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The darkness before the dawn–Long COVID is lurking around

Huan Wang, PhD

As we are starting to live with the facts that COVID-19 is not leaving us any time soon, sense of danger and urgency start to fade away. More than two years have passed, we have made great strides in combating the pandemics. With advanced technologies, vaccine and antiviral drug developments provide us potential means out of this seemingly never-ending battle. Viruses constantly change through mutation. While Delta variant is phasing out, Omicron variant begins its domination globally. Current research suggest that Omicron variant is less deadly compared to the Delta variant, especially to fully vaccinated people. However, the high spread rate of Omicron variant is a major concern to the public.

 

Some of us may wonder, it might not be a big deal. Since most evidence suggest that the symptoms of fully vaccinated patients are rather minor, especially the chance of suffering severe symptoms if you had a booster shot is even less. After a few days discomfort, you might end up obtaining better immunity after building up antibodies through infection. It might be partially true to some people. However, some unlucky ones continue to suffer from post-COVID conditions even after four or more weeks. These post-COVID conditions are also known as long COVID, long-haul COVID, post-acute COVID, long-term effects of COVID, or chronic COVID.

 

What is long COVID?

According to the US Centers for Disease Control and Prevention (CDC), long COVID describes the condition as sequelae that extend beyond four weeks after initial infection1. The timeline of post-acute COVID-19 shows as Fig1. The list of common symptoms of post-COVID conditions is growing. Symptoms which people commonly report include difficulty breathing, fatigue, brain fog, cough, chest/stomach pain, headache, heart palpitations, muscle pain, diarrhea, sleep problems, fever, lightheadedness, rash, mood changes, changes in smell or taste, and changes in menstrual period cycles2,3. The challenges of diagnosing long COVID are multiple layers. The social isolation resulting from pandemic prevention measures can cause mental health stress such as depression, anxiety, and mood changes. Complications of pre-existing conditions may unmask after COVID infections. Reinfection of COVID could be mistaken as persistent symptoms. Multiple organs are reported being the victims of SARS-CoV-2 infection, for example, lungs, heart, brain, kidney, spleen, liver and the cardiovascular systems4 (Fig2). Some people have severe illness with COVID experience combinations of multiorgan effects or autoimmune conditions with symptoms lasting for weeks or months after initial infection. Long COVID is a serious concern. We just begin to understand it, and the path to be able to treat it with ease is winding.

Various guidelines have been established focus on treating and managing COVID5,6 and long COVID7. While the guidelines will undoubtedly improve as new evidence comes to light. The etiology, mechanism, and consequences of COVID and long COVID remain elusive currently. Large epidemiology studies are undergoing to help us understand mechanisms and develop targeted treatments. American Heart Association just establishes a new funding program to invite more researchers to study the mechanisms underlying cardiovascular consequences associated with COVID-19 and long COVID in January 2022. Scientific communities are racing to understand COVID and long COVID.

 

The COVID pandemics is a serious public crisis. Although the situation may seem be getting better, healthcare staff shortages caused by pervasive Omicron variant infections and the lack of rapid COVID tests are posing imminent danger to the public healthcare system. Moreover, the effects of long COVID vary person by person, it’s better to stay vigilant and not get infected than taking it callously and passing it to vulnerable people unintentionally.

 

REFERECE

  1. Datta SD, Talwar A, Lee JT. A Proposed Framework and Timeline of the Spectrum of Disease Due to SARS-CoV-2 Infection: Illness Beyond Acute Infection and Public Health Implications. JAMA. 2020;324(22):2251–2252.
  2. Al-Aly Z, Xie Y, Bowe B. High-dimensional characterization of post-acute sequelae of COVID-19. Nature. 2021;594(7862):259–264.
  3. Nalbandian A, Sehgal K, Gupta A, Madhavan M V, McGroder C, Stevens JS, Cook JR, Nordvig AS, Shalev D, Sehrawat TS, Ahluwalia N, Bikdeli B, Dietz D, Der-Nigoghossian C, Liyanage-Don N, et al. Post-acute COVID-19 syndrome. Nature Medicine. 2021;27(4):601–615.
  4. Crook H, Raza S, Nowell J, Young M, Edison P. Long covid–mechanisms, risk factors, and management. BMJ. 2021;374.
  5. World Health Organization. COVID-19 clinical management: living guidance. 2021. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
  6. National Institute of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2021. https://www.covid19treatmentguidelines.nih.gov/
  7. National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing the long-term effects of COVID-19 NICE guideline; c2020. https://www.nice.org.uk/guidance/ng188

 

 

 
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Moyamoya Disease

Moss Zhao, PhD

Moyamoya disease is a progressive cerebrovascular disorder that often begins during childhood. Patients with Moyamoya disease have injuries in their blood vessels at the base of the brain. The term ‘moyamoya’ comes from Japanese and means ‘puff of smoke’, which describes the appearance of abnormal blood vessels. Symptoms of Moyamoya disease include acute strokes, transient ischemic attacks (TIA), blurred vision, and weakness of one side of the body. Some researchers believe that Moyamoya disease is the result of inherited genetic disorders because individuals with Moyamoya often have close relatives who are also affected.

If the disease is not treated properly, patients will suffer from mental decline and recurrent strokes due to insufficient blood supply caused by moyamoya vessels in the brain. In severe cases, Moyamoya disease can cause death and life-long disabilities. The primary goal of treatment is to reduce the risk of strokes using medical and/or surgical interventions. In mild cases, medications are effective to prevent acute or recurrent strokes. In more severe cases, revascularization surgeries can restore normal blood flow bypassing affected blood vessels.

Imaging exams (such as CT or MRI) are often performed to diagnose Moyamoya disease and identify the location of the affected blood vessels. The most widely used techniques include CT perfusion, digital subtraction angiography, and MR angiography. In recent years, more advanced techniques such as arterial spin labeling have been employed to evaluate the blood flow and circulation without radiation or contrast agents.

AHA has been a pioneer in providing support for Moyamoya patients and funding research on this disease. I am honored to be supported by AHA to develop advanced imaging technologies to identify Moyamoya patients with a higher risk of stroke.

A recent story of a patient recovering from Moyamoya disease was covered by the AHA news:

https://www.heart.org/en/news/2019/03/27/after-4-strokes-rare-disease-and-brain-surgery-woman-helps-others

Image source: Moyamoya Foundation

 

References:

https://www.ninds.nih.gov/Disorders/All-Disorders/Moyamoya-Disease-Information-Page

https://stanfordhealthcare.org/medical-clinics/moyamoya-center.html

https://moyamoya-foundation.org/inspiration

 

“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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Elevated Lipoprotein A, are we ready to intervene?

Reza Mohebi, MD

Lipid abnormalities can be classified into four clinical groups:1) elevated triglycerides, 2) low high-density lipoprotein cholesterol (HDL-C),3) elevated low-density lipoprotein cholesterol (LDL-C), and 4) elevated lipoprotein A.  Lipoprotein A disorder has been the least lipid abnormality studied from a clinical standpoint. Although many mendelian and genome-wide association studies have shown an association between elevated lipoprotein A and risk of incident atherosclerotic cardiovascular disease (ASCVD), the causality relationship still lacks the final corroboration of a randomized Lp(a) lowering intervention clinical trial1.

In 1963, for the first time, Kare Berg described the existence of Lp(a). Lp(a) consisted of apolipoprotein (a) bound to apolipoprotein B-100, an apolipoprotein also found on LDL-C particles. Distinct from other lipoproteins greatly affected by diet and genetics, Lp (a) is determined by more than 90% by individuals’ genetics. Lp(a) is synthesized in hepatocytes and is released into blood circulation. Plasma concentrations of Lp(a) are inversely associated with the size of apolipoprotein(a). It is postulated that small isoforms can be synthesized faster than large ones, and apolipoprotein(a) size can account for up to 70% influence on Lp(a) blood concentration. Other known factors include single nucleotide polymorphisms, sex hormones, inflammatory mediators, and dietary factors2.

Many medications have been tested to lower Lp(a) concentration. A large-scale meta-analysis of 5,256 patients (1,371 on placebo and 3,885 on statin) enrolled in a randomized clinical trial showed that most statins significantly increase Lp(a) concentration by 8-24%3. Niacin may lower Lp(a) concentration by 20-30%. However, studies did not show any significant reduction in risk of ASCVD event, once niacin was added to the medication list of patients already receiving a statin. Estrogen can also lower Lp(a) concentration by 20%; however, the usage is limited due to concern about increasing the risk of thrombotic events. Proprotein convertase subtilisin Kexin type 9 inhibitors (PCSK9 inhibitors) have been shown to lower Lp(a) concentrations. In 2 major PCSK-9 inhibitors clinical trials- FOURIER and ODYSSEY OUTCOME- the fourth quartile of Lp(a) in the treatment arm was associated with a 25% increase risk of major adverse cardiovascular events. This implies the presence of residual risk of ASCVD despite very low LDL-C4. In a recent sub-analysis of ODYSSEY OUTCOME trial, alirocumab reduced Lp(a) concentration. Each 5mg/dl decrease in Lp(a) by alirocumab resulted in a 2.5% reduction in risk of cardiovascular events5. It should be noted that none of the above medications have primarily been initially designed to test the hypotheses of the beneficial effect of medication on Lp(a) concentration.

Genetic studies have shed light on the role of each allele on Lp(a) concentrations and have provided a base for pharmacological intervention. Antisense oligonucleotides (ASO) have revolutionized the treatment of Lp(a). ASOs are short DNA fragments designed complementary for a target messenger RNA. LPA gene transcribes the two alleles of apolipoprotein(a) mRNA. ASO like Pelacarsen binds to the mRNA and generates the mRNA-ASO complex. Hepatocytes recognized this complex as foreign objects, and RNase H1 cleaves the sense strand. Four clinical trials have been conducted to assess the efficacy of ASOs to lower Lp(a) concentrations. All the clinical trials have shown promising results, from 40% to up to 90% reduction in Lp(a) depending on the type of ASO, dosage, and frequency of administrations6.

Currently, the pivotal phase 3 of Lp(a)HORIZON7 (ClinicalTrials.gov Identifier: NCT04023552) randomized controlled trial is enrolling up to 8280 individuals, aged >18 years with Lp(a) ≥ 70 mg/dl and with a history of myocardial infarction, ischemic stroke, or symptomatic peripheral artery disease. Participants are double blindly randomized to receive TQJ230 80 mg injected monthly subcutaneously or placebo and will be followed for the primary outcome of MACE (CV death, non-fatal MI, non-fatal stroke, and urgent coronary revascularization). The estimated primary completion date is May 29, 2025. So, we need to be patient and wait to see if the causal relationship between Lp(a) and ASCVD will be established by 2025.

 

References:

  1. Miksenas H, Januzzi JL, Jr. and Natarajan P. Lipoprotein(a) and Cardiovascular Diseases. JAMA. 2021;326:352-353.
  2. Tsimikas S. A Test in Context: Lipoprotein(a): Diagnosis, Prognosis, Controversies, and Emerging Therapies. J Am Coll Cardiol. 2017;69:692-711.
  3. Tsimikas S, Gordts P, Nora C, Yeang C and Witztum JL. Statin therapy increases lipoprotein(a) levels. Eur Heart J. 2020;41:2275-2284.
  4. Ruscica M, Greco MF, Ferri N and Corsini A. Lipoprotein(a) and PCSK9 inhibition: clinical evidence. Eur Heart J Suppl. 2020;22:L53-L56.
  5. Szarek M, Bittner VA, Aylward P, Baccara-Dinet M, Bhatt DL, Diaz R, Fras Z, Goodman SG, Halvorsen S, Harrington RA, Jukema JW, Moriarty PM, Pordy R, Ray KK, Sinnaeve P, Tsimikas S, Vogel R, White HD, Zahger D, Zeiher AM, Steg PG, Schwartz GG and Investigators OO. Lipoprotein(a) lowering by alirocumab reduces the total burden of cardiovascular events independent of low-density lipoprotein cholesterol lowering: ODYSSEY OUTCOMES trial. Eur Heart J. 2020;41:4245-4255.
  6. Tsimikas S, Moriarty PM and Stroes ES. Emerging RNA Therapeutics to Lower Blood Levels of Lp(a): JACC Focus Seminar 2/4. J Am Coll Cardiol. 2021;77:1576-1589.
  7. Assessing the Impact of Lipoprotein (a) Lowering With TQJ230 on Major Cardiovascular Events in Patients With CVD (Lp(a)HORIZON). https://clinicaltrialsgov/ct2/show/NCT04023552. 2019.

“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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The Needle Moves Slowly on MINOCA

Bhavya Varma, MD

I remember being a medical student and listening to a podcast where I first heard the term MINOCA (myocardial infarction with nonobstructive coronary arteries) in 2019. I was deciding between internal medicine and OBGYN at this time, and learning about heart disease specific to and common in women naturally grasped my attention. Dr. Bairey Merz from Cedars-Sinai provides a fantastic overview of the disease process and evaluation. I kept thinking about all the ways we’ve made incredible strides in heart disease over the years. Now, I was thinking they were unequal.

Dr. Brent Gudenkauf, a PGY-2 at the Johns Hopkins Hospital, et al. recently published a review in the Journal of the American Heart Association entitled “Role of Multimodality Imaging in the Assessment of Myocardial Infarction with Nonobstructive Coronary Arteries: Beyond Conventional Coronary Angiography”1. They do a wonderful job of taking us through diagnostic criteria, preferred imaging modalities, and guideline recommendations regarding MINOCA. This term is still not commonplace outside of cardiology, and in the early days some thought these patients were having “false positive MIs” as they outline in the paper. This led to mostly women missing out on necessary diagnostic work up and targeted therapies. Today we have specific diagnostic criteria from the AHA and ESC including positive serum myocardial biomarkers and clinical evidence of MI (which can include ischemic symptoms, new ST segment changes, new LBBB, new pathologic Q waves among others) and no epicardial coronary lesions >50% stenosis on angiography.2,3

What I find disheartening is how slowly our needle has moved in terms of therapies. As they highlight in this paper, even after diagnosis of MINOCA 25% of patients continue to experience angina5 and experience worse quality of life compared with MI-CAD (MI associated with obstructive coronary artery disease) due to persistent anginal symptoms and inadequate treatment with existing antianginal therapies. They were less often treated with beta blockers and less often referred to cardiac rehab5. It is clear that this patient population of majority young women is faring worse than its traditional myocardial infarction counterpart in terms of therapies and quality of life.

For these reasons, we should all develop a good understanding of diagnostic pathways and targeted treatments. The recommended imaging modality is IVUS (intravascular ultrasound) or OCT (optical coherence tomography) 2,4. As a young trainee myself, I am not familiar with either of these modalities and was introduced to these concepts via #AHA21. OCT is an optical analogue of IVUS and can “differentiate tissue characteristics such as fibrous, calcified, or lipid-rich plaque and identify thin-cap fibroatheroma”6. During PCI, OCT can also provide information about dissection, tissue prolapse, and thrombi6; this is significant given SCAD (spontaneous coronary artery dissection), in situ thrombosis, and epicardial and microvascular spasms are all causes that can lead to MINOCA1. Cardiac MR is also useful when MINOCA is suspected as it will show late gadolinium enhancement and can also uncover mimics like myocarditis and Takotsubo cardiomyopathy. Additionally, if embolism to coronary arteries is suspected then thrombophilia workup is recommended. They do a wonderful job outlining this algorithm in Figure 2 in the paper by Gudenkauf et al.1 We should all be working to familiarize ourselves with this figure and its recommendations and integrating this into our evaluation for chest pain.

Although the advancements in diagnosis and evaluation are exciting and important, there are no randomized clinical trials evaluating treatments for patients with MINOCA. The MINCOA-BAT trial is an upcoming randomized multi-center study which will hopefully help to move the needle forward in evidence-based targeted therapies (clinicaltrials.gov, NCT 03686696). This excellent review by Gudenkauf et al should be shared widely as this is an important and still too often underdiagnosed and undertreated condition among our patients.

 

References

  1. Gudenkauf, B., Hays, A. G., Tamis‐Holland, J., Trost, J., Ambinder, D. I., Wu, K. C., Arbab‐Zadeh, A., Blumenthal, R. S., & Sharma, G. (2021). Role of multimodality imaging in the assessment of myocardial infarction with nonobstructive coronary arteries: Beyond conventional coronary angiography. Journal of the American Heart Association. https://doi.org/10.1161/jaha.121.022787
  2. Tamis‐Holland JE, Jneid H, Reynolds HR, Agewall S, Brilakis ES, Brown TM, Lerman A, Cushman M, Kumbhani DJ, Arslanian‐Engoren C, et al. Contemporary diagnosis and management of patients with myocardial infarction in the absence of obstructive coronary artery disease: a scientific statement from the American Heart Association. Circulation. 2019; 139:e891–e908. doi: 10.1161/CIR.0000000000000670
  3. Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli‐Ducci C, Bueno H, Caforio ALP, Crea F, Goudevenos JA, Halvorsen S, et al. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST‐segment elevation: the Task Force for the management of acute myocardial infarction in patients presenting with ST‐segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018; 39:119–177. doi: 10.1093/eurheartj/ehx393
  4. Agewall S, Beltrame JF, Reynolds HR, Niessner A, Rosano G, Caforio AL, De Caterina R, Zimarino M, Roffi M, Kjeldsen K, et al. ESC working group position paper on myocardial infarction with non‐obstructive coronary arteries. Eur Heart J. 2017; 38:143–153. doi: 10.1093/eurheartj/ehw149
  5. Grodzinsky A, Arnold SV, Gosch K, Spertus JA, Foody JM, Beltrame J, Maddox TM, Parashar S, Kosiborod M. Angina frequency after acute myocardial infarction in patients without obstructive coronary artery disease. Eur Heart J Qual Care Clin Outcomes. 2015; 1:92–99. doi: 10.1093/ehjqcco/qcv014
  6. Terashima, M., Kaneda, H., & Suzuki, T. (2012). The role of optical coherence tomography in coronary intervention. The Korean journal of internal medicine, 27(1), 1–12. https://doi.org/10.3904/kjim.2012.27.1.1.

“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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Looking back at AHA21: reflection from a vascular neurology trainee

Meghana Srinivas, MD

It has been just over a month since the American Heart Association Scientific Session 2021 concluded and I am elated to be a part of the Early Career Blogger program with a sponsored free access to the scientific sessions which also included the media pass!

My first thought after glancing at the schedule was, there is content for everybody to view and learn from, this includes researchers to nurses to clinical providers. Healthcare is vast and this session emphasizes that we do it as a community!

The virtual platform was very well organized which made it easy to navigate between the live sessions, posters, resuscitation science symposium and quality of care and outcomes sessions. I was truly fascinated by the quality of posters and presentations, with each one being unique. As an attendee, I had the option to pre-select the sessions of my choice, and add them to my calendar to keep track. The sessions covered topics from basic to clinical research and also included the most recent clinical trial updates. Apart from this, they discussed the role of social media on promoting cardiovascular health, emphasis on Diversion, Equality and Inclusion and Women’s Health.  The sessions were very concise, with the most updated content and were moderated very well. The platform made it easy to ask questions without interrupting the presentation. Despite challenging times of a pandemic, there were many groundbreaking research, which tells us, science doesn’t stop and we are always learning and discovering to contribute to the betterment of quality of life and health.

As we evolve, disease pathologies evolve, making them complex; There is always an overlap between systems, and we can never delineate one system from another and that’s when a platform like the American heart association brings the scientific community together and this year, to your computer screen, which helps researchers and clinicians learn and apply science to their practice.

As a vascular neurology trainee, I particularly enjoyed the sessions focusing on cerebrovascular health and the broad overlap between cardiovascular and cerebrovascular diseases. Some of the topics that drew my attention were, stroke epidemiology including the effect of hypertension on future brain health, gender-based outcomes after left atrial appendage occlusion, stress cardiomyopathy after aneurysmal subarachnoid hemorrhage, and case fatality associated with cardioembolic strokes, Atrial Fibrillation in 2021: Prepare for New Directions. Impact of COVID-19 on Cardiovascular Diseases, Secondary Stroke Prevention Guidelines: What Cardiologists Need to Know, Controversies in Stroke Management and Prevention and Updates in Stroke: Careers & Future Directions in Vascular Neurology (was privileged to blog on this session) to name a few. And it was not limited to listening to the lectures but felt even better when I apply it to patient care.

Apart from the scientific content, there were many educational discussions lead by seasoned panelists centered around, factors influencing various career vectors which addressed issues, events, and influential colleagues/mentors that contributed to their career choices with emphasis directed towards Early career attendees. The AHA journal editors gave us an insight on, What They Are Looking For? How to Publish? Opportunities for FIT’s to Be Involved and provided tips and advices for trainees to advance their career in publishing. One session that meant a lot to me was brought together by the ATVB Women’s Leadership Committee (WLC) who shared their own experiences on identifying and getting involved in volunteering activities such as, becoming a member of the early career committee, WLC program committee, leadership committee, as well as serving as a blogger etc. which were discussed in great detail.

It has only been a couple of months since being an AHA Fellow In Training and some of the perks that I’m already enjoying are, being able to engage with colleagues and mentors from around the world, volunteer opportunities with the AHA/ASA and gain national exposure, creating a pathway to Fellowship of the American Heart Association (FAHA), and making an impact in building healthier lives, free of cardiovascular disease and stroke.

The icing on the cake is the incredible opportunity to view all of the material with the on-demand access which is easy to access and can be viewed at your own pace. (https://ahasessions.heart.org/).

 

“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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Moving from ‘Luck of the Draw’ to making BLS and Defibrillator availability basic

Olubadewa Fatunde, MD MPH

The AHA ReSS council had a fascinating 2021 meeting, including trials making us reassess the optimal temperature for patients following cardiac arrest (TTM2) and those investigating the potential new application of existing meds repurposed to cardiac arrest (e.g. Tocilizumab [IL-6 inhibitor] to reduce cytokine storm post-arrest, LPC-DHA to improve mitochondrial function). What really put these clinical trials into perspective was the plenary session, featuring actual survivors of sudden cardiac arrest discuss their experiences with the frustrating lack of established resources as they journey to find the new normal for their lives.

Perhaps the most memorable part of AHA 2021 was the harrowing account of Dr. Kevin Volpp, a cardiology and behavioral economics researcher at the University of Pennsylvania, reflect on his own sudden cardiac death experience. The morning of July 9, 2021 started as just a regular day. Volpp traveled to Cincinnati, Ohio to watch his daughter, Anna, play in a squash tournament. While dining with Anna, her Coach (Gina Stoker), and her Coach’s boyfriend (John White) the night before, Volpp suddenly became unresponsive, slumping his chair into the arms of White. Coach Stoker called 911. White, who is himself a squash coach at Drexel University, laid Volpp flat, could not find a pulse, and initiated bystander CPR. EMS arrived four minutes later. Ultimately, he received 14 minutes of CPR with three shocks from the automated external defibrillations before his circulation was restored. He was rushed to University of Cincinnati Hospital, where he was found to have a 99% blockage in his LAD artery, which was opened and stented (1).

Volpp, who had a strong family history of premature heart attacks, had been undergoing primary prevention measures including CAC screening, medications, and well exceeding the AHA’s minimum recommendation for weekly exercise, as he was training with Anna for an Ironman 70.3 triathlon (1). Sudden cardiac death does not always occur in those with a strong family history with plaque in their arteries. During his 3rd year of internal medicine residency, Dr. Anezi Uzendu suffered cardiac arrest while he was playing basketball, with no prior family history. Fortunately, through high quality CPR and persistent resuscitation (receiving a total of 13 defibrillation attempts before he was revived!)(2), he eventually recovered and completed both general and interventional cardiology fellowships.

Ultimately, the prompt recognition and initiation of the cardiac chain of survival that allowed Drs. Volpp and Uzendu to have good outcomes. Coach White credited Drexel University’s requirement that Coaches keep their training in Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) active (1). BLS is the use of high-quality chest compressions (2 inches deep at 100-120 beats per minute) to maintain adequate circulation to the brain, before additional help can arrive to provide higher level of care (ACLS). Out of hospital cardiac arrest and recovery is far from normal across the country, occurring in less than 8% of individuals (3). Acknowledging the critical nature of illnesses causing cardiac arrest, why do so few survive? Low rates of education and implementation of bystander CPR and AEDs, two of the most important interventions linked to improving survival  by as much as 3-fold (3). These interventions are not independent, as defibrillator effectiveness increases, with increasing quality of CPR (optimal depth & speed) administered (4). In 2014, Dr. Monique Anderson and colleagues at Duke University found that, only 1.29-4.07% of the US population is certified in BLS—a shockingly low statistic for the number one cause of death in America (heart disease) (3, 5). Unfortunately, disparities are more likely in racial minority, older, rural, and Southern communities (5). Dr. Maryam Naim and colleagues found similar disparities in a pediatric population (6). Not surprisingly, average rates of bystander in America CPR are only 38.2% (7), with significant geographic variation (10-65%) (8) and lower rates of proper technique (compression depth of 2 inches and pace of 100-120 beats per minute (9). These findings are compounded by the fact that almost 90% of cardiac arrests occur in or near the home (10).

What’s the best method of increasing this? Anywhere from 71.5% to 85.3% of American high school seniors have their driver’s license (11). Many obtain this through taking driver’s education class in school. One long term solution would be providing BLS courses to all high schoolers, with the option to advance to ACLS certification for those interested. While logistics can be debated, this would increase the proportion of individuals ready to perform by stander CPR from the 70% of Americans who don’t feel prepared (10) to adequately administer CPR. For adults, there are many available BLS courses available. The AHA Knowledge Booster App is a fun and interactive resource for those who want to learn more, but don’t know where to start. There are several Spotify playlists of songs with a tempo of 100-120bpm (12-14), but “Staying Alive,” by the Bee gees seems to be the most enduring. Dr. Uzendu founded an organization—Make BLS Basic—that focuses on increasing bystander CPR rates in minority communities (15).

Increasing bystander CPR rates is only half of the prehospital equation. When bystanders perform CPR and use a defibrillator, the survival to hospital discharge approaches 50-60%, with improved survival and neurological outcome with earlier defibrillation of shockable rhythms (3). The meager rates of Automated External Defibrillator (AED) availability in public spaces are similarly shocking. In a Cleveland Clinic survey, only 27% of Americans reported an AED in their workplace. After his experience, Volpp posed the question, should national chains be required to install AEDs, given that most adults spend 15-20 (pre-pandemic) minutes a day in a restaurants or bar (1). To be sure, AEDs require maintenance (replacement of defibrillator pads & batteries) and untrained lay providers may struggle to use them effectively (3). Several cost-effectiveness analyses have found a benefit of widespread dissemination of public AEDs (16-18), though not all are as optimistic (19, 20).   AED Laws vary by state (21); there has also been federal legislation (22). The Sudden Cardiac Arrest Foundation states a goal of having an AED accessible within 90 seconds of any public area that people congregate (e.g. schools, state & federal buildings, casinos, etc.). We are far from this important goal.

I think the ultimate questions are: Should one’s survival following cardiac arrest depend on being with the right person at the right time or where you live, shop, eat, or pursue leisure? Will we accept the status quo? How can we improve rates of bystander CPR and AED availability to give everyone an equitable chance at surviving these life-threatening events, and a new lease on life? How can we better support SCA survivors during their recovery? Looking forward to answering these questions at future meetings.

 

References:

  1. Avril T. “A Penn professor’s heart stopped at restaurant that had no defibrillator. Few are equipped with the lifesaving devices.” Philadelphia Inquirer. 2021. https://www.inquirer.com/health/aed-defibrillator-restaurant-cardiac-arrest-20211213.html
  2. Uzendu A. From “delivered to the cath lab alive” to Interventional Cardiologist on call in 5 years. God is good. #CPRSavesLives. In: @DrUzendu, editor. 2021. https://twitter.com/DrUzendu/status/1465120531317989382
  3. Brady WJ, Mattu A, Slovis CM. Lay Responder Care for an Adult with Out-of-Hospital Cardiac Arrest. N Engl J Med. 2019;381(23):2242-51.
  4. Edelson DP, Abella BS, Kramer-Johansen J, Wik L, Myklebust H, Barry AM, et al. Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Resuscitation. 2006;71(2):137-45.
  5. Anderson ML, Cox M, Al-Khatib SM, Nichol G, Thomas KL, Chan PS, et al. Rates of cardiopulmonary resuscitation training in the United States. JAMA Intern Med. 2014;174(2):194-201.
  6. Naim MY, Griffis HM, Burke RV, McNally BF, Song L, Berg RA, et al. Race/Ethnicity and Neighborhood Characteristics Are Associated With Bystander Cardiopulmonary Resuscitation in Pediatric Out-of-Hospital Cardiac Arrest in the United States: A Study From CARES. J Am Heart Assoc. 2019;8(14):e012637.
  7. Promotion OoDPaH. Increase the rate of bystander CPR for non-traumatic cardiac arrests — PREP‑01. In: Promotion OoDPaH, editor.: Office of the Assistant Secretary for Health, Office of the Secretary, U.S. Department of Health and Human Services. https://health.gov/healthypeople/objectives-and-data/browse-objectives/emergency-preparedness/increase-rate-bystander-cpr-non-traumatic-cardiac-arrests-prep-01/data
  8. Brown LE, Halperin H. CPR Training in the United States: The Need for a New Gold Standard (and the Gold to Create It). Circ Res. 2018;123(8):950-2.
  9. New Cleveland Clinic Survey: Only Half Of Americans Say They Know CPR [press release]. Newsroom: Cleveland Clinic, February 1, 2018 2018. https://newsroom.clevelandclinic.org/2018/02/01/new-cleveland-clinic-survey-only-half-of-americans-say-they-know-cpr/
  10. CPRBlog [Internet]. www.heart.org: American Heart Association. [cited 2021]. https://cprblog.heart.org/cpr-statistics/
  11. Ranzetta T. Question of the Day: What percent of high school seniors have a driver’s license? : Next Gen Personal Finance; 2019 [Budgeting]. Available from: https://www.ngpf.org/blog/budgeting/question-of-the-day-what-percent-of-high-school-seniors-have-a-drivers-license/.
  12. American Heart Association. Hands-Only CPR’s ‘Keep The Beat’ 100BPM Playlist: Spotify; 2015. https://open.spotify.com/playlist/18uMyHJHboUUCCwbtwdj3k
  13. nyphospital. Songs to do CPR to: Spotify. https://open.spotify.com/playlist/7oJx24EcRU7fIVoTdqKscK
  14. seigfriedb. CPR playlist (110 bpm). https://open.spotify.com/playlist/67BxVmgXqjr2lQqXKsyLxw: Spotify.
  15. Uzendu A. Make BLS Basic http://www.makeblsbasic.org2019 [Available from: http://www.makeblsbasic.org.
  16. Andersen LW, Holmberg MJ, Granfeldt A, James LP, Caulley L. Cost-effectiveness of public automated external defibrillators. Resuscitation. 2019;138:250-8.
  17. Nichol G, Huszti E, Birnbaum A, Mahoney B, Weisfeldt M, Travers A, et al. Cost-effectiveness of lay responder defibrillation for out-of-hospital cardiac arrest. Ann Emerg Med. 2009;54(2):226-35.e1-2.
  18. Weisfeldt ML, Sitlani CM, Ornato JP, Rea T, Aufderheide TP, Davis D, et al. Survival after application of automatic external defibrillators before arrival of the emergency medical system: evaluation in the resuscitation outcomes consortium population of 21 million. J Am Coll Cardiol. 2010;55(16):1713-20.
  19. Atkins DL. Realistic expectations for public access defibrillation programs. Curr Opin Crit Care. 2010;16(3):191-5.
  20. Pell JP, Walker A, Cobbe SM. Cost-effectiveness of automated external defibrillators in public places: con. Curr Opin Cardiol. 2007;22(1):5-10.
  21. Roszak AR. CPR / AED Laws: Sudden Cardiac Arrest Foundation; [Available from: https://www.sca-aware.org/about-sudden-cardiac-arrest/cpr-aed-laws.
  22. State Laws on Cardiac Arrest and Defibrillators National Conference of State Legislatures [cited 22 Dencee. Available from: https://www.ncsl.org/research/health/laws-on-cardiac-arrest-and-defibrillators-aeds.aspx.

“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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Mental Health at the Forefront of Cardiovascular Health Discussions at AHA21

Jessica Monterrosa Mena

Mental health was a big topic of conversation at AHA21, a fitting topic when pandemic related stress, clinician burn out, and depression seem to be at an all-time high. As a graduate student myself, I was interested in attending sessions that touched on depression, wellness, and work-life balance topics. A Health and Tech panel session titled, “Mental Health and Cardiovascular Disease,” addressed how depression and languishing mental health can heighten the risk of cardiovascular diseases and cardiovascular events. This is because chronic stress activates our sympathetic nervous system and promotes changes in heart rate, blood pressure, and stress hormone levels. While there is a diverse array of known factors that influence depression, clinicians are now taking on the challenging task to measure how mental health contributes and modulates cardiovascular health outcomes.

Clinicians often connect patients with resources and educate patients about chronic disease self-management. However, when patients are coping with chronic physical conditions, mental health conditions can go unrecognized and may further impact health outcomes. As stated in the panel conversation, an astonishing 22% of people with heart disease struggle with depression as well. Properly identifying patients with depression is particularly important as mental health challenges that accompany traumatic health crises can interfere with cardiovascular disease treatments, often managed with lifestyle changes and adherence to strict medication regiments. Clinicians who are willing to attain mental health training to recognize mental health symptoms may provide more useful resources to patients. For example, routine mental health screening during visits were discussed to be a powerful tool that can help clinicians assess depression and anxiety symptoms and facilitate patients getting comprehensive assessment and specific resources that may improve overall health outcomes.

Digital solutions may also be effective tools for managing mental health and heart-healthy behaviors in the future. There is biotechnology in the works that may help patients track physiological reactions to daily stressful experiences, and individual step count and heart rate variability data may one day help clinicians make better informed decisions. One digital intervention program in the works in the works is Happify Heart and Mind, tailored to address lifestyle changes that would benefit individuals with heart disease risk factors. Clinical trial data presented at this session showed that depression, anxiety, and overall wellbeing was improved in patients who used Happify compared to traditional psychoeducation. The take-away question to walk away with after this session is to reflect on who would benefit the most from digital solutions. While scientists can leverage technology to touch on the complex relationship between mental health and cardiovascular health, these solutions need to be adapted to cross the digital literacy divide. Patients who face social inequities would stand to benefit most from personalized and adaptable comprehensive interventions, and clinicians can help connect the most underserved patients with digital resources and support programs.

Resources:

https://www.heart.org/en/healthy-living/healthy-lifestyle/mental-health-and-wellbeing/how-does-depression-affect-the-heart

“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 Reaffirmation on Medical Conferences

Devika Aggarwal, MBBS

It is safe to say that AHA Scientific Sessions 2021, conducted virtually from November 13th to 15th was a big hit. The ease and flexibility of attending the Sessions from the comfort of my couch made me forget my initial concerns of missing out on the in-person experience. It will be interesting to see how the pandemic, and seeping of Zoom into our lives, change the future of medical conferences. Regardless of time and place, conferences will continue to be an important feature in medicine, especially in a constantly evolving field like cardiology. Here I discuss some of the reasons that drive us to attend medical conferences, and why we should continue to do so.

(Image from Creative Commons)

Present your work

Disseminating your research can be as important as the scientific process itself. Conferences are an excellent forum to present your findings in a timely manner, especially since publication can be a very long-drawn-out process. Presenting abstracts at conferences helps trainees build their CVs to reflect their interests and scholarly work. Although it can be nerve-wracking, presenting at conferences forces you to communicate about your work effectively. Addressing questions from experts and incorporating the feedback received can help with framing the manuscript for publication.

Keep up-to-date with the latest science

Undoubtedly the release of new study data creates the loudest buzz during medical conferences. Audiences gather to witness the release of trials that will influence clinical practice. You have the opportunity to interact with the investigators and address questions relevant to you and your patients. When not in the late-breaking sessions, there are poster/ presentation sessions to attend. You can also learn about the latest innovations from the industry and try your hand at new technologies showcased by vendors.

Get inspired

Even when not presenting, attending scientific conferences is an active process. Reviewing the latest trials and abstracts promotes critical thinking and sparks ideas. You notice the gaps in knowledge and may be inspired to address that in your research. You can learn from others’ successes and mistakes.

Learn/ refresh your knowledge

Medical conferences are a good place to catch up on the existing knowledge and earn CME points. Most conferences have workshops or skills-training sessions incorporated within the schedule. Lectures from distinguished speakers can provide you with a high-level review of a topic. Panel discussions bring together opinions from trainees, established clinicians, and researchers and can give a sense of what the coming years will bring to the field.

Form connections

Networking has become crucial for a career in medicine, whether in academia or private practice. Conferences are arguably the best place to establish and foster contacts with people at different stages of their careers. You have the opportunity to meet experts who you look up to, introduce yourself, and take advice. Your name might stick with potential employers, increasing your chances of landing a position in the future. For trainees, it may translate into gaining lifelong mentors or sponsors. Conferences are also a good place to meet peers, share ideas and experiences, and potentially set up collaborations.

Share the passion

Finally, there is a special joy in nerding along with others who nurture the same passion for medicine as you. People from different countries and at varying stages of their careers are brought together during the conferences. Knowing that there is a whole community of people with similar interests can motivate you for long after the conference is over.

All in all, attendees come out of a conference smarter, inspired, and excited for the next conference.

Below is a list of the upcoming major conferences in Cardiology. Hope to see you there!

 

“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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Cut from the same clot? – High-risk primary prevention vs secondary prevention in CVD

Melody Chemaly, PhD

Atherosclerotic cardiovascular disease (CVD) prevention has been traditionally divided into primary or pre-event prevention and secondary or re-event prevention. The AHA 2021 joint session with the American Society of Preventive Cardiology entitled “Blurred Lines-Overlap in High-Risk Primary Prevention vs Secondary Prevention” challenged this traditional concept. The session tackled the case of a high-risk patient where using stricter treatment approaches, usually applied in secondary prevention, might be more relevant for her primary prevention. The invited speakers gave an overview of the different treatment options currently available for high-risk primary prevention and highlighted the knowledge gaps in the field.

It is well established that most cardiovascular events (CVE), such as myocardial infarction (MI) and stroke, occur in patients with prior no symptoms. When it comes to predicting CVE, it has been shown that the plaque burden (calculated by Coronary Artery Calcium (CAC) score for example) is a better predictor than the severity of stenosis. This is because the type and certain features of an atherosclerotic plaque can render it more vulnerable regardless of the stenosis degree.

 

The lines between primary and secondary prevention become blurry when studies such as the one recently conducted by Peng and colleagues demonstrated that primary prevention individuals with very high CAC score (~900) had a similar rate of CVE compared to stable treated high risk secondary prevention patients such as those in the FOURRIER trial. These results show that high-risk primary prevention population might benefit from intense management. Additional risk factors can be taken into account when optimizing the treatment while keeping in mind that not all high-risk primary prevention patients are the same despite presenting with a high CAC score. Before selecting a treatment strategy for a high-risk patient in primary prevention, it is important to evaluate the severity of the patient’s risk factors and act on them accordingly.

Reducing LDL-C levels, ideally below 70 mg/dl, is a good starting point. This can be done using intensive statin therapy or adding ezetimibe or a PCSK9 inhibitor for patients with additional risk factors who do not achieve LDL-C targets. It is of note that PCSK9 inhibitors can reduce Lp(a), triglycerides and ApoB levels which are known to increase CVD risk. The ongoing VESALIUS trial is evaluating the effect of using the PCSK9 inhibitor evolocumab on CVE in primary prevention high-risk patients with no history of myocardial infarction or stroke. For patients with high triglyceride levels, the results of the REDUCE-IT trial demonstrated a reduction of CVE (CV deaths, MI and stroke) when using icosapent ethyl, an EPA derivative. In this trial, 1% of patients had an increase in atrial fibrillation and atrial flutter which can be managed considering the advantageous reduction in stroke risk. However, the REDUCE-IT trial was conducted in a prevalent secondary prevention population and the benefit in high-risk primary prevention needs to be further investigated.

Metabolic syndrome is another risk factor than can be monitored in high-risk primary prevention as it increases the risk of CVE and type 2 diabetes. SGTL2 inhibitors have been shown to reduce CVE in patients with heart failure and reduced ejection fraction offering a benefit of using this anti-diabetic drug class in a non-diabetic population. About a third of the patients enrolled in the CANVAS trial were high-risk primary prevention and had a reduction of CVE while using SGLT2 inhibitors. The REWIND trial on the other hand, which enrolled about 69% of high-risk primary prevention patients, showed that GLP1-RA, another class of anti-diabetics, decreased the occurrence of CVE. However, SGLT2 and GLP1-RA are not yet FDA approved for high-risk primary prevention and the current alternative is managing lifestyle. Patients with metabolic syndrome can be advised to improve the quality (Mediterranean and DASH diets) and quantity (1600 to 3000 calories) of their diet and encouraged to include a fasting period of 14 hours per day to improve their blood pressure and atherogenic lipids profile.

In addition to controlling lipids, blood pressure and pre-diabetes, aspirin can also be considered for high-risk patients in primary prevention but only in those with low bleeding risk as shown by the recent data from the Dallas Heart Study (DHS).

References

  1. Van Venrooij FV, Stolk RP, Banga JD, Erkelens DW, Grobbee DE. Primary and secondary prevention in cardiovascular disease: an old-fashioned concept? J Intern Med. 2002;251(4):301–6.
  2. Mortensen MB, Dzaye O, Steffensen FH, B øtker HE, Jensen JM, R  ønnow SNP, et al. Impact of Plaque Burden Versus Stenosis on Ischemic Events in Patients With Coronary Atherosclerosis. J Am Coll Cardiol. 2020 Dec 15;76(24):2803–13.
  3. Peng AW, Dardari ZA, Blumenthal RS, Dzaye O, Obisesan OH, Iftekhar Uddin S m., et al. Very High Coronary Artery Calcium (≥1000) and Association With Cardiovascular Disease Events, Non–Cardiovascular Disease Outcomes, and Mortality. Circulation. 2021 Apr 20;143(16):1571–83.
  4. Arbab-Zadeh A, Fuster V. From Detecting the Vulnerable Plaque to Managing the Vulnerable Patient: JACC State-of-the-Art Review. J Am Coll Cardiol. 2019 Sep 24;74(12):1582–93.
  5. Amgen. A Double-blind, Randomized, Placebo-controlled, Multicenter Study to Evaluate the Impact of Evolocumab on Major Cardiovascular Events in Patients at High Cardiovascular Risk Without Prior Myocardial Infarction or Stroke [Internet]. clinicaltrials.gov; 2021 Dec [cited 2021 Dec 10]. Report No.: NCT03872401. Available from: https://clinicaltrials.gov/ct2/show/NCT03872401
  6. McMurray JJV, Solomon SD, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA, et al. Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction. N Engl J Med. 2019 Nov 21;381(21):1995–2008.
  7. Wilkinson MJ, Manoogian ENC, Zadourian A, Lo H, Fakhouri S, Shoghi A, et al. Ten-Hour Time-Restricted Eating Reduces Weight, Blood Pressure, and Atherogenic Lipids in Patients with Metabolic Syndrome. Cell Metab. 2020 Jan 7;31(1):92-104.e5.
  8. Bhatt DL, Steg PG, Miller M, Brinton EA, Jacobson TA, Ketchum SB, et al. Cardiovascular Risk Reduction with Icosapent Ethyl for Hypertriglyceridemia. N Engl J Med. 2019 Jan 3;380(1):11–22.
  9. Ajufo E, Ayers CR, Vigen R, Joshi PH, Rohatgi A, de Lemos JA, et al. Value of Coronary Artery Calcium Scanning in Association With the Net Benefit of Aspirin in Primary Prevention of Atherosclerotic Cardiovascular Disease. JAMA Cardiol. 2021 Feb 1;6(2):179–87.

“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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Fruits, Vegetables, Wholegrains, Plant proteins, and your Heart

Gaganpreet Kaur

Cardiovascular diseases (CVD) are the leading cause of death in Western countries and accounts for 17.3 million deaths/year globally1. In the United States, one in every three deaths are caused by CVD, and more than 130 million adults are projected to express CVD by 2035 clinically1. The unhealthy diet and physical inactivity, obesity, stress, smoking, and alcohol consumption are major risk factors for CVD development1. Nutrition has been reported to be the most preventable risk factor of CVD death1,2. Further, a healthy diet is crucial for managing body weight, diabetes, and hypertension1,3. Therefore, it is essential to identify foods and dietary patterns beneficial for cardiovascular health.

AHA 2021 Dietary Guidance to Improve Cardiovascular Health was presented for the first time by Dr. Alice Lichtenstein, a lead scientist at Tufts University, at #AHA21 scientific sessions and was recently published in Circulation4. AHA suggests that instead of emphasizing one food/nutrient, one should focus on dietary patterns that are the sum of all foods and beverages consumed4. The dietary habits can be adapted to personal preferences, ethical/religious practices, and life stages so that healthy patterns can be followed in the long run4. A heart-healthy diet promotes a healthy planet, meets essential nutrients and fiber requirements, and benefits stroke, type 2 diabetes, kidney disease, and cognitive function4. AHA 2021 Dietary Guidance is organized in following ten features:

 

  1. Adjust energy balance to achieve and maintain healthy body weight.
  2. Include plenty and a variety of fruits and vegetables.
  3. Pick food made with whole grains rather than refined grains.
  4. Choose healthy protein sources, mostly plants, fish, and seafood, and low-fat/fat-free dairy products. If meat or poultry is desired, replace red and processed meat with lean cuts and unprocessed form.
  5. Use liquid plant oils rather than tropical oils and trans-fat.
  6. Choose minimally processed foods.
  7. Minimize consumption of beverages and foods with added sugars.
  8. Consume food prepared with no or little salt.
  9. Limit intake of alcohol. If you do not drink alcohol, do not start.
  10. Adhere to this guidance regardless of where food is prepared or consumed,

 

However, is it easy for everyone to follow a heart-healthy diet? Our food environment is an essential element when we talk about diet quality and can make it difficult for people to adhere to heart health guidelines. Although diet quality improved from 1999 to 2012, disparities are evident based on race/ ethnicity, education, and income5. Dr. Maya Vadiveloo, assistant professor at the University of Rhode Island, explained that the food environment mainly consists of:

  1. Regulatory environment (federal, state, and local practices, and food marketing).
  2. Physical environment (places we eat, live, and acquire food).
  3. Social environment (family and peers).
  4. Individual choices.

She further explained that several state and federal policies, structural racism, neighborhood segregation, unhealthy built environments impede the adaption to a healthy diet. Furthermore, availability, price, and varied access make choosing unhealthy and processed food easier4. Federal food assistance programs, including Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), are not universally effective and only cover a fraction of the monthly household supply4. Food companies tend to target low-income and racial minorities households. High processed food and beverages are telecasted more on TV, digital media, and print advertisements4. Dr. Vadiveloo concluded her talk by discussing the concept of precision nutrition which includes the evaluation of genetics, microbiome, dietary intake, and socioeconomic and physical environment to determine the most fruitful dietary plan to prevent and treat disease.  Increased access to affordable housing, enhancing access to supermarkets and green space, and increased access to online food delivery can help achieve dietary goals. She emphasized the power of artificial intelligence, which is unfortunately used for promoting unhealthy food. Still, it can help design personalized dietary interventions, population-level diet quality, and help people choose healthier and medical tailored diets when they buy groceries.

Following this, Dr. Lawrence J Appel, professor at John Hopkins University, explained how a multisector approach including government (regulatory and agriculture policy), health care sector, private sector, and health advocacy organizations is needed to change the default of food sector/eating. Dr. Appel focused on how policy changes can help individuals to eat healthily. In the US, processed and restaurant foods are significant sources (>70%) of sodium6. FDA generated guidance for food manufacturers and restaurants to reduce salt in their processed, packaged, and prepared foods to achieve a 12% reduction in sodium and slash rates of heart diseases7. WHO has generated public food procurement policies that require food and beverages served/sold in a public setting to promote a healthy diet8, indirectly influencing manufacturers to reformulate their products. Although not common in the US, several other countries have front-of-pack warning labels (nutrient specific labels, nurtiscore and guideline daily amount) and health taxes on sugary drinks and salty food. Currently, only New York City requires restaurants to post a warning label next to the menu that contains more than 2300 mg of sodium and applies to restaurants with more than 15 locations nationwide. He concluded his talk by the importance of advocating and supporting policies that improve the health of patients and the broader community.

The last talk of the session was by Dr. Anne N. Thorndike from Massachusetts General Hospital and Harvard Medical school. Dr. Thorndile explained how clinicians and the healthcare sector could help implement 2021 dietary guidelines. She suggested that clinicians emphasize overall nutritional patterns and ask patients about barriers to access and consuming a healthy diet. Further, a clinician can deliver simple patient-centered guidance consistently over time by encouraging fruits/vegetables, plant proteins and oils, whole grains and discouraging the use of added sugars, processed meat, and excess alcohol. Further, hospitals employ approximately 6 million people and treat 750 million people annually. Therefore, many patients are exposed to cafeteria food. Hospitals can opt for traffic-light labels to promote healthy eating where green light suggests choosing often, yellow light means choosing less often, and a red light indicates a better choice available.

There is plethora of scientific evidence present that have helped in building 2021 AHA dietary guidelines. However, we need a multisector approach which will help imply the dietary goals to a larger population.

Reference

  1. Casas R, Castro-Barquero S, Estruch R, Sacanella E. Nutrition and Cardiovascular Health. Int J Mol Sci. Dec 11 2018;19(12)doi:10.3390/ijms19123988
  2. Mozaffarian D, Ludwig DS. Dietary guidelines in the 21st century–a time for food. JAMA. Aug 11 2010;304(6):681-2. doi:10.1001/jama.2010.1116
  3. Lacroix S, Cantin J, Nigam A. Contemporary issues regarding nutrition in cardiovascular rehabilitation. Ann Phys Rehabil Med. Jan 2017;60(1):36-42. doi:10.1016/j.rehab.2016.07.262
  4. Lichtenstein AH, Appel LJ, Vadiveloo M, et al. 2021 Dietary Guidance to Improve Cardiovascular Health: A Scientific Statement From the American Heart Association. Circulation. Dec 07 2021;144(23):e472-e487. doi:10.1161/CIR.0000000000001031
  5. Rehm CD, Peñalvo JL, Afshin A, Mozaffarian D. Dietary Intake Among US Adults, 1999-2012. JAMA. Jun 21 2016;315(23):2542-53. doi:10.1001/jama.2016.7491
  6. Harnack LJ, Cogswell ME, Shikany JM, et al. Sources of Sodium in US Adults From 3 Geographic Regions. Circulation. May 09 2017;135(19):1775-1783. doi:10.1161/CIRCULATIONAHA.116.024446
  7. Edward E. New FDA guidance aims to drastically cut salt in food supply. NBC News. Accessed December 15, 2021. https://www.cnbc.com/2021/10/13/new-fda-guidance-aims-to-drastically-cut-salt-in-food-supply.html
  8. Public Food Procurement and Service Policies for Healthy Diet. WHO. Accessed December 15, 2021. https://apps.who.int/iris/bitstream/handle/10665/338525/9789240018341-eng.pdf

“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.”