journal of the American College of Cardiology: Heart Failure with a focus on diversity, equity, and inclusion.

There is so much power in sharing stories and listening to understand.

Francis, I read the editorial Dr. O’Oconnor wrote about you (will link JACC HF editorial) and I knew you were a legend, but when I met you over Zoom, your magic was palpable. How has your journey from Jennings, Louisiana to Country Music to being the first Black cardiologist in the Inova Health System changed how you live life?

Dr. Francis: My journey is an act of defiance in a system of racial suppression and stereotypical fulfillment. This was and still is an amazing journey through time. I feel like someone from the past living in the present and able to influence the future. I was a witness to some of the horrors and hopelessness of racism and segregation. Learned from the love and strength of my mother’s challenge to me to not to be overcome by sadness or anger but to envision a better future. The journey from Jennings to Northern Virginia and Inova was a mixture of hard work, faith, luck, hope, and help from complete strangers and mentors who helped guide me along the way. It was a journey of focus and taking advantage of every possibility using the talents I was born with.

I read about the gut-wrenching stories of your college roommate not realizing you were Black before your arrival to the college dorms and packing up his stuff when he realized you were Black and you being profiled and security called on you at your own hospital. How have moments like that fueled your advocacy efforts?

Dr. Francis: Those episodes taught me that this was someone else’s problem. I felt sorry for my medical school roommate that was embarrassed by his family. I did later speak to him and he said that they had threatened to take him out of the school if he remained my roommate. I had seen enough of this kind of thing to not be bothered for one second. I was the only medical student with a private room- a good thing. The incident at the hospital reminded me what it is like to be in a white culture. You will always be Black and would not be given the benefit of a doubt. It was never assumed that I just might be a physician. The lesson here is to not let one negative incident alter one’s focus.

How has the landscape of cardiology changed since you first became a cardiologist? Or has it really?

Dr. Francis: Today cardiology has changed and there are many more Black professionals. In my earlier journey, racism was very explicit. There were signs saying, “whites only”. Today there are no explicit warning signs, but structural racism, institutional racism, and implicit bias continue to devastate the Black community.  Other minoritized people have simply used laws passed as the result of Black protest and struggle to advance themselves while Black communities have been stranded.

O’Connor, what was your initial impression when you first heard Dr. Francis’s story?

Dr O’Connor: I grew up in an area of the DC suburbs that was and is very culturally diverse. I was aware of racism on some level, but I hadn’t given much thought to how the experiences of others in high school, college, and medical training might be different than mine.

I was not at all prepared for what I learned from Dr. Francis. I was tremendously moved by hearing the challenges and barriers he had to overcome and inspired by his resilience and determination. I was certain that others were similarly unaware of the pervasiveness of racism and the bias in the medical and healthcare profession, and I was even more certain that I wanted to do all I could to turn this situation around.

O’Connor, how has hearing Dr. Francis’s remarkable journey, with its challenges, wins, lessons, and record-shattering changed how you lead your institution and journal with regards to diversity, equity, and inclusion?

Dr. O’Connor: My conversations with Dr. Francis helped me to view processes, systems, and individual encounters in the workforce, in running the journal, and in the care of patients through a different lens. I became increasingly aware of racism and bias, however unintentional, that exists in our healthcare system and the medical profession at large.  It was clear that so much more could be done to promote inclusion and I was determined to develop and implement a plan of action.

An important first step was to schedule a virtual Town Hall so that healthcare workers could hear Dr. Francis’s story firsthand. His sincerity and optimism in the face of challenges and indignities was so inspiring to me and I felt certain it would have the same effect on others.

I quickly put an Anti-Racism/Diversity/Inclusion Task Force in place, with Dr. Francis and Dr. Wayne Batchelor as Co-Chairs, and charged them to address: (1) education, awareness, and training; (2) diversity in talent recruitment; (3) community relations, and (4) disparities in cardiovascular care.

Similarly, I have resolved to take concrete steps to encourage diversity and inclusiveness in the review process for manuscripts and in heart failure research in general. As researchers and an editorial team, we must be more attentive to differences in the implications of research findings for the various subsets of the broad range of patients we serve and demand inclusiveness in research.  I’m counting on your continued guidance in this regard.

The murder of George Floyd on Memorial Day 5/25/2020, in the middle of a pandemic that disproportionally disseminated Black and brown communities ignited the medical community to look internally and develop initiatives to dismantle oppressive systems. Drs. Francis and O’Connor, what changes would you like to see in medicine and in cardiology specifically from a patient and clinician perspective?

Dr. Francis: In the face of the complexity of our discipline as cardiologists, we can build a tremendous level of trust between us and our patients. Our relationships extend over the years in many cases. We convince ordinary people with varying levels of “education” to undertake some of the most complex and dangerous procedures and treatments. In this pandemic, we should become one of the “Trusted Messengers “in advocating vaccination. We need to become more aware and involved in the social determinants of health for each of our patients and know that many factors outside of our medical offices and hospitals will ultimately determine the fate of our patients.

Dr. O’Connor: I would hope to see a greater outreach regarding risk factors and the importance of prevention. We need to take a more active role in screening for cardiovascular disease and assuring that appropriate and timely treatment is made available. More aggressive efforts to deliver care to underserved areas is critical, as is doing all we can to strengthen the bond between patient and physician.  But even more importantly, we have to increase efforts to enroll representative cohorts in clinical trials to further the development of customized and individualized treatment strategies.

Francis, what advice do you have for my generation and the generation coming after mine? How do we get people in power to listen? How do we make lasting change?

Dr. Francis: From medical schools to advanced heart failure, we need to start treating people with diseases rather than treating diseases associated with people. When we continue to treat diseases, we assume no personal connection with the patient, and we have absolutely nothing in common with them. Things such as implicit bias would have little impact if we individualized each patient in our care. If we put it upon each of us to be personally aware of personal as well as structural and institutional matters. I disagree with forced bias training, but it should be available to all of those who seek it. It is good to advance the ideas of diversity and inclusion, but these are no substitute for equity. Institutions must ask themselves how many Black people do we have on-staff or in our administration? Unless this number reflects the general population, there is no equity and only inclusion and diversity. The correction of these disparities must be “intentional”.

O’Connor, what advice do you have for leaders in cardiology? Why should they be bold? Should they be concerned about backlash for speaking up against injustice? How can we change the face of who leads cardiology?

Dr. O’Connor: Most of us entered the medical profession to alleviate suffering and save lives. However unintentional, racism and bias in the system at large and its impact on patient care are not consistent with these goals. Bold action is needed to create a more equitable system and bring about change in research and day to day practice.

Francis, what is your biggest hope for 2021?

Dr. Francis: My greatest hope for 2021 is that we continue the efforts as Dr. Christopher O’Connor has done by appointing a task force of peers to work some of these issues out. At Inova for example, the Inova Heart and Vascular Institute Antiracism/Equality Taskforce that I co-chair with Dr. Wayne Batchelor has taken on issues of recruitment, healthcare disparities, community outreach, mentoring, training of cardiology fellows, and onboarding of new physicians. These efforts are already having an impact on our institution. These efforts are supported by the top administration in Inova.

O’Connor, what is your biggest hope for 2021?

Dr. O’Connor: COVID-19 has made the inequalities in our healthcare system even more apparent.  While my biggest hope for 2021 is an end to the pandemic, I am equally hopeful that we will use the lessons from this pandemic to continue to work toward a healthcare system where disparities in care are a thing of the past.

This is how we change the things that are not right in our world, by listening to understand, by having empathy, by showing courage, by being resilient in our resolve but also working to dismantle systems that have oppressed Black people in America, by identifying true allies willing to use their privilege, power, and platforms to drive change, and by having hope. Thank you, a million times, over, Drs. Francis and O’Connor for sharing your stories and your advice, leaders like you give me hope for our future.

 

“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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A Roadmap for Understanding COVID Vaccines

Yes, we are still in the middle of the COVID pandemic. With the help of more people getting vaccinated and mask mandates in effect, a post-pandemic world is no longer a mere imagination. While waiting for the pandemic to be over, there are some doubts about whether the COVID vaccines should be cleared to facilitate a faster transition back to normal life.

  1.  What are the leading COVID vaccines?

    Figure: Overview of the diverse types of vaccines, and their potential advantages and disadvantages (Dong et al. 2020).

Currently, two COVID-19 vaccines are authorized and then recommended for use in the United States–the Pfizer-BioNTech COVID-19 vaccine(Polack et al. 2020) and the Moderna’s COVID-19 vaccine(Baden et al. 2020). Both of the vaccines used a cutting-edge technology, the messenger RNA (mRNA) vaccine which has been developed in the 1990s.

As of December 28th, 2020, three other COVID-19 vaccines are undergoing large-scale (Phase 3) clinical trials in the United States: AstraZeneca’s COVID-19 vaccine(Knoll and Wonodi 2021), Janssen’s COVID-19 vaccine and Novavax’s COVID-19 vaccine(Sadoff et al. 2021). Both the AstraZeneca COVID-19 vaccine and Janssen’s COVID-19 vaccines (Johnson& Johnson) used a weakened adenovirus vector strategy to tackle the spike protein on the SARS-CoV-2 virus. The weakened virus vector serves as a “Trojan horse” to deliver “information” to the cells in order to stimulate the memory of immune defense against SARS-CoV-2 virus. The adenovirus-based vaccines are relatively less foreign to the public, currently they are used against a wide variety of pathogens such as Mycobacterium tuberculosis, human immunodeficiency virus (HIV), and Plasmodium falciparum. The AstraZeneca COVID-19 vaccine has already authorized to use in Europe on January 12th, 2021 and possibly obtains approval in the United States early 2021. On January 29th, Johnson& Johnson announced its interim clinical Phase 3 trial results and a single-shot Janssen COVID-19 vaccine is on the way for FDA approval.

Novavax COVID-19 vaccine, a protein subunit-based vaccine, just announced its interim UK Phase 3 clinical trial results on January 28th, 2021. It shows promising protection to the SARS-CoV-2 virus, as well as the UK and South Africa variants. The company has already signed purchase agreements with many governments including Australia and Canada.

Two other vaccines– Russia’s sputnik V vaccine and China’s COVID-19 vaccine developed by Sinovac Biotech are also the lead runners in the vaccine race. The sputnik V vaccine which has obtained authorization to use in Russia back in November 2020, just published its Phase 3 data on February 2nd(Logunov et al. 2021). It’s an adenovirus-based vaccine, similar as the AstraZeneca COVID-19 vaccine and Janssen’s COVID-19 vaccine.

China’s COVID vaccine used a relatively well-understood technology: an inactivated SARS-CoV-2 virus. The inactivated virus vaccine approach has been implemented for a wide range of vaccines such as polio vaccine, hepatitis A vaccine, rabies vaccine and most flu vaccines. So far it received some inconsistent results from Brazil, Indonesia and Turkey and it’s not applicable in the United States. Overall, the efficacy is encouraging (50.38% to 91.25%) and requires more data to reach a more consistent result.

  1. How to understand the efficacy?

It’s a numbers game or is it? The high efficacy (95%) data released from Pfizer and Moderna at the end of last year received with great applause. The 70% protection starting after a first dose from AstraZeneca seems less impressive. The AstraZeneca COVID-19 vaccine confirms 100% protection against severe disease, hospitalization and death in the primary analysis of Phase 3 trial suggesting a total success. The recent Phase 3 trial results from Johnson& Johnson’s single-shot vaccine shows 72% effective in the United States and 66% effective overall at preventing moderate to severe COVID-19, 28 days after vaccination. The efficacy number simply cannot be interpreted as the higher the better. Like all of the clinical trials, compounding factors need to take into consideration. Their vaccine impact may depend on sex, age, genetics, geography, the timing of assessment of the end-point, the percentage of population affected by new variant compared to the original variant.

The thing matters the most is to reduce hospitalization and death. So far most of the leading vaccines have showed great promise. At the current stage, whatever vaccine is available to you could protect you from getting serious disease and prevent the virus spread to your loved ones one way or another. Herd immunity could finally be reached if enough people are getting vaccinated in the near future.

  1. mRNA technology: what is it? And is it safe?

Considering mRNA vaccine is the new kid on the block, it’s understandable that certain hesitancy and reluctance towards getting vaccinated. mRNA therapy has been developed and used to target certain types of cancer for more than twenty years. It has recently been used to target SARS-CoV-2 virus. The nucleic acid fragment of SARS-CoV-2 virus spike protein is packaged in a lipid nanoparticle. Like how most vaccine works, it tricks your body to formulate a defense memory using a small piece of information from the virus. When the actual attacks occurred, you are protected with a pre-programmed defense mechanism already. It does not change your DNA. It just helps your body to remember what it feels like to successfully combat the virus. Some of the side effects from clinical trials could be another reason to cause hesitancy. Don’t blame the messenger. The individual response elicited by the vaccines is just a small fraction of what you might experience when the real attack occurs. Some extreme allergic responses, a few reported in a million cases are rare. The chance is as similar as winning a Powerball or Mega Millions lottery. At the end of the day, the benefits still outweigh the risks.

  1. Early progress and new variants

Israel’s vaccination program shows encouraging outcome, results from a recently published preprint(Chodick et al. 2021). It’s in agreement with the Phase 3 clinical trial results from Pfizer. Data collected by Israel’s Ministry of Health shows a 41% reduction in confirmed COVID-19 infections in people aged 60 and order. Close to 90% of that age group has been administered with the first dose of Pfizer’s 2-dose vaccine. For people aged 59 and younger, the infected cases and hospitalization are also dropped.

Viruses like SARS-CoV-2 mutate all the time. There are 3 concerned variants: the UK variant (B.1.1.7), Brazil (P.1) and South Africa (B.1.351) have already been found in the United States. With the surge of new variants of SARS-CoV-2, the effectiveness of the COVID-19 vaccine also dropped. Some new data from Johnson& Johnson and Novavax suggest that the COVID-19 vaccines can prevent a lot of mild and moderate cases, and are still very effective against preventing hospitalization and deaths. Other company such as Moderna, has already developed booster shots to combat new variants. If most of the population got vaccinated, it will stop the virus’s replication and ultimately stop mutation completely. The recommended measure is to vaccine as many people as possible at current stage.

In conclusion, no matter which vaccine you got or are going to get, as long as it’s approved and authorized by the FDA, the chance of having effective protection is still very good. At the end of the day, the benefits outweigh the risks.

Reference

Baden, Lindsey R., Hana M. El Sahly, Brandon Essink, Karen Kotloff, Sharon Frey, Rick Novak, David Diemert, et al. 2020. “Efficacy and Safety of the MRNA-1273 SARS-CoV-2 Vaccine.” New England Journal of Medicine. https://doi.org/10.1056/nejmoa2035389.

Chodick, Gabriel, Lilac Tene, Tal Patalon, Sivan Gazit, Amir Ben Tov, Dani Cohen, and Khitam Muhsen. 2021. “The Effectiveness of the First Dose of BNT162b2 Vaccine in Reducing SARS-CoV-2 Infection 13-24 Days after Immunization: Real-World Evidence.” MedRxiv, January, 2021.01.27.21250612. https://doi.org/10.1101/2021.01.27.21250612.

Dong, Yetian, Tong Dai, Yujun Wei, Long Zhang, Min Zheng, and Fangfang Zhou. 2020. “A Systematic Review of SARS-CoV-2 Vaccine Candidates.” Signal Transduction and Targeted Therapy. https://doi.org/10.1038/s41392-020-00352-y.

Knoll, Maria Deloria, and Chizoba Wonodi. 2021. “Oxford–AstraZeneca COVID-19 Vaccine Efficacy.” The Lancet. https://doi.org/10.1016/S0140-6736(20)32623-4.

Logunov, Denis Y, Inna V Dolzhikova, Dmitry V Shcheblyakov, Amir I Tukhvatulin, Olga V Zubkova, Alina S Dzharullaeva, Anna V Kovyrshina, et al. 2021. “Safety and Efficacy of an RAd26 and RAd5 Vector-Based Heterologous Prime-Boost COVID-19 Vaccine: An Interim Analysis of a Randomised Controlled Phase 3 Trial in Russia.” The Lancet, February. https://doi.org/10.1016/S0140-6736(21)00234-8.

Polack, Fernando P., Stephen J. Thomas, Nicholas Kitchin, Judith Absalon, Alejandra Gurtman, Stephen Lockhart, John L. Perez, et al. 2020. “Safety and Efficacy of the BNT162b2 MRNA Covid-19 Vaccine.” New England Journal of Medicine. https://doi.org/10.1056/nejmoa2034577.

Sadoff, Jerald, Mathieu Le Gars, Georgi Shukarev, Dirk Heerwegh, Carla Truyers, Anne M. de Groot, Jeroen Stoop, et al. 2021. “Interim Results of a Phase 1–2a Trial of Ad26.COV2.S Covid-19 Vaccine.” New England Journal of Medicine. https://doi.org/10.1056/nejmoa2034201.

 

“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.”