hidden

Civility in Scientific Debate

Disagreement, dissent, challenges to commonly held positions? Cool. Ad-hominum attacks, sexist language and images, name-calling? Not cool.

Critique and dissent can be eloquently expressed, and often they are. I have read thoughtful letters to the editor and received constructive, if painful, reviews of my work (side note: learn how to write constructive reviews!). There are well-established professional norms in these contexts. On social media, however, discourse is less measured and formal. A benefit of this democratization of publication means that ideas challenging power structures and status quo can propagate more easily, cross-pollination among disciplines flows naturally, and historically underrepresented voices can gain a wide audience. But a downside to this lack of gate-keeping is sometimes the deterioration of debate.

Scientists and clinicians use Twitter for education and conversation (for great examples, see #FOAMed— free open-access medical education). Many of us use the platform to communicate ideas and research findings to a wide audience, both other scientists and the public. Social media offers a channel to interact with people whose work you admire, too. It’s a great way to share your hard work, comment on debates, ask questions, and yes, disagree.

But Twitter isn’t without its downsides, one of which is immediacy: the second you hit publish, your words are out there, associated with your name. It’s too easy for something you dashed off in a fit of pique to come to represent your professional self. It’s also easy to forget that there are people behind the hashtags and handles: if you wouldn’t say something to a human in front of you, it’s likely not wise to tweet it, either— but the sense of anonymity encouraged by social media platforms can embolden some people. In combination, these factors can create conditions where bullying and other bad behavior, rather than reasoned debate, take over.

Take a recent online kerfuffle involving cardiology trainee Danielle Belardo, MD, and Jeff Nelson, who owns the website VegSource.com. Dr. Belardo recommends olive oil to her patients as part of a plant-based diet, and she shares this information on her social media channels. She bases her advice on scientific evidence and the recommendations of professional bodies such as the American College of Cardiology. There is plenty of conflicting evidence on dietary approaches to reduce risk of heart disease, and many disagree on the conclusions, including Nelson. Dietary patterns stir up lots of dissent, and that’s good. But rather than engage in conversation about the differing viewpoints on the science, Nelson posted an inflammatory meme including blatantly sexist imagery, in an apparent attempt to ridicule discredit Dr. Belardo. This behavior is, unfortunately, not unusual. People, especially women, who voice controversial ideas online are frequently subject to this kind of bullying and often to sustained harassment also. Outside of social media, a physician who promotes an evidence-based but controversial idea will likely have fans and detractors, but on twitter, she has trolls and bullies. Suddenly, rather than an intellectual back-and-forth focused on difference of opinion and evaluation of evidence, we have the digital equivalent of name-calling, schoolyard insults, and stalking.

This behavior isn’t only bad for the targets, it’s also bad for science. Unfortunately, incivility online can have a chilling effect of innovation and conversation. Afraid of triggering flame wars, some may hesitate to ask excellent probing questions. Afraid of trolls, some may hesitate to speak controversial truths. And fearing aggressive bullying, some (especially women, who are the targets of much egregious behavior) may resist speaking altogether. Diversity of methods, opinions, identities, and backgrounds should always be welcome in science, and it’s hugely detrimental to progress when brilliant people are silenced.

How can we promote civility and dissent, which are good for science? I don’t know that there’s an easy answer, but I will leave you with these words from social scientist Amy Cuddy, who has weathered her share of online incivility: “The only way to elevate the civility and quality of scientific debate is to radically depart from personal attacks and public shamings. We have to replace fear and indignation with excitement and curiosity. If there’s a genuine interest in understanding any complicated scientific phenomenon, there is a way forward. It requires openness, listening, trust, and collaboration.” (source: https://amycuddyblog.com/2017/11/29/civility-in-science-is-not-a-luxury-its-a-necessity/)

How can you contribute to openness, listening, trust, and collaboration?

#scicomm #supportwomen

 

“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.”

 

 

hidden

The Health Costs of Hunger

I hope someday we will be able to proclaim that we have banished hunger in the United States, and that we’ve been able to bring nutrition and health to the whole world. –Senator George McGovern

Food. Nothing is more basic to our existence than eating. However, in our modern era of plenty, we often take the presence of food for granted. That is, we take it for granted until we no longer have access to it or it makes us sick.

Food insecurity, when individuals lack access to adequate and safe food due to limited resources, is pervasive in the United States. In 2018, 37.2 million Americans were food insecure and of that, 6 million were children. A recent analysis found that 20-50% of college students were food insecure and hunger affects their ability to learn, be economically stable, and navigate social situations. While food insecurity tends to be higher in rural areas, it affects people of every gender, age, race and ethnicity throughout the United States.

The health consequences of food insecurity are well-described and have a disproportionate impact on cardiovascular health. In children, food insecurity is associated with birth defects, cognitive and behavioral problems, increased rates of asthma, depression, suicide ideation, and an increased risk of hospitalization.  In adults, food insecurity is linked to mental health problems, diabetes, high blood pressure, and high cholesterol. Food insecurity affects health in multiple ways (Figure 1). Conceived of as a cyclical process (in which people have periods fluctuating between food adequacy and inadequacy), fewer dietary options lead to increased consumption of cheap, energy dense, but nutritionally poor foods. Over-consumption of these foods during periods of food adequacy can lead to weight gain and high blood sugar, and reduced consumption of food during food shortages can lead to weight loss and low blood sugar. These cycles are exacerbated by stress and result in obesity, high blood pressure, and ultimately diabetes and coronary artery disease. The cycle continues until access to adequate, safe, high-nutrition foods stabilizes.

As a driver of poor nutritional intake, food insecurity is among the leading causes of chronic disease-related morbidity. As such, there is increasing recognition that for many food insecurity is not behavioral challenge but a structural one. Indeed this is the reason for the creation and continued re-authorization of the supplemental nutritional assistance program (or SNAP) that in 2018 provided $60.8 billion to more than 40 million Americans. SNAP was initially conceived during the Great Depression as a strategy to stave off mass starvation while providing American farmers with a fair price for their surplus agricultural products. It has gone through many legislative and administrative updates since the 1930’s (for a full history, please see Dr. Marion Nestle’s recent review in the American Journal of Public Health) and today remains the 3rd largest, and one of the most effective anti-hunger programs in the United States. Yet, despite its success at reducing food insecurity, today, proposals to reduce the monthly benefit levels and impose restrictions to limit access to SNAP are gaining political traction.  If the proposed SNAP reforms were enacted, 2.2 million American households would no longer be eligible for SNAP and an additional 3.1 million households would receive reduced benefits–many of those affected would be elderly and disabled. Thus, the cycle of food insecurity and chronic disease would worsen.

Food nourishes us and provides the sustenance we need to get through each day with our health, livelihood, and dignity intact.  While I have outlined the public health case for mitigating food insecurity; it is clear that food insecurity is not just a health issue, or even just a political issue. Above all else, it is a moral issue and one that we that we cannot be on the fence on. We must decide if today, in the richest country on the planet, at its most prosperous time in history, our friends, patients, and neighbors – men, women, and children who are just like us – should be hungry.

If your answer is no, then thankfully there is much that we can do about it. Check back for next month’s blog on strategies that health care providers, neighbors, citizens, and professional associations can do to help address food insecurity in America. In the meantime, please share your experiences addressing food insecurity in your own practice or community with me at @AllisonWebelPhD.

“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.”

 

hidden

Nutrition in the New Year: What is Our Role as Cardiologists?

As we embark on this new year, we are bound to field questions from our patients (and likely, family members) centered around the most popular new year’s resolution: Eating healthier. Reflecting upon my own answers to these questions in clinic over the years, I realize they have been some combination of:

“Eat smaller portions.” “Eat less meat.” “Cut out soda or juice.” “Don’t eat for 3 hours before going to bed.” “Have you heard of the Mediterranean diet?”

And the basis for my recommendations? While I’m sure my years of medical training were factored in somewhere, I feel like these suggestions were largely based on a combination of my own experiences with managing my nutrition, anecdotes from colleagues and friends, and quite possibly my favorite podcasts.

Upon further reflection, though, this is not all too surprising. For all the years that we spend in medical school, residency, and fellowship learning about pathophysiology and pharmacology, we receive much less structured education on nutrition.1 In four years of medical school, one study estimates that the average medical student receives approximately only 19 hours of didactic lectures in total on nutrition, with most of this education focusing on the manifestations of nutritional deficiencies (thiamine, vitamin C, etc.).2 If your recollection is like mine though, 19 hours seems like an overestimation, and it only declines in post-graduate medical training. In a recent study published in the American Journal of Medicine, 31% of cardiologists reported receiving no nutrition education in medical school, 59% reported none during residency, and 90% reported receiving no or minimal nutrition education during fellowship.3

Nutrition Education from Medical School to Fellowship. (From Devries et al.3)

Figure 1: Nutrition Education from Medical School to Fellowship. (From Devries et al.3)

“But we are cardiologists, not nutritionists,” one might say. Yet in the same study, 95% of cardiologists believed that their role is to provide their patients at least basic nutrition information (68.6% believed they should personally provide detailed nutrition information to patients).3 While many of our cardiovascular care teams include dieticians specifically trained to counsel our patients on their nutrition habits, we as cardiologists often find ourselves directly answering these questions from our patients.

Indeed, some physicians have made names for themselves by proselytizing specific diets for their patients. Yet what I find a bit unsettling is the variability of the messages we deliver to our patients when it comes to nutrition. While the AHA provides dietary recommendations we can share with our patients, new diets continue to pop up and gain traction in the headlines, inevitably leading to questions from our patients about whether it is safe for them to adhere to these diets. Notably, (1) intermittent fasting, (2) plant-based or vegan, and (3) ketogenic or “keto” appear to be the diets du jour.

While I personally have experimented with intermittent fasting and a plant-based diet, I am a bit uncomfortable fully endorsing one or the other to my patients, each with his or her own metabolic profile and potential list of glucose-lowering medications. When it comes to diet, more than anything, individualization is key. More so than exercise and medications, diet has deeper roots in the cultural, financial and societal environments in which our patients live. Helping them navigate a healthy lifestyle through these obstacles requires not only more time in clinic but also a deeper, more evidence-based foundation in cardiovascular nutrition.

Fortunately, we are entering an era in which we are gathering more evidence in nutrition science. A recent study published earlier this month in Cell Metabolism studied “time-restricted eating” (AKA intermittent fasting with a 10-hour eating window) in patients with metabolic syndrome,4 finding that it had beneficial effects on weight loss and metabolic profile in its albeit small sample size. (Figure 2) Additionally, a New England Journal of Medicine review article published over the holidays highlighted the existing evidence we have, both in animals and in humans, of intermittent fasting on health, longevity, and various disease states (including cardiovascular disease and cancer).5 Importantly, these recent publications and the responses they have elicited in the news and on social media have called attention to the need for more dedicated studies to address the safety and efficacy of specific diets and dietary patterns in our patients with metabolic and/or cardiovascular diseases. Indeed, more clinical trials are underway: a quick search on ClinicalTrials.gov shows that 24 registered clinical trials with an “intermittent fasting” intervention are actively recruiting participants, including the LIFE AS IF trial from the University of Chicago.

Graphical Abstract from Wilkinson et al study on Time-Restricted Eating in Metabolic Syndrome.4

Figure 2: Graphical Abstract from Wilkinson et al study on Time-Restricted Eating in Metabolic Syndrome.4

In a prior blog post on “Wearables in Medicine,” I recommended that we consider trialing wearable devices ourselves before counseling patients based on data obtained from them. While I do think our own experiences with diets and dietary patterns may be informative, our personal experiences should not be the sole pillar upon which we base our nutritional recommendations to our patients. Again, individualization is key, and a nuanced approach, factoring in living environments, medications, and metabolic profiles, is necessary.

So what should we do as members of cardiovascular care teams? Well, to provide basic nutrition recommendations to our patients, we can use the AHA Diet & Lifestyle Recommendations. However, we must acknowledge our own limitations regarding the lack of formal training on nutrition during our medical education. As such, my resolution this year is to further my education on nutritional science and attempt to understand how these popular diets may fit within modern cardiovascular disease management. To achieve these goals, I will:

  • Read: Some books recommended by my attendings that I plan to read include The Obesity Code by Jason Fung, MD and The Plant Paradox by Steven Gundry, MD. Additionally, for those interested in learning more about the role of a “keto” diet in cardiology, the ACC.org Sports and Exercise Cardiology section recently published a series of high-yield, informative articles (Link 1 and Link 2).
  • Collaborate: We have a dietician in our cardiovascular care team with whom I regrettably had not spoken directly with until recently. I previously had just referred patients to her, but I did not necessarily know exactly what advice she was giving to our shared patients. Opening and maintaining this channel of communication is essential to delivering a consistent message from our team.
  • Ask: I am now making it a habit to include a simple question in my clinic encounters: “How’s your diet?” I have found the open-endedness of the question to be quite enlightening, often helping me to uncover a new aspect of the world my patient lives in and their own perspective on how their nutrition impacts their health.

I would love to hear your input on this topic. What do you feel our roles are in nutrition counseling for our patients? What are reliable resources to learn more about this topic? How can we be better at delivering appropriate nutrition information to our patients? Please reach out to me on Twitter (@JeffHsuMD) with your thoughts and ideas.

References:

  1. Devries S, Willett W, Bonow RO. Nutrition Education in Medical School, Residency Training, and Practice. JAMA. 2019;321:1351–1352.
  2. Adams KM, Butsch WS, Kohlmeier M. The State of Nutrition Education at US Medical Schools. Journal of Biomedical Education. 2015;2015:357627.
  3. Devries S, Agatston A, Aggarwal M, Aspry KE, Esselstyn CB, Kris-Etherton P, Miller M, O’Keefe JH, Ros E, Rzeszut AK, White BA, Williams KA, Freeman AM. A Deficiency of Nutrition Education and Practice in Cardiology. Am J Med. 2017;130:1298–1305.
  4. Wilkinson MJ, Manoogian ENC, Zadourian A, Lo H, Fakhouri S, Shoghi A, Wang X, Fleischer JG, Navlakha S, Panda S, Taub PR. Ten-Hour Time-Restricted Eating Reduces Weight, Blood Pressure, and Atherogenic Lipids in Patients with Metabolic Syndrome. Cell Metab. 2020;31:92-104.e5.
  5. de Cabo R, Mattson MP. Effects of Intermittent Fasting on Health, Aging, and Disease. N Engl J Med. 2019;381:2541–2551.

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.

 

 

hidden

To Stent or not to Stent?

In the wake of the ISCHEMIA trial results being published, and the media firestorm that ensued, I’ve run into some interesting scenarios, including STEMI patients saying they don’t want to be revascularized because they heard on the news that stents are useless (oh boy!). However, after a robust discussion with an intern, I decided to do a quick n dirty rundown of who does and does not need immediate revascularization, and which strategy to go with.

If there’s one thing you should know about the ISCHEMIA trial, it is that this study sought to answer the question of whether or not STABLE ischemic heart disease would benefit from an aggressive revascularization strategy vs a conservative strategy of goal-directed medical therapy. This had nothing to do with patients who had ACS. I will also add that with long-term followup, the results might change, nobody knows for certain. The reason I say this is because the PCI arm had a signal towards harm in the first 6 months after revascularization, but as they approached 4 years, the mortality curves started to separate in favor of the aggressive revascularization arm. As it stands, their conclusions were not in favor of an aggressive strategy over a conservative one. Interestingly, these results didn’t differ very much from the COURAGE trial, where they found no significant difference between optimal medical therapy vs PCI for stable ischemic heart disease. Differences to note include the fact that COURAGE did NOT use FFR, and did not have routine use of DES.

Keep in mind, patients with left main stenosis > 50% were excluded from both of these trials, as were those who had recent revascularization within the past 6 to 12 months (PCI or CABG). The reason I mention this is because some people thought these results contradicted the findings of the COMPLETE trials – but no, these trials looked at different sets of patients altogether!

A few big wins for the ISCHEMIA trial:

  • CT-angiography was shown to be very reliable
  • FFR-guided PCI is becoming more routinely accepted as the preferred method of PCI
  • Optimal medical therapy really helps…even if there turns out to be a mortality benefit in favor of early-PCI, the fact that it takes several years to emerge is a statement about how helpful these medications truly are.

 

With regards to stable ischemic heart disease, clear indications for revascularization include left main stenosis > 50%, proximal LAD with >50% stenosis, or multi-vessel disease with signs of impaired ventricular function. Typically, cardiologists will employ the SYNTAX score, which is a validated system used to grade the severity and complexity of lesions. Typically, SYNTAX scores < 23 are amenable to PCI and non-inferior to CABG. The typical scenario for PCI is when you have isolated disease in only 1 or 2 vessels, and this is amenable to stenting.

Once you have significant left main disease, especially in conjunction with 2-3 vessel disease, the SYNTAX score is > 32, and CABG is superior.

Until very recently, it was generally accepted that isolated left main disease could be treated by PCI or CABG. However, some controversy has erupted recently after the results of the EXCEL trial were published. Specifically, the EXCEL trial had a composite endpoint of stroke, MI, or death, and there was no statistically significant differences between the two groups. Surgeons will tell you that the higher rates of the composite endpoint were driven by excess all-cause mortality in the PCI arm, as compared to peri-procedural MI in the CABG arm…in other words, while the composite endpoints were similar in both groups, the individual endpoint of mortality was higher with PCI, whereas peri-procedural MI was higher with CABG. This can certainly be a bit contentious, especially if you wonder what the clinical significance of a troponin elevation is after CABG. Nonetheless, the trial was powered to detect differences in the COMPOSITE endpoint, not in the individual endpoint of mortality.

The STICH trial demonstrated a significant benefit (albeit 10 years out) in favor of revascularization (this study only looked at CABG) for patients with ischemic heart failure. The FREEDOM trial took it one step further and tried to compare DES to CABG for mutli-vessel CAD in diabetics. The findings were strongly in favor of CABG over PCI, and this has become the accepted paradigm.

 

When you’re not sure, if they have funky looking anatomy AND they’re diabetic, you can make a safe gamble and ask your attending if they think this patient is a CABG candidate. 9 times out of 10, you’ll look like a genius.

In Conclusion:Stable ischemic heart disease has some controversy surrounding the role of revascularization, but ALL patients should be on optimal medical therapy

Patients with significantly reduced EF, Left main, proximal LAD disease, all should warrant a closer look at whether or not they would benefit from revascularization

Always try to involve a multi-disciplinary team when thinking about revascularization, at the end of the day, we are in the business of do no harm, so a second set of eyes can be beneficial.

 

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:

https://www.ischemiatrial.org/

Boden, W. E., O’rourke, R. A., Teo, K. K., Hartigan, P. M., Maron, D. J., Kostuk, W. J., … & Chaitman, B. R. (2007). Title LM, Gau G, Blaustein AS, Booth DC, Bates ER, Spertus JA, Berman DS, Mancini GB, Weintraub WS; COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med356(15), 1503-16.

Campos, C. M., van Klaveren, D., Farooq, V., Simonton, C. A., Kappetein, A. P., Sabik III, J. F., … & Serruys, P. W. (2015). Long-term forecasting and comparison of mortality in the Evaluation of the Xience Everolimus Eluting Stent vs. Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial: prospective validation of the SYNTAX Score II. European heart journal36(20), 1231-1241.

Stone, G. W., Kappetein, A. P., Sabik, J. F., Pocock, S. J., Morice, M. C., Puskas, J., … & Banning, A. (2019). Five-year outcomes after PCI or CABG for left main coronary disease. New England Journal of Medicine381(19), 1820

hidden

Can artificial intelligence save our lives?

The role of artificial intelligence (AI) in our life is advancing rapidly and is making strides in the early detection of diseases. The consumer market is composed of wearable health devices that enables continuous ambulatory monitoring of vital signs during daily life (at rest or physical activity), or in a clinical environment with the advantage of minimizing interference with normal human activities1. These devices can record a wide spectrum of vital signs, including: heart rate and rhythm, blood pressure, respiratory rate, blood oxygen saturation, blood glucose, skin perspiration, body temperature, in addition to motion evaluation. However, there is a lot of controversies whether these health devices are reliable and secure tools for early detection of arrhythmia in the general population2.

Atrial fibrillation (afib) is the most common arrhythmia currently affecting over 5 million individuals in the US and it’s expected to reach almost 15 million people by 2050. Afib is associated with an increased risk of stroke, heart failure, mortality, and represents a growing economic burden3. Afib represents a diagnostic challenge, it is often asymptomatic and is often diagnosed when a stroke occurs. Afib represents also a long term challenge and often involves hospitalization for cardioversion, cardiac ablation, trans-esophageal echo, anti-arrhythmic treatment, and permanent pacemaker placement. However, if afib is detected, the risk of stroke can be reduced by 75% with proper medical management and treatment3.

Physicians need fast and accurate technologies to detect cardiac events and assess the efficacy of treatment. A reliable, convenient and cost-effective tool for non-invasive afib detection is desirable. Several studies assessed the efficacy and feasibility of wearable technologies in detecting arrhythmias. The Cleveland Clinic conducted a clinical research where 50 healthy volunteers were enrolled. They tested 5 different wearable heart rate monitors including: (Apple Watch, Garmin Forerunner, TomTom Spark Cardio, and a chest monitor) across different types and intensities of exercises (treadmill, stationary bike and elliptical). The study found that the chest strap monitor was the most accurate in tracking the heart rate across different types and intensities of exercises4.

Apple and Stanford’s Apple Heart Study enrolled more than 419,297 Apple Watch and iPhone owners. Among these users, 2,161 (roughly 0.5%) received a notification of an irregular pulse. Of those who received the notifications, only about 450 participants scheduled a telemedicine consultation and returned a BioTelemetry ECG monitoring patch. When the Apple Watch notification and ECG patch were compared simultaneously, researchers found 71% positive predictive value, and about 84% of the cases were experiencing Afib at the time of the alert. Additionally, 34% of participants whose initial notification prompted an ECG patch delivery were later diagnosed with Afib. This finding shows that Apple watch detected afib in about one-third of the cases which is “good” for a screening tool considering the “intermittent nature of afib and that it may not occur for a whole week” says Dr. Christopher Granger, a professor of medicine at Duke University who participated on the steering committee for the Apple Heart study5.

These studies are observational studies and are not outcome-driven. They are not randomized and are not placebo-controlled. There are potentials for false negatives, where the Apple watch fails to detect the afib and false-positive where it detects arrhythmia that does not exist. Unfortunately, patients who are false negative don’t consult the physician about their symptoms of palpitations and shortness of breath since it provides false security. While patients with false-positive are sent unnecessarily to the clinic that could lead to further unnecessary tests and anxiety for the patient.

Is the Apple Watch ready to be used as a default screening tool to monitor the heart rate and rhythm in the general population and by physicians with patients with or at high risk for Afib is still unclear and warrant further studies. In conclusion, physicians should be cautious when using data from consumer devices to treat and diagnose patients.

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:

  1. Cheung, Christopher C., Krahn, Andrew D., Andrade, Jason G. The Emerging Role of Wearable Technologies in Detection of Arrhythmia. Canadian Journal of Cardiology. 2018;34(8):1083-1087. doi:10.1016/j.cjca.2018.05.003
  2. Dias D, Paulo Silva Cunha J. Wearable Health Devices-Vital Sign Monitoring, Systems and Technologies. Sensors (Basel). 2018;18(8):2414. Published 2018 Jul 25. doi:10.3390/s18082414
  3. Chugh, S., Sumeet, Havmoeller, J., Rasmus, Narayanan, F., Kumar, et al. Worldwide Epidemiology of Atrial Fibrillation: A Global Burden of Disease 2010 Study. Circulation. 2014;129(8):837-847. doi:10.1161/CIRCULATIONAHA.113.005119
  4. Wrist-Worn Heart Rate Monitors Less Accurate Than Standard Chest Strap. Medical Design Technology. http://search.proquest.com/docview/1875621494/. Published March 9, 2017.
  5. Turakhia, Mintu P., Desai, Manisha, Hedlin, Haley, et al. Rationale and design of a large-scale, app-based study to identify cardiac arrhythmias using a smartwatch: The Apple Heart Study. American Heart Journal. 2019;207:66-75. doi:10.1016/j.ahj.2018.09.002

 

 

hidden

What Does Tobacco 21 Mean for Adolescent Tobacco Use?

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:

  1. 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
  2. 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
  3. 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
  4. 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
  5. The Prize in Economic Sciences 2019. https://www.nobelprize.org/prizes/economic-sciences/2019/press-release/
hidden

Building an academic portfolio during medical training: Part 1 – research outside the box

As a medical trainee in the US, whether you are pursuing an academic career or applying for a fellowship or advanced fellowship, your academic profile is one of the most important currencies you rely on for this endeavor. Academia as a general term refers to 2 main areas: research and education. Many trainees, like myself, start their residency with no or very minimal research experience. It then becomes essential to create a reasonable research portfolio during medical training, which is often not an easy task, especially in clinically demanding specialties. In this series of blogs, I will try to share some ideas and tips that can help you build a competitive research résumé during residency and fellowship. These ideas also apply to medical students, inside or outside the US, who are trying to match their dream US residency program.

The first idea that I would like to talk about is one that I thought was particularly a game changer for me when it comes to research. I like to call this one “research outside the box”, and by the box here, in addition to the abstract meaning of doing things in unorthodox ways, I’m also referring to the literal box that is the walls of your training institution. Residents and fellows are rarely involved in multicenter clinical trials or prospective studies. In fact, the vast majority of research done during medical training is retrospective observational studies. One of the main reasons trainees rely on retrospective studies is the time factor. Prospective studies often take longer to execute, and it becomes difficult to get a tangible product, a conference abstract, or a published manuscript on time for your next fellowship or job application. Therefore, retrospective studies become the more realistic option, and traditionally, these are carried out using institutional databases (i.e. clinical data from patients treated at your own training hospital), which is and will remain one of the most valuable research resources. Then comes the fundamental question – why should I consider doing research in a non-traditional way, or “outside the box”? – For many reasons:

  • Many training hospitals do not have large clinical databases that can produce impactful research projects.
  • You may not find a good research mentor in your training institution.
  • Even with available databases and good research mentors, some retrospective studies may still take long to come to fruition, sometimes longer than you can afford without a back-up plan.
  • Diversifying the ways you do research by pursuing both traditional and non-traditional means, can lead to a marked increase in productivity.
  • Most importantly, collaborating with motivated medical students, residents, and fellows around the country (and sometimes even around the globe), not only enhances your research output but is in itself a great learning and networking opportunity.

The next logical question would be – as a student or a trainee, what type of research can I do outside my institution?

For the same practical reasons that I previously mentioned, I am still referring to retrospective observational research rather than multicenter trials or prospective studies. In that case, to be able to easily collaborate with researchers across different institutions the data has to be publicly available and not protected by privacy laws. There are different types of publicly available data, some are mostly free, such as already published literature, some can be purchased for a fee, such as national and state administrative databases, and others require a research proposal that goes through a grant-like process, such as societal databases. The latter typically requires a higher degree of research expertise and are restricted by application cycles, so I would not recommend them as the first go-to option if you are still taking your very first steps in medical research. Here are some examples of observational research work that can be done collaboratively using these publicly available data sources, without being limited by institutional boundaries:

  • Published medical literature can be used for meta-analyses and systematic reviews. These types of studies commonly address hot topics in medicine or topics with controversy or equipoise. A common scenario where topics are considered “hot” is immediately after the publication of a large clinical trial, particularly if the results are not in line with prior trials on the topic. Meta-analyses are also ideal for examining uncommon side effects or complications of medications or medical procedures.
  • National administrative databases can be used to perform retrospective observational studies, e.g. the National Inpatient Sample (NIS) and the Nationwide Readmissions Database (NRD), which are commonly used in cardiovascular research. They are particularly helpful in researching rare conditions or special populations where getting a large sample size using single-center data is challenging, or to examine trends in diseases or therapies over time. Most of these databases are available for purchase per calendar year (e.g. 2010, 2011, 2012 etc.), meaning that you can buy one or more year worth of data, depending on your budget and your research question.
  • Societal databases can also be used for original outcomes and quality improvement research, e.g. the American Heart Association (AHA) Get With The Guidelines and the American College of Cardiology (ACC) National Cardiovascular Data Registry (NCDR) Although these do not cost money, yet, they mostly require more work including submission of a proposal during an annual or bi-annual application cycle, which is a very competitive process.

These are just examples of what can be done and some common resources that can be used to start with, but in reality, the possibilities and the available resources are endless. Now that we talked about “why” and “what”, the next question is “how” – how to reach potential collaborators? how to build a successful multi-institutional team of young researchers? And what are the challenges to this approach? This will be the topic of my next monthly AHA Early Career Voice blog. 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.

hidden

A Paycheck Away: Financial Fitness in Medicine Part I

Piggy bank with bandages

(source: flickr/teegardin)

Picture this. You’re an established cardiologist practicing in the city of your dreams. You have the car, the house, the second car, the country club membership, and a few luxury items in your wardrobe. Life is good. But it throws you a curveball, as it has the tendency to. You injure yourself while skiing in Aspen, and after a few painful operations, have to complete an intense rehabilitation program before returning to work. Can you afford to take a month off? How about two weeks?

A recent survey found that 69% of Americans have less than $1000 in savings, and one in three have $0 saved for retirement. I know what you may be thinking – these data primarily represent lower-income households. True. But that same survey found that 23% of respondents making greater than $150,000 had less than $1000 in emergency funds (6% had nothing set aside). A 2015 Nielsen study found that 25% of Americans earning more than $150,000 per year lived paycheck to paycheck. Couple that with this story of a physician-physician couple with a household income of $750,000 but a net worth of $0. This is the plight of many high earning but not rich yet Americans (or HENRYs as they’re referred to in financial circles).

How can you prevent yourself from becoming a perpetual HENRY? How can you break the Work = Income redundancy? If you’re reading this, it’s now. And it begins with changing your mindset towards money/finances. We, as physicians weren’t exposed to much of the finance world as we spent our income-free 20s buried in textbooks and Prometric centers. In fact, many of us resent money, we ignore money and whenever someone talks too much about money it makes us cringe (re: contract negotiations). Then, we received a few short years of lower-middle-class income before being thrust into the top 1% of earners. Like a first-round draft pick, we rush to the local dealerships and realtors with our big smiles and our big checks ready to make up for the lost time.

This is precisely the moment, in the first three to five years of being an attending, that we set our financial trajectory. Here are a few tips that I’ve gathered from people much smarter than I to hopefully help you set your trajectory high.

  • Don’t fall for bad advice

Most physicians don’t know much about personal finance, and an advisor is a great idea if that’s your situation. However, choose your advisor like you to choose your barber. Don’t just jump at the first offer. Do your research, ask your attendings, ask financially responsible friends/family. And don’t be afraid to do it yourself! Here are a few sources to check out: WhiteCoatInvestor podcast, Valuetainment on youtube, RyanScribner on youtube

  • Live like a resident initially

It’s easier said than done but hold off on buying that house or that car for the first few months or years. This allows you to pay off debt, improve your credit, save/invest and settle into your new income. If you have student loans, it also allows you to refinance them and determine what your new payment structure will be. Some rules of thumb for early spending: do not spend more than 15-20% of your annual income on a car, 20% goes to savings & investments, set up an emergency fund 2-5%, give to charity (variable). Check out this Charles Schwab survey on why people live paycheck to paycheck; the responses might surprise you.

  • Retirement is closer than you think

It’s not too early to start planning for retirement. Many physicians work well into their 70s and 80s due to the reliance on an income to maintain their lifestyle. Do a simple calculation now. How much per year of income would you need to live comfortably? Multiply that by 25. That is the amount of money you need to have for retirement by age 65. Check out this tale of two doctors for more.

It’s important for physicians to tend to our financial fitness as we tend to our physical fitness. Just like everything in life, practice makes perfect. Try saving 20% of your resident/fellow salary this month. Practice trading stocks using a simulator like Investopedia’s. If you’re going to be an attending in July 2020, plan out how the rest of the year looks for you financially, so it won’t be such a surprise when you get there. I hope this post was informative and even a little entertaining. Please look out for more on this topic in the future.

Back to your regularly scheduled programming…

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 (embedded links):

https://content.schwab.com/web/retail/public/about-schwab/Charles-Schwab-2019-Modern-Wealth-Survey-findings-0519-9JBP.pdf

https://www.fa-mag.com/news/nielsen–even-many-high-earners-live-paycheck-to-paycheck-22704.html

https://drcorysfawcett.com/success-is-not-measured-by-income/

https://thephysicianphilosopher.com/tale-of-two-doctors/

hidden

We Need to Be Better About Recognizing Sudden Cardiac Arrest

“10-year-old dies of an apparent heart attack on Delta flight,” “High School Football Player Dies Suddenly,” “Teen Dies on the Court,”— these stories shock the community, cause people to ask questions, and are too soon forgotten. We need to be better about recognizing cardiac arrest in the young, and that starts with better cardiac arrest education. Many people do not realize the difference between cardiac arrest and myocardial infarction or “heart attack.” While a heart attack is often preceded by chest pain and other symptoms, cardiac arrest is usually not.

Sudden Cardiac Arrest (SCA) is a life-threatening emergency that occurs when the heart suddenly stops beating; 1 this can be due to a structural abnormality of the heart, a rhythm disturbance, or often an unknown cause.2 A heart attack usually has a different cause, occurring when the supply of blood to the heart becomes blocked, typically by a plaque or blood clot in an artery.3

Sudden Cardiac Death (SCD) is the leading cause of death in athletes during a sport.4 Delay in recognition leads to a rapid decline in survival, with a decline of survival by 10% for every 1-minute defibrillation is delayed.5 Studies show that survival can be improved if AED is applied and used within 3-5 minutes of arrest. Schools with on-site AED demonstrate survival from SCA as high as 71%.4 However, in order for proper AED use to occur the arrest must be recognized quickly.

What makes it hard to recognize sudden cardiac arrest?

  • Lack of Education on the subject— SCA is not on peoples’ radar for the young patient. Our brains are programmed to think about heart attacks involving older people clenching their chest, sweating, proclaiming pain, and not about SCA, which is much more silent. Anyone who suddenly collapses and is non-responsive to verbal stimuli should be treated as a sudden cardiac arrest until proven otherwise.5
  • SCA may present with seizure-like activity; in as many as 20% of SCA events, there will be myoclonic jerking activity such as shaking, quivering, or twitching.5 This activity may lead to observers mistaking the arrest for a seizure and not applying the right emergency protocol.
  • A victim of SCA may still be “breathing”; Agonal respirations/gasping appear like chest and abdominal movement. These breaths can be mistaken for breathing, but are ineffective to sustain life.4
  • Lack of AED’s or access to AED’s and Emergency Action Plans (EAP); some schools may not have AED’s, or they are locked after hours in an office or locations far from the athletic venue. Surveys have demonstrated that low socioeconomic status, schools with primarily black race, and rural schools are the most common barriers to AED use.6

Recently, the Parent Heart Watch has started a campaign to make the use of AED’s easier and to educate the public on their use with the campaign Call, Push, Shock. In addition, Dr. Jonathan Drezner and the NFL to educate the public on recognizing sudden cardiac arrest (Recognize, React, Rescue). These resources are helpful in sending a unified message to the public, providers and to everyone involved to help save lives.

What can we do to improve?

  • Early recognition and emergency activation – Suspect SCA in any collapsed or unresponsive athlete/person and call 911 immediately.
  • Access to early defibrillation – the goal is less than 3-5 minutes until the first shock.
  • Provide high-quality CPR and early access to advanced life support/EMS – Currently, the average time of EMS arrival is 6.1 minutes and can be longer in some communities.4 The more people trained and educated to start CPR while awaiting EMS, the better the outcomes.
  • Make sure all venues have EAP’s that encompass the above and more. An EAP should be established at any athletic venue and should be specific to the athletic venue. An effective EAP should encompass emergency communication (working with local EMS and having a detailed location/address of the venues available, including directions to access points from major roads), personnel, and equipment. They should be reviewed and practiced annually to ensure they work with mock SCA scenarios.
  • Continue to push for legislation to enforce the use of AED’s in schools. As of 2017, only 17 states required AED installation in schools, and only 5 of these offered funding for AED equipment.7

Want to learn more? Check out the Call, Push, Shock page to explore the mission and find local organizations— chances are there is a passionate person in your state or city who has been directly affected by SCA and could use your support and help!

 

Sources:

  1. “You Can Save A Life from Sudden Cardiac Arrest.” Call, callpushshock.org/.
  2. Harmon, Kimberly G. “Incidence and Etiology of Sudden Cardiac Death in Athletes.” IOC Manual of Sports Cardiology, 2016, pp. 63–73., doi:10.1002/9781119046899.ch7.
  3. “Heart Attack.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 30 May 2018, www.mayoclinic.org/diseases-conditions/heart-attack/symptoms-causes/syc-20373106.
  4. Toresdahl, Brett, et al. “Emergency Cardiac Care in the Athletic Setting: from Schools to the Olympics.” British Journal of Sports Medicine, vol. 46, no. Suppl 1, 2012, pp. i85–i89., doi:10.1136/bjsports-2012-091447.
  5. Drezner, Jonathan A., et al. “Inter Association Task Force Recommendations on Emergency Preparedness and Management of Sudden Cardiac Arrest in High School and College Athletic Programs: A Consensus Statement.” Prehospital Emergency Care, vol. 11, no. 3, 2007, pp. 253–271., doi: 10.1080/10903120701204839.Soun ds
  6. Saberian, Sepehr, et al. “Disparities Regarding Inadequate Automated External Defibrillator Training and Potential Barriers to Successful Cardiac Resuscitation in Public School Systems.” The American Journal of Cardiology, vol. 122, no. 9, 2018, pp. 1565–1569., doi:10.1016/j.amjcard.2018.07.015.
  7. Lou, Nicole. “Few States Require AEDs in Schools.” Medical News and Free CME Online, MedpageToday, 27 Mar. 2017, www.medpagetoday.com/cardiology/arrhythmias/64159.

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.

hidden

ECPR: What is it? And what do we know in 2020?

Despite advances in the resuscitation field, cardiac arrest, especially cardiac arrest in the setting of cardiogenic shock, continues to carry significant morbidity and mortality. This topic continues to challenge healthcare providers on ways to improve outcomes in patients with refractory cardiac arrest. Extra-Corporeal Membrane Oxygenation (ECMO) is a type of mechanical circulatory support device utilized for various conditions, including cardiogenic shock and multi-organ failure. I heard about ECPR recently, so I wanted to share what is out there, and potentially motivate colleagues and professionals to share their thoughts on this important topic.

What is ECPR?

ECPR (Extra-corporeal Cardio-Pulmonary Resuscitation) is the implementation of ECMO in selected patients with cardiac arrest, and may be considered when conventional CPR efforts fail in a setting with expeditious implementation and support.by skilled providers When/where does ECMO cannulation occur in these patients?

Patients with cardiac arrest and ongoing CPR are transported to the hospital while ongoing resuscitation efforts are being taken. ECMO potentially provides the circulatory and respiratory support these sick patients need until reversible conditions are addressed. ECMO cannulation usually occurs at the healthcare center, where skilled personnel and healthcare providers have expertise in ECMO. Figure 1 shows a simple illustration veno-arterial VA-ECMO utilized in ECPR.

Figure 1: Simple schematic illustration of veno-arterial VA-ECMO utilized in EPCR.

Figure 1: Simple schematic illustration of veno-arterial VA-ECMO utilized in EPCR.

What is the scientific evidence for the use of ECPR?

Unfortunately, there are no randomized controlled trials (RCTs) on the use of ECPR in cardiac arrest patients at this time. The evidence supporting ECPR comes from observational studies in the past two decades, in patients with out-of-hospital cardiac arrest, and studies looking at ECPR in in-hospital cardiac arrest. Many, but not all, of the observational studies showed overall favorable neurological outcomes in those who receive ECPR compared to conventional CPR. It is important to note, however, that these studies had variable inclusion criteria, and potential risk for confounding bias, making their validity and generalizability questionable.

Are there any AHA guidelines supporting the use of ECPR?

AHA 2019 Guidelines Updates:

Recommendations—Updated 2019

  • There is insufficient evidence to recommend the routine use of ECPR for patients with cardiac arrest.
  • ECPR may be considered for selected patients as rescue therapy when conventional CPR efforts are failing in settings in which it can be expeditiously implemented and supported by skilled providers (Class 2b; Level of Evidence C-LD).

Why is this important?

Some studies in the past 2 decades have shown that ECPR might be associated with favorable neurological outcomes compared to conventional CPR. It is known that neurological outcomes in cardiac arrest patients have a significant effect on morbidity and mortality. As such, although these are observational studies with limited evidence, they shed light on a potential therapy that could lead to better outcomes in this very sick population. Future studies, including RCTs, are much needed to assess the outcomes of ECPR and identify patients who would benefit the most from this potential therapy.

I would like to say special thank you to my friend and colleague, Dr Khaldia Khaled, for her help on this blog.

Reference

Panchal et al: 2019 American Heart Association Focused Update on Advanced Cardiovascular Life Support: Use of Advanced Airways, Vasopressors, and Extracorporeal Cardiopulmonary Resuscitation During Cardiac Arrest: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2019;140:e881–e894. DOI: 10.1161/CIR.0000000000000732.

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.