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Medications to Avoid in patients with Heart Failure

The number of patients being diagnosed with heart failure (HF) is increasing worldwide, and thus we need to know which medications to avoid or be cautious with prescribing that may cause or exacerbate this medical condition. So, we decided to talk about these medications, how they cause these adverse events in these patients, and their mechanism of action.

How these medications cause adverse events in HF patients?

Overall, these medications might cause these adverse effects by one of the following mechanisms: 1) causing direct myocardial toxicity; 2) by negative inotropic effect; 3) chronotropic effects; 4) by exacerbating hypertension; 5) by delivering a high sodium load; or 6) by drug-drug interactions that limit the beneficial effects of HF medications.

Here, we will talk briefly about the common medication classes that should be avoided in heart failure and their mechanism of causing these adverse events.

1. Non-dihydro Calcium Channel Blockers (CCB):

Including (diltiazem and verapamil) è have a negative inotropic effect, thus might increase adverse outcomes [1].

2. Nonsteroidal Anti-Inflammatory Drugs (NSAID) : Diclofenac , indomethacin , ketorolac ..etc AND COX-2 selective inhibitors (Celecoxib) :

Commonly Dispensed as over the counter drugs or as anti-inflammatory prescribed drugs è these medications are associated with increased risk of HF exacerbation, causing decline in renal function, and peripheral vasoconstriction; as such they can attenuate the efficacy and enhance the toxicity of diuretics and angiotensin converting enzyme inhibitors [2]. 

US Boxed Warning regarding Serious cardiovascular risk: (NSAIDs) cause an increased risk of serious cardiovascular thrombotic events, including myocardial infarction (MI), and stroke, which can be fatal. This risk may occur early in the treatment and may increase with duration of use. Celecoxib is contraindicated in the setting of coronary artery bypass graft (CABG) surgery [2].

3. Some Oral Hypoglycemic Agents:

Thiazolidinediones such as Pioglitazone è are associated with fluid retention

US Boxed Warning: Thiazolidinediones may cause or exacerbate heart failure è  closely monitor for signs and symptoms of HF particularly after initiation or dose increases. If HF develops, treat and consider dose reduction or discontinuation of pioglitazone. Initiation of therapy is contraindicated in patients with NYHA class III or IV HF [3].

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors: Sitagliptin, saxagliptin, and linagliptin

In a scientific statement from American Heart Association (AHA) , saxagliptin has been determined to be an agent that may exacerbate underlying myocardial dysfunction , 2016 . The ADA recommends avoiding the use of saxagliptin in patients with HF, 2020) [4].

Bies ( Metformin ) is associated withguanid lactic acidosis, which can be fatal in patients with CHF

US Boxed Warning regarding Lactic acidosis: Risk factors include renal impairment, ≥65 years and hypoxic states, e.g: acute congestive heart failure. Metformin may be used in patients with stable heart failure, ADA 2020 [5].

4. Tumor Necrosis Factor alpha inhibitors (Anti-TNF-alpha):

Including infliximab, etanercept, and adalimumab.

Use with caution in patients with mild HF (NYHA class I, II) or decreased left ventricular function. Infliximab doses >5 mg/kg are contraindicated with moderate to severe HF (NYHA class III/IV). In a scientific statement from AHA, TNF blockers have been determined to cause either direct myocardial toxicity or exacerbate underlying myocardial dysfunction, 2016 [6,7].

5. Antiarrhythmic medications:

Class I: Flecainide, disopyramide [8]

Class III: Dronedarone, Sotalol [8]

6. Anti- Cancer medications:

Anthracyclines: doxorubicin, Daunorubicin, Mitoxantrone

US Boxed Warning: Myocardial damage (including acute left ventricular failure) can occur with doxorubicin with incidences from 1% to 20% for cumulative doses from 300 mg/m2 to 500 mg/m2 when administered every 3 weeks è monitor LVEF before, during and after treatment [9]

Targeted therapy: Bevacizumab, Lapatinib, Trastuzumab

US Boxed Warning: Trastuzumab is associated reductions in left ventricular ejection fraction (LVEF) and heart failure; the incidence is highest in patients receiving trastuzumab with an anthracycline-containing chemotherapy regimen è  Evaluate LVEF in all patients prior to and during treatment; discontinue for cardiomyopathy [10]

7. Cilostazol

This is a selective inhibitor of phosphodiesterase type 3, antiplatelet and vasodilatory agent used primarily in patients with intermittent claudication and peripheral arterial disease [11].

US Boxed Warning: Cilostazol is contraindicated in patients with heart failure of any severity è causing decreased survival in patients with class III to IV heart failure [11].

8. Anti-depressant drugs:

Citalopram, Tricyclic antidepressants (TCA) such as amitriptyline, Imipramine … etc.

  • TCAuse with extreme caution in patients with a history of CVD or family history of sudden death, dysrhythmias, or conduction abnormalities. In a scientific statement from AHA, TCA has been determined to exacerbate underlying myocardial dysfunction,2016 è monitor EKG [12]
  • Citalopram risk of dose-dependent  QT prolongation ECG and torsade de pointes (TdP) . Risk factors include Structural heart disease, e.g: MI or HF [12]

9. α1 -Blockers:

Such as prazosin and doxazosin

In a scientific statement from the AHA, -Zosin has been determined to exacerbate underlying myocardial dysfunction , 2016 [13].

10. Pregabalin

Peripheral edema may occur in patients with or without a prior history of heart failure, which may result in acute decompensated heart failure. Risk factors: Pre-existing heart failure (NYHA Class III or IV) (cautious use recommended due to limited data in this patient population [14]

11. Beta-blockers (except those approved for HF treatment: Metoprolol, Bisoprolol, Carvedilol) [15]

12. Selected Intravenous and Oral Medications High in Sodium content:

  • Oral meds: Alendronate effervescent tablet, Sodium polystyrene sulfonate suspension, Polyethylene glycol powder for solution, erythromycin
  • Injection meds: Piperacillin/tazobactam, Metronidazole, Ticarcillin/clavulanate, azithromycin

13. Trimethoprim-sulfamethoxazole (TMP/SMX)

==> by increasing the risk of Hyperkalemia which can be life-threatening [16].

Figure 1: Summary of medications to avoid in heart failure patients.
AAA: anti-arrhythmic agents

 

A special thank you to my sister, Pharm.D Rawan Ya’acoub, Clinical pharmacist and Research assistant at Jordan university .

References:

[1] Kostis JB, Lacy CR, Cosgrove NM, Wilson AC. Association of calcium channel blocker use with increased rate of acute myocardial infarction in patients with left ventricular dysfunction. Am Heart J. 1997 May;133(5):550-7. doi: 10.1016/s0002-8703(97)70150-9. PMID: 9141377.

[2] Ungprasert P, Srivali N, Kittanamongkolchai W. Non-steroidal anti-inflammatory drugs and risk of heart failure exacerbation: A systematic review and meta-analysis. Eur J Intern Med. 2015 Nov;26(9):685-90. doi: 10.1016/j.ejim.2015.09.012. Epub 2015 Oct 1. PMID: 26427540.

[3] Singh S, Loke YK, Furberg CD. Thiazolidinediones and heart failure: a teleo-analysis. Diabetes Care. 2007 Aug;30(8):2148-53. doi: 10.2337/dc07-0141. Epub 2007 May 29. PMID: 17536074.

[4] Scirica BM, Braunwald E, Raz I, Cavender MA, Morrow DA, Jarolim P, Udell JA, Mosenzon O, Im K, Umez-Eronini AA, Pollack PS, Hirshberg B, Frederich R, Lewis BS, McGuire DK, Davidson J, Steg PG, Bhatt DL; SAVOR-TIMI 53 Steering Committee and Investigators*. Heart failure, saxagliptin, and diabetes mellitus: observations from the SAVOR-TIMI 53 randomized trial. Circulation. 2014 Oct 28;130(18):1579-88. doi: 10.1161/CIRCULATIONAHA.114.010389. Epub 2014 Sep 4. Erratum in: Circulation. 2015 Oct 13;132(15):e198. PMID: 25189213.

[5] Kinsara AJ, Ismail YM. Metformin in heart failure patients. Indian Heart J. 2018 Jan-Feb;70(1):175-176. doi: 10.1016/j.ihj.2017.05.009. Epub 2017 May 15. PMID: 29455774; PMCID: PMC5902828.

[6] Behnam SM, Behnam SE, Koo JY. TNF-alpha inhibitors and congestive heart failure. Skinmed. 2005 Nov-Dec;4(6):363-8. doi: 10.1111/j.1540-9740.2005.04502.x. PMID: 16276152.

[7] Chung ES, Packer M, Lo KH, Fasanmade AA, Willerson JT; Anti-TNF Therapy Against Congestive Heart Failure Investigators. Randomized, double-blind, placebo-controlled, pilot trial of infliximab, a chimeric monoclonal antibody to tumor necrosis factor-alpha, in patients with moderate-to-severe heart failure: results of the anti-TNF Therapy Against Congestive Heart Failure (ATTACH) trial. Circulation. 2003 Jul 1;107(25):3133-40. doi: 10.1161/01.CIR.0000077913.60364.D2. Epub 2003 Jun 9. PMID: 12796126.

[8] Køber L, Torp-Pedersen C, McMurray JJ, Gøtzsche O, Lévy S, Crijns H, Amlie J, Carlsen J; Dronedarone Study Group. Increased mortality after dronedarone therapy for severe heart failure. N Engl J Med. 2008 Jun 19;358(25):2678-87. doi: 10.1056/NEJMoa0800456. Erratum in: N Engl J Med. 2010 Sep 30;363(14):1384. PMID: 18565860.

[9] Songbo M, Lang H, Xinyong C, Bin X, Ping Z, Liang S. Oxidative stress injury in doxorubicin-induced cardiotoxicity. Toxicol Lett. 2019 Jun 1;307:41-48. doi: 10.1016/j.toxlet.2019.02.013. Epub 2019 Feb 25. PMID: 30817977.

[10] Nemeth BT, Varga ZV, Wu WJ, Pacher P. Trastuzumab cardiotoxicity: from clinical trials to experimental studies. Br J Pharmacol. 2017 Nov;174(21):3727-3748. doi: 10.1111/bph.13643. Epub 2016 Nov 25. PMID: 27714776; PMCID: PMC5647179.

[11] Wu CK, Lin JW, Wu LC, Chang CH. Risk of Heart Failure Hospitalization Associated With Cilostazol in Diabetes: A Nationwide Case-Crossover Study. Front Pharmacol. 2019 Jan 7;9:1467. doi: 10.3389/fphar.2018.01467. PMID: 30666197; PMCID: PMC6330376

[12] Teply RM, Packard KA, White ND, Hilleman DE, DiNicolantonio JJ. Treatment of Depression in Patients with Concomitant Cardiac Disease. Prog Cardiovasc Dis. 2016 Mar-Apr;58(5):514-28. doi: 10.1016/j.pcad.2015.11.003. Epub 2015 Nov 10. PMID: 26562328.

[13] Hundemer GL, Knoll GA, Petrcich W, Hiremath S, Ruzicka M, Burns KD, Edwards C, Bugeja A, Rhodes E, Sood MM. Kidney, Cardiac, and Safety Outcomes Associated With α-Blockers in Patients With CKD: A Population-Based Cohort Study. Am J Kidney Dis. 2021 Feb;77(2):178-189.e1. doi: 10.1053/j.ajkd.2020.07.018. Epub 2020 Sep 11. PMID: 32920153.

[14] Lund M, Poulsen G, Pasternak B, Worm Andersson N, Melbye M, Svanström H. Use of Pregabalin and Worsening Heart Failure: A Nationwide Cohort Study. Drug Saf. 2020 Oct;43(10):1035-1044. doi: 10.1007/s40264-020-00969-6. PMID: 32651945

[15] Kotecha D, Flather MD, Altman DG, Holmes J, Rosano G, Wikstrand J, Packer M, Coats AJS, Manzano L, Böhm M, van Veldhuisen DJ, Andersson B, Wedel H, von Lueder TG, Rigby AS, Hjalmarson Å, Kjekshus J, Cleland JGF; Beta-Blockers in Heart Failure Collaborative Group. Heart Rate and Rhythm and the Benefit of Beta-Blockers in Patients With Heart Failure. J Am Coll Cardiol. 2017 Jun 20;69(24):2885-2896. doi: 10.1016/j.jacc.2017.04.001. Epub 2017 Apr 30. PMID: 28467883.

[16] Michel A, Martín-Pérez M, Ruigómez A, García Rodríguez LA. Risk factors for hyperkalaemia in a cohort of patients with newly diagnosed heart failure: a nested case-control study in UK general practice. Eur J Heart Fail. 2015 Feb;17(2):205-13. doi: 10.1002/ejhf.226. Epub 2015 Jan 10. PMID: 25581138.

“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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In pursuit of power productivity: key mindsets for career success from an MD MBA director (part 1)

In Santa Clara County, 75.6% of individuals (12 years+) are currently fully vaccinated. With cases of COVID-19 down and street traffic on the rise, it is clear that the “normal” I once dreamed of is quickly approaching. I am a postdoctoral researcher at Stanford University. In the laboratory, most restrictions are gone; there are no shifts, no distancing limits, and no limited room capacities. Yet, I still feel like I’m struggling. I still feel like I’m functioning at reduced productivity levels. While I completely acknowledge that my pre-pandemic lab hours were a bit crazy, and I should be okay with where I am, I want to get back to where I was. To help me with this, I spoke with an expert on productivity and stress, Dr. Steven Chan. Dr. Chan is on faculty at Stanford University, has taught students at the School of Business and School of Medicine, and has spoken and written on mental health at venues such as Google, NPR, and the American Psychiatric Association.

Please describe yourself and your pursuit of improved productivity? 

I am currently a medical director at a busy service in Northern California. I also work on healthcare technology, focusing on projects in the area of digital mental health. I am interested in the application of mental health on technology, and how this can improve people’s lives.

Productivity has always been a lifelong pursuit for me. Growing up, I was always very busy with extracurriculars: music, martial arts, exam prep, newspaper, the list goes on. There was always a lot to do that required a lot of time to excel at it. Then, when I went to college, the pattern continued. Same thing again with work life.

Over time, I’ve realized that it’s not only important to understand how the right tools can help you get more done, but also how to identify the right work to tackle.

What do you mean by “right work?” How do you decide where to invest your time?

When I am approached with a new opportunity, I choose to take on new projects based on three criteria:

  1. Enjoyment. Is this something I enjoy doing? Do I have good feelings?
  2. Skills. Am I good at this task? Or, is this an opportunity to learn new skills?
  3. Returns. Is there a return on investment (ROI)? This return doesn’t have to be purely financial and monetary; it could be rich in social connections. It could be valuable for your organization and yourself.

Ideally, new projects would have all three. Otherwise, a project would be imbalanced. Take enjoyment, for example. If a project involved evaluating pizza, well, I enjoy eating pizza, but it doesn’t take much skill and it’s unlikely someone would pay me to eat pizza.

Time is your most precious commodity. In careers such as medicine and science, there is an abundance of work and projects. Choose to do things that you enjoy, you are skilled at, and are worth your time.

I find myself saying “yes” to a lot of things — and I get overwhelmed! How do you say “no”? How do you deal with feelings that you are passing up on an opportunity?

Anytime you say “yes” to something, you have to be aware that you are saying “no” to other opportunities.

When people think about the Fear of Missing Out (FOMO) or the fear of disappointing others, they think that they are permanently closing the door on an opportunity. This is simply not true.

In the past, I used to say “yes” to a lot of opportunities because I didn’t know where to best invest my time. The key to choosing good opportunities is to first have a good bird’s eye view of the opportunities out there. This requires some work and reflection. Know all the things going on in your life, identify your goals and values, and then get to know all the opportunities available to you. And after doing all this, make commitments using the three criteria we discussed earlier.

One final point, have regularly-scheduled reviews of your commitments. Do a weekly assessment, think about all the things you want to accomplish in a week, a month, and a year. Then adjust your commitments to ensure your maximal efforts line up with your long-term goals.

I feel like I am always short on time. What are the top 3 things I can do to help me with my productivity?

There are a lot of calendar hacks and to-do tips out there. But having the right mindset is critical before taking on new apps and new techniques:

Keep experimenting. There is no one perfect solution or single app that will organize your life. However, there is a whole community out there devoted to time optimization and productivity. These solutions and best practices evolve and change as you move through life. For example, when I transitioned from medical school to the work world, I quickly realized that it was no longer sufficient to write things down on paper. So, I turned to automated calendars. Now I use Busycal and Google Calendar, with Outlook at my main job.

Do reflections and get to know yourself. You can’t understand what you are good at, what you enjoy, and what you want in life without self-reflection. I remember going through the motions of classes and training, and it wasn’t until I got to stop and reflect that I truly was able to ensure a better balance between work and self-care.

Know your energy levels. For example, I know that I can’t get anything done in the evenings because I’m exhausted. When I was in medical school, I used to beat myself up over this because I felt the need to study every evening. But, now I know that I have much more energy in the mornings and commit more time to getting work done then. In addition to knowing when you work best, you can hack your energy levels by optimizing caffeine intake and exercise to boost energy levels when required.

Lastly, adjust your surroundings. Equip yourself with the right technology — fast, reliable computers; fast, reliable internet; and fast, reliable smartphones. Surround yourself with the right people to maximize your output. The energy levels of your peers matter. Establishing an environment with minimal toxicity and drama is essential. Do this at work, at home, and in your relationships.

How do you quiet that inner critic? How do you deal with feelings that you are not doing enough or not making enough progress?

Recontextualize or reframe this to determine if this feeling of inadequacy is true. Again, make time for reflection. List out all your projects and accomplishments, and then assess if you really are not doing enough. Ideally, a therapist, counselor, or coach can help you with this reflection — but there are so many worksheets and courses on the internet to guide you in doing the same.

Every year, instead of making New Year’s resolutions, I assess all the things I have done and the things I have failed at. Yes, I keep a failure list, which sounds horrifying. I can’t tell you how many internships, jobs, relationships, and projects of mine have failed! But, I feel having a list of failures is an important step in beating perfectionism. A failure isn’t a bad thing. It means you are experimenting! Experimentation is good, leads to growth, and helps you learn. While failure can be a brutal blow to self-esteem, we need to fail in life. Failure provides feedback. In fact, if we have repeated failures, this tells us that we need to make significant changes in what we’re doing!

Are there resources that you would suggest to help with improved productivity and mental health?

Take a look at articles published in the business world regarding productivity and human performance. In business, people want to get the most out of their precious resources: time, money, and human resources. Read up on project management techniques, as these will help you run efficient labs, manage clinical teams, and even run research papers and grant-writing projects.

Where can you find these? A major resource is a library or even your HR team: many universities and workplaces have access to LinkedIn Learning and Skillshare. And, Mental Power Hacks — the website I run — plus my social media feeds at @mpowerhacks, also feature a lot of these techniques. I know this is a lot, and you won’t conquer it all in one sitting, but incorporate this learning in your routines to build these skills over time.

Thank you so much for these! In our next blog entry, we’ll talk about how to improve your productivity by managing relationships in both work and social life.

 

“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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Bridging the Disparity Gap in Cardiovascular Health in Transgender and Gender Diverse Population: Insight into the Scientific Statement from the American Heart Association

In recent years, there has been increased attention to health-related disparities experienced by the transgender and gender diverse population (TGD).  In fact, it has become a public health priority to improve the health, safety, and well-being of lesbian, gay, bisexual, and transgender people in the U.S. Therefore, one of the Healthy People 2030 goals is to target the collection of data on LGBT health issues to help inform effective health promotion strategies for LGBT people.1  The topics of adolescents, drugs and alcohol use, mental health issues, sexually transmitted infections, and our public health infrastructure are highlighted as key objectives for the Healthy People 2030 Goals.1

Nearly a decade ago, the 2011 report from The Institutes of Medicine (IOM) highlighted the need to look at the distinct health concerns and needs of the TGD community and its subgroups. It also reported on the importance of understanding differences based on race, ethnicity, socioeconomic status, geographic location, age, and other factors among lesbians, gay men, bisexual men and women, and transgender people.2  Based on the 2011 IOM report, lesbians and bisexual women encounter higher rates of breast cancer than heterosexual women. The data on whether lesbians had a higher risk for cardiovascular disease was conflicting at the time. Limited research suggested that transgender groups may experience negative health outcomes, because of long-term hormone use.2

Recent studies suggest that trans people appear to have an increased risk for myocardial infarction and death due to cardiovascular disease when compared to cisgender people.  In studies that followed trans people on hormone therapy, the rates of myocardial infarction and stroke were consistently higher in trans women than trans men. Estrogen therapy for trans women has been reported to increase their risk for venous thromboembolism.3  This presents opportunities for screening TGD groups for cardiometabolic risk factors in much the same way as their cisgender counterparts.4  A recent scientific statement from the American Heart Association emphasizes on the importance of screening and risk reduction for cardiovascular disease in TGD people.

In this scientific statement, distal and proximal minority stressors are presented, which may contribute to higher overall stress levels that can increase the risk for poor mental and physical health outcomes in TGD individuals.  The Gender and Minority Stress Resilience model is presented and highlights these factors, as well as the presence of resilience factors that may counteract the effects of transphobic violence and stigma, and promote TGD health equity.5   This Scientific Statement is definitely a step in the right direction to address cardiovascular related health disparities for TGD people.  It addresses the value of Life’s Simple 7 (tobacco use, physical activity, diet, weight status, blood pressure, glycemic status, and lipids), targeting key risk factors towards the reduction of cardiovascular disease.  Other factors such as HIV infection status, vascular dysfunction, alcohol use, lack of sleep, stigma, discrimination, violence, lack of affordable housing and access to health care are also discussed.5

Advancing the cardiovascular health of people who are TGD will require a multifaceted approach that integrates best practices into health promotion, cardiovascular care, and research for this understudied population.  This presents opportunities for innovation in areas such as the electronic health record, especially to capture sociocultural factors relevant to heart health among TGD groups. Longitudinal research examining psychosocial, behavioral, and clinical determinants of optimal cardiovascular health in TGD people at the individual, interpersonal, and structural levels is also advocated. Healthcare professionals and clinician training on the proper assessment of sex and gender in healthcare settings, and identification of TGD health disparities will also be necessary to the identification of interventions and the reduction of disparities experience by TGD groups.5

In conclusion, the recent Scientific Statement from the American Heart Association on TGD people highlights the unique, health care needs of TGD individuals. It also highlights opportunities to improve their health status though screening and preventive lifestyle practices incorporating Life’s Simple 7. Clinician education and training on the psychosocial, cultural, behavioral, and biological factors in TGD people may help bridge the gaps in cardiovascular care for these groups.

References:

  1. S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2030. LGBT: Goal: Improve the health, safety, and well-being of lesbian, gay, bisexual, and transgender people. https://health.gov/healthypeople/objectives-and-data/browse-objectives/lgbt. Published 2020. Accessed July 13, 2021.
  2. Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington (DC): National Academies Press (US); 2011. https://www.ncbi.nlm.nih.gov/books/NBK64806/ doi: 10.17226/13128. Accessed July 12, 2021.
  3. Irwig MS. Cardiovascular health in transgender people. Rev Endocr Metab Disord. 2018;19(3):243-251. doi:10.1007/s11154-018-9454-3
  4. Slack DJ, Safer JD. Cardiovascular health maintenance in aging individuals: the implications for transgender men and women and hormone therapy. Endocr Pract. 2021;27(1):63-70. doi:10.1016/j.eprac.2020.11.001
  5. Streed CG Jr, Beach LB, Caceres BA, et al. Assessing and Addressing Cardiovascular Health in People Who Are Transgender and Gender Diverse: A Scientific Statement from the American Heart Association [published online ahead of print, 2021 Jul 8]. Circulation. 2021; CIR0000000000001003. doi:10.1161/CIR.0000000000001003

“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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Goodbye Self-Inflicted Intimidation and Hello Learning: A fellow’s experience working with Dr. Rick Nishimura

“Don’t speak out, you may answer incorrectly and embarrass yourself.” This thought was not uncommon during my first two years of fellowship. Yes, I evolved out of this which is why I am sharing my experience. At the same time, I am here to tell you to not make this mistake early in fellowship.

You may or may not have heard of Dr. Rick Nishimura, a master clinician, and educator of cardiovascular hemodynamics. You may have seen his name authored in many of the national guidelines or his face at national and international conferences. Now, imagine him (or your own respective master clinician-educator at your own program) leading weekly hemodynamic sessions and asking escalating difficult questions to the audience. Would you answer? How confident would you need to be to articulate this out loud?

I am about a month away from completing my general cardiology fellowship (my 3 years were slightly extended from two maternity leaves) and I have had time to reflect on my clinical experience. I remember my first year sitting in our auditorium and can vividly recall answering a question about x and y descents incorrectly in front of everyone. I rarely spoke out again for the rest of that year.

As a third-year at the Mayo Clinic, I had the opportunity to work in “Nish” clinic amongst a handful of other fellows and participate in his hemodynamic sessions. Every fellow before me, alongside me, and after me all feel the same way: to work with him requires a great deal of preparation and meticulous chart review of patients, repetitive review of all the guidelines, and an attempt at reading published research relevant to each case. The more I thought about it, it became clear that I had a unique opportunity to challenge myself before graduating. I’m glad I did.

I’d like to share reflections, learning pearls, and takeaways from my experience working with and learning from Dr. Nishimura:

  1. Find passionate clinician educators early in training and don’t be timid about learning from them.

The way he lectures to hundreds of people in a room is the exact way he teaches you and it is incredibly motivating. By explaining complicated pathophysiology with such simplicity, I became deeply entrenched in the learning process. I cannot overemphasize the hours I spent preparing for the potential questions he might ask yet I still left clinic with at least 4+ things to look up, feeling inspired and motivated to be a better learner and educator. This is the art of teaching.

  1. Do a good physical exam and use it to determine whether the rest of the workup is concordant or discordant.

One example I learned was the location of the P2 component of S2 on the chest can tell you the degree of elevated pulmonary pressure.

  1. Look at the data (i.e. echocardiograms) yourself.

Avoid only reading reports as they can sometimes mislead you into making life-altering management decisions for patients. For example, do not accept pulmonary artery systolic pressures without looking at the tricuspid valve regurgitant Doppler profile yourself. Confirm if this was measured correctly because it can change management.

  1. Know the guidelines but understand that not all patients fit perfectly in them.

An elderly woman with severe aortic stenosis may be eligible for both SAVR and TAVI, which stresses the importance of individualization and shared decision-making with the patient and heart valve team.

  1. Communication with the referring provider and follow up with the patient cannot be overstated.

Reaching out to referring providers via letter and phone will develop your communication skills, professionalism, and collaborations. Following up with the patient is not only the right thing to do but also allows you to learn whether your management decision resulted in the best outcome for your patient or if there is a learning opportunity for the next patient who presents similarly.

  1. Teach one another.

Create an environment where you are sharing cases with your co-fellows and colleagues and practice teaching to one another with the hope that one day with dedication you will also inspire trainees.

  1. Lastly, do not be afraid to ask questions and answer questions. Even when you are intimidated.

I eventually told Dr. Nishimura how intimidated I initially felt. If you haven’t had the privilege of meeting him, he is one of the most down-to-earth and welcoming teachers you will ever come across. He laughed and said there was nothing to be intimidated about. Many of the questions you have in your head are also questions others have. In that light, more learning, engaging, and teaching can occur if you allow yourself to.

 

“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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National and worldwide blood shortage, we need blood! But we don’t want YOUR blood!

Back in Colombia, the minimum age to donate blood was 18 years old, coinciding with the minimum legal drinking age and attending bars. The excitement to party causes a lot of expectancy to everyone’s 18th-year-old birthday, and although I love to party, I was looking forward mostly to be able to donate blood. As I was finishing the first semester of medical school, I had wanted to be a regular blood donor. I saw it as a way of walking the talk of being a physician that wanted to advocate for healthcare beyond the mere consult room, and to be honest, how much does it cost to most of us to donate blood? A few minutes of our time. How much does it mean to someone that needs it? Everything.

On my 18th birthday, before my party, the first order of business was to donate blood as I was finally eligible! I arrived with my mom at the Red Cross, and I filled out some questionnaires and headed to see the physician for further questions. As she reviewed my questionnaire, she mentioned that I had stated that I had sex with men; thus, I was not eligible to donate blood. I was in shock; I tried to explain that I have never had any risky behavior and that, at that recently, I only had sex with a woman. She then elaborated that even if it was with one man, I could not donate blood ever, as I was at risk of transmitting HIV or hepatitis. I then told my mom that my hemoglobin levels were low, so I needed to return in a few weeks. I must admit, this was a heartbreaking moment in my life, which added another layer of burden to the journey of self-acceptance as a bisexual man because my blood was undesirable because of who I am.

The emergency of the HIV and AIDS pandemic during the ‘80s initially identified groups that had a higher risk for having HIV and potentially transmitting it with blood transfusions; these were men who have sex with men (MSM), heterosexual commercial sex workers, and intravenous drug users.1To reduce the risk of transmissions, the FDA put a first donor deferral policy to identify if the persons were in the high-risk groups to prevent them from donating blood. Since 1985 and until December of 2015, the FDA recommended blood establishments to ban FOREVER, indefinitely, for a lifetime, male donors who had sex with another male, even if it was only a one-time encounter. The reason behind this preposterous and anachronic decision, according to the FDA, was “due to strong clustering of AIDS illness and subsequent discovery of high rates of HIV in that population (MSM).”2

In 1988 the Blood Donation Rules Opinion Study (BloodDROPS) found that the prevalence of HIV infection in men that reported male-to-male sexual contact was 0.25%, much lower than the previously thought 11-12%, which could have been a strong argument towards the discriminatory life ban of blood donation to MSM.1

In addition to prejudice-based decisions, a question arises, even if there is a higher prevalence in MSM, doesn’t HIV exist in heterosexual people? Doesn’t their blood get screened as well? Yes, HIV also exists in heterosexual people (currently account for 23% of all HIV diagnoses)3 and yes, ALL blood gets tested. Although surveys rely on the honesty of people and serve as a first screening, according to the CDC, all blood that is collected undergoes rigorous testing for HIV, Hepatitis B virus, HCV, HTLV, syphilis, West Nile virus, and Zika virus.4 Additionally, modern HIV tests can identify HIV as early as ten days after infection.

In 2015 the FDA lifted the lifetime ban for homosexual, bisexual, and MSM to donate blood, if they abstained from having sexual contact with other men for 12 months. Although an improvement from the previous ban, the policy was still highly discriminatory and baseless from science, as it assumes that all homosexual sexual interactions are high-risk interactions. This new policy meant that a male, homosexual, monogamous couple that takes drugs to prevent HIV (PreP) would not be able to donate blood if they did not abstain from sex for a year. Still, a man in a heterosexual monogamous couple that does not use protection was by default consider eligible for donation. Thus, once again, attaching the label of presumptive HIV carrier to all bisexual and gay men.

The latest change on these policies was last year during the peak of the COVID-19 pandemic. Facing severe blood shortages nationwide, the FDA randomly reduced the deferral period of sexual abstinence from 12 months to 3 months; no new data was presented to suggest such changes. 4 Agreeing with what Jon Oliveira said to the American Journal of Managed Care regarding this abrupt policy change, “The FDA’s decision to ease restrictions on blood donations from men who have sex with men proves what medical experts have been saying for decades: that this ban is not based in science but rather discriminatory politics. The FDA’s policy change is a sign of progress—even if forced by the needs of the current crisis—but we must follow the science and continue fighting for a complete end to this archaic, demeaning ban.” 2

The risk of contracting HIV and other blood-transmitted diseases is not linked to one’s sexual orientation or gender identity. They are linked to the actions we take as individuals. Individualizing high-risk behavior (multiple partners, no condom usage, IV drug use, etc.) instead of stigmatizing a particular sexual orientation would still serve its purpose of screening before blood donation. It would allow thousands of bisexual and gay man that want to donate blood. It would put an end to a discriminatory policy that perpetuates the narrative of an unequivocal link between HIV and MSM.

But there is hope after all. While researching for this blog, I found that there is a multicenter clinical trial taking place in various cities ( San Francisco, Los Angeles, New Orlean&Baton Rouge, Memphis, Atlanta, Orlando, Miami, Washington), named the ADVANCED study (Assessing Donor Variability And New Concepts in Eligibility). This pilot study is focused on the FDA’s deferral policy for MSM. The purpose of the study is to determine if different eligibility criteria for a bisexual and gay man can be used, such as an additional history questionnaire, to assess individual risk for HIV, instead of deferring our blood donation according to our last male-to-male sexual contact. The study will be groundbreaking and be the first big step towards changing blood donation eligibility criteria for bisexual and gay men.

I enrolled for the study and will have my first appointment in 3 weeks, I’ beyond thrilled to be part of this trial, so I encourage all bisexual and gay men who reside in these cities to participate in the study. The results of this study are likely to contribute and provide yet another evidence to make the FDA eliminate this prejudice ban permanently. We must gain our dignity in every field of life, and small steps such as getting equal treatment in blood donations is the right step forward.

ADVANCE study: https://advancestudy.org

References:

  1. https://www.fda.gov/media/92490/download
  2. https://www.ajmc.com/view/fdas-revised-blood-donation-guidance-for-gay-men-still-courts-controversy
  3. https://www.hiv.gov/hiv-basics/overview/data-and-trends/statistics)
  4. https://www.cdc.gov/bloodsafety/basics.html
  5. https://www.cnn.com/2015/12/21/health/fda-gay-men-blood-donation-changes/index.html

“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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Diet, Fat, and Healthy Heart

What type of milk do you prefer? Most people will give you their answers quickly without much hesitation. Besides taste and flavor, whether to choose whole milk (~3.5% fat), reduced-fat milk (2% fat) or skim milk (0% fat) depends mostly on how much fat do you prefer in your diet. Reduced fat milk and skim milk have become the poster children for heart beneficial diets in the past decades. The long-held belief that fat is bad for your heart originates from a famous epidemiology study conducted by Ancel Keys and colleagues1.

Ancel Keys’ Seven Countries Studies influenced dietary recommendation on fat for decades. Keys believed that fatty foods such as dairy products and red meat are the culprit for coronary heart disease. He studied diet, lifestyle, and incidence of coronary heart diseases in about 13,000 adult men in Finland, Greece, Italy, Japan, the Netherlands, the United States, and Yugoslavia1, and found that countries with diets high in saturated fat including the United States have the highest blood cholesterol levels and heart-attack death rates. Based on Keys’ studies and other similar findings, the United States and the United Kingdom introduced dietary guidelines which recommend reducing consumption of saturated fat to about 10% of total energy intake, to lower cholesterol in the blood and therefore decrease the risks of a heart attack. A low-fat diet has been associated with good health practices ever since. Here is a twist to this story, Keys didn’t include France, where the nation’s high-fat diet doesn’t correlate with the occurrence of heart diseases. It turns out to be the opposite.

Not all fat is created equal. Let’s take milk fat for example. Milk fat contains a variety of fats such as saturated fat, unsaturated fat, and trans-fat. Generally, trans-fat is considered as “bad” fat in processed foods and fried foods, however, naturally found trans-fat in milk is beneficial. Another example is cholesterol. It’s taken for granted to associate dysregulated blood cholesterol levels with dietary cholesterol intake. In fact, it’s not cholesterol itself that causes high blood cholesterol levels, but rather the lipoproteins that move cholesterol in and out of cells. Broadly, there are the “good” cholesterol– high-density lipoprotein (HDL) and the “bad” cholesterol­­­– low-density and very-low-density lipoproteins (LDL and VLDL). Seventy percent of milk fat is saturated fat, and saturated fats in milk raise both HDL (good) and LDL (bad) cholesterol. The net effect of milk fat might be neutral. Processed foods, fried foods and stick margarine have lots of trans-fats from production and are known for raising LDL cholesterol and lowering HDL cholesterol.

The “good” and “bad” cholesterol levels are considered as the golden standard for cardiovascular risk prediction. However, recent research shows that high HDL levels in some cases associated with higher risks in heart disease2. The plot is thickened. It turns out that some people with a genetic mutation in HDL receptor gene fail to transport cholesterol outside of blood, therefore results in higher level of fats in the body despite having high levels of HDL cholesterols in the circulation. In conclusion, blindly relying on fat content in the Nutrition label is simply not enough.

Now, let’s go back to the milk choice question one more time. Not only we need to consider what type of fat in cow milk, but we also need to look at other factors too. Sugar is often ignored when it comes to buying milk. Reduced fat and skim milk contain slightly more carbohydrates than whole fat milk does. If your goal is to lose weight by reducing fat content in your milk, you might get disappointed. The relationship between milk fat and weight management is still not clear. An epidemiology study shows that women who consumed more than 1 serving of whole fat milk per day were 15% less likely to gain weight compared to those who drink low fat milk3. Also recent research show that consuming saturated fat does not directly cause heart disease4. Therefore, how much you eat doesn’t necessarily translate to how much will end up in your body. It depends on how you body metabolizes it, what’s your genetic makeup and what else in your diet potentially positively or negatively contribute to the net outcomes. Last not the least, even not all fat creates equal, trans-fat from fried foods and processed foods are still universally considered bad for your health. Try to avoid those if it’s possible.

 

REFERENCE

  1. Keys A. Seven Countries. Harvard University Press; 2013.
  2. Zanoni P, Khetarpal SA, Larach DB, Hancock-Cerutti WF, Millar JS, Cuchel M, DerOhannessian S, Kontush A, Surendran P, Saleheen D, Trompet S, Jukema JW, De Craen A, Deloukas P, Sattar N, et al. Rare variant in scavenger receptor BI raises HDL cholesterol and increases risk of coronary heart disease. Science. 2016;351(6278):1166 LP – 1171.
  3. Rosell M, Håkansson NN, Wolk A. Association between dairy food consumption and weight change over 9 y in 19 352 perimenopausal women. The American Journal of Clinical Nutrition. 2006;84(6):1481–1488.
  4. Weinberg SL. The diet–heart hypothesis: a critique. Journal of the American College of Cardiology. 2004;43(5):731–733.
  5. “The facts on fats infographic” [Image] (2017). American Heart Association. https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/fats/the-facts-on-fats

“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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Patients with concurrent heart failure and kidney disease are not getting proper GDMT

We have all seen the story play out before: a patient with heart failure with reduced ejection fraction (HFrEF) who is new to a hospital system is hospitalized for acute decompensated heart failure. A look at their complete metabolic panel shows a Cr of 2.0 mg/dL (with a corresponding eGFR of 35 mL/min/1.73m2), and despite diuresis, the Cr does not really budge. What was initially thought to be an acute kidney injury from possible renal vascular congestion or from renal hypoperfusion turns out to be a more longstanding chronic kidney disease (CKD). Because the medical team has only met the patient for the first time during this hospitalization and they “do not know where the kidney function is going to shake out,” the patient is perhaps started on a beta-blocker but no other guideline-directed medical therapy (GDMT). The patient is discharged from the hospital on only one guideline-recommended agent. Patients like this, with concurrent HFrEF and CKD, can easily get trapped in a vicious cycle in which they are recurrently hospitalized with heart failure exacerbations and varying degrees of kidney injury; their kidney function becomes an impediment to starting the crucial GDMT which will lower their mortality, reduce their likelihood of being hospitalized again, and even improve their quality of life.

This anecdotal experience is supported by data from a new study published in the Journal of the American College of Cardiology (JACC), “Kidney Function and Outcomes in Patients Hospitalized with Heart Failure.” This study utilized the Get With the Guidelines-Heart Failure (GWTG-HF) registry and analyzed over 365,000 hospitalizations with heart failure, including about 157,000 patients hospitalized for heart failure with a reduced ejection fraction (HFrEF, EF ≤40%). Hospitalized patients had kidney function all across the spectrum, ranging from those with a normal estimated glomerular filtration rate (eGFR) of ≥90 mL/min/1.73 m2 (10% of patients) to those on dialysis (5% of patients). As patients’ eGFR decreased (as kidney function worsened), in-hospital mortality rates for heart failure patients increased from about 1% for those with a normal eGFR to 4-5% for those with an eGFR <30 mL/min/1.73m2 or on dialysis.

Among patients with HFrEF, those with lower eGFR or on dialysis were less likely to be discharged on GDMT such as beta-blockers, mineralocorticoid receptor antagonists, angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), or angiotensin receptor II blocker-neprolysin inhibitors (ARNI), than those with normal renal function. This pattern was consistent regardless of race/ethnicity and sex. Patients with worse renal function (measured as lower eGFR at time of discharge) were also less likely to have an appointment made after discharge.

These disparities in quality metrics for heart failure patients, particularly those with CKD, are disheartening because 1) many patients with heart failure also have concurrent chronic kidney disease and 2) hospitalized heart failure patients with worse kidney function already experience worse clinical outcomes, such as higher mortality (as shown in this and other studies). Though the use of evidence-based medical therapies is often suboptimal among all patients with HFrEF, patients with comorbid HFrEF and CKD are an especially vulnerable group who would especially benefit from treatment with medications that are proven to improve outcomes. Additionally, though they seem to less frequently have post-discharge outpatient appointments made, these patients would benefit from more (and not less) post-hospital monitoring.

This large contemporary study of patients from a major heart failure registry highlights a gap that we must address among heart failure patients at various stages of kidney disease. More work must be done to prevent or slow the progression of chronic kidney disease in heart failure patients. Finally, special attention should be given to the utilization of guideline-directed medical therapy in this vulnerable population of patients in order to help improve their outcomes, particularly when they are hospitalized for acute decompensated heart failure.

“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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Diabetic medications with benefit in cardiac patients

In the past 1-2 years, strong evidence from randomized clinical trials has shown that certain diabetic medications have benefits in cardiac patients, including improved survival [1-3]. One of these medication classes is Sodium glucose co-transporter 2 (SGLT2inhibitors. The DAPA-HF trial showed the benefit of Dapagliflozin [1], EMPEROR trial showed the benefit of Empagliflozin [2] and CANVAS trial showed the benefit of Canagliflozin [3]. Long-term pharmacologic therapy in patients with heart failure with reduced ejection fraction and chronic kidney disease has been evaluated and proved to have survival benefits and reduce the disease progression through multiple mechanisms. In this blog, we will discuss some of the SGLT-2 inhibitors data, doses in diabetes and heart failure, and some of their common side effects.

Mechanism of action: SGLT2- inhibitors ( -gliflozin ) reduce blood glucose by increasing urinary glucose excretion and they reduce the risk of progression of diabetic kidney disease.

 

Agent name

 

Dose in heart failure patients

 

Usual dose for Diabetes Melleitus

 

Initial eGFR to initiate drug therapy

 

 

Side effects

 

 

 

Empagliflozin

 

 

 

 

10 mg once daily

With/without DM

 

 

 

 

10-25 mg once daily ,  taken with or without food

 

 

 

≥45 ml/minute/ 1.73 m2

 

 

 

-Vulvo-vaginal candidiasis

 

-urinary tract infections

 

-bone fractures

 

-thirst and Increased urine out put

 

– hypovolemia / reduced systolic pressure

 

-acute kidney injury

 

-increased risk of lower limb amputation

 

– DKA

 

-Necrotizing fasciitis (Fournier gangrene)

 

– long-term safety not established

 

 

 

 

Dapagliflozin

 

 

 

 

10 mg once daily

With/without DM

 

 

 

 

5-10 mg once daily , taken with or without food

 

 

 

≥45 ml/minute/ 1.73 m2

 

 

 

 

 

 

Canagliflozin

 

 

 

 

100 mg once daily

With type 2 DM

 

 

 

100-300 mg once daily , taken with or without food

 

 

 

≥30 ml/minute/ 1.73 m2

 Table 1: Summary of the doses, acceptable GFR and side effects of SGLT-2 inhibitors.

Abbreviations: GFR (Glomerular Filtration Rate), DKA (Diabetic Ketoacidosis)

     Contraindications and precautions — SGLT2 inhibitors should be avoided in the following clinical settings

  • Presence of type 1 DM.
  • Presence of type 2 DM with prior diabetic ketoacidosis (DKA) or a condition predisposing to DKA (including pancreatic insufficiency, drug or alcohol addiction).
  • Volume depletion or symptomatic hypotension.
  • eGFR <30 ml per minute per 1.73 m2(except for empagliflozin, for which the threshold is <20 ml per minute per 1.73 m2), end-stage kidney disease, or rapidly declining renal function.
  • Presence of the following conditions :
  • Frequent bacterial urinary tract infections or genitourinary yeast infections. •Presence of risk factors for foot amputation (including those with neuropathy, foot deformity, vascular disease, and/or history of previous foot ulceration).

In conclusion, SGLT-2 inhibitors have shown to have benefits in heart failure with reduced ejection fraction and chronic kidney disease. Health care practitioners, including primary care doctors, cardiologists, endocrinologists, nephrologists, clinical pharmacists and nurse practitioners among other members of the health care team, should familiarize themselves with these medications and their doses in order to provide the best care to our patients.

A special thank you to my sister, Rawan Ya’acoub, a clinical pharmacist and assistant professor at the University of Jordan, who helped me write this blog.

References:

  • McMurray JJV, Solomon SD, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA, Ponikowski P, Sabatine MS, Anand IS, Bělohlávek J, Böhm M, Chiang CE, Chopra VK, de Boer RA, Desai AS, Diez M, Drozdz J, Dukát A, Ge J, Howlett JG, Katova T, Kitakaze M, Ljungman CEA, Merkely B, Nicolau JC, O’Meara E, Petrie MC, Vinh PN, Schou M, Tereshchenko S, Verma S, Held C, DeMets DL, Docherty KF, Jhund PS, Bengtsson O, Sjöstrand M, Langkilde AM; DAPA-HF Trial Committees and Investigators. Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction. N Engl J Med. 2019 Nov 21;381(21):1995-2008. doi: 10.1056/NEJMoa1911303. Epub 2019 Sep 19. PMID: 31535829.

 

  • Packer M, Anker SD, Butler J, Filippatos G, Pocock SJ, Carson P, Januzzi J, Verma S, Tsutsui H, Brueckmann M, Jamal W, Kimura K, Schnee J, Zeller C, Cotton D, Bocchi E, Böhm M, Choi DJ, Chopra V, Chuquiure E, Giannetti N, Janssens S, Zhang J, Gonzalez Juanatey JR, Kaul S, Brunner-La Rocca HP, Merkely B, Nicholls SJ, Perrone S, Pina I, Ponikowski P, Sattar N, Senni M, Seronde MF, Spinar J, Squire I, Taddei S, Wanner C, Zannad F; EMPEROR-Reduced Trial Investigators. Cardiovascular and Renal Outcomes with Empagliflozin in Heart Failure. N Engl J Med. 2020 Oct 8;383(15):1413-1424. doi: 10.1056/NEJMoa2022190. Epub 2020 Aug 28. PMID: 32865377.

 

  • Neal B, Perkovic V, Mahaffey KW, de Zeeuw D, Fulcher G, Erondu N, Shaw W, Law G, Desai M, Matthews DR; CANVAS Program Collaborative Group. Canagliflozin and Cardiovascular and Renal Events in Type 2 Diabetes. N Engl J Med. 2017 Aug 17;377(7):644-657. doi: 10.1056/NEJMoa1611925. Epub 2017 Jun 12. PMID: 28605608.

 

 

“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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Cardiac Critical Care Fellowship: Insights From a Fellow Who Recently Completed Her Training

I am pleased to have the opportunity to share the experiences of Dr. Alejandra Gutierrez-Bernal who was one of my general cardiology chief fellows and she recently completed her cardiac critical care fellowship!

Please describe yourself and your prior training.
I am a Latin American woman who loves cardiology, spending time outside, running, swimming, painting, and reading novels. I am the youngest of three and have a baby niece who brightens my days. I was born in Colombia and was fortunate enough to live in different places growing up including Mexico, here in the US and my native Colombia. I did my medical school training in Colombia and then spent some time doing research with my great mentor, Dr. Mina Chung, and Dr. Van Wagoner at the Cleveland Clinic. We studied the molecular mechanisms leading to atrial fibrillation which increased my interest in cardiology as a field. I then did my internal medicine residency at CCF and moved on for my cardiology fellowship at the University of Minnesota. I am currently finishing my critical care fellowship here too.

When and why did you decide to pursue cardiac critical care training?
As a medical student, I was fascinated by cardiology, specifically electrophysiology. I loved to look at ECG’s and try to figure out the exact origin of different PVC’s or arrhythmias. By the end of the residency, I was sure I was going to do electrophysiology. However, during my first year of fellowship, I spent a lot of time in the intensive care unit and everything it involved including VA ECMO, cardiogenic shock, and acute heart failure, and was given enormous autonomy. I found that at the end of the day, I was very tired but felt extremely accomplished and happy. I have had great mentors during my training and one of the people that has influenced me as a person and as a doctor, the most is Dr. Bartos. He is an interventional cardiologist and an intensivist. One day he told me I should think about this as a career and the thought had not occurred to me. The idea stuck with me and now after completing my training I wouldn’t have it any other way.  I have the opportunity to make a difference, establish connections with families and help them when they are most vulnerable. I couldn’t be happier with the choice I have made.

What unique experiences does a cardiac critical care physician who completed a cardiology fellowship have compared to those who pursue cardiac critical care training after completing an anesthesiology residency?
Critical care training is interesting because you work with various specialties. We all have very different perspectives which has made this past year of training so much more enjoyable.  When I approach a patient, I can’t stop myself from looking through the ECG, echocardiogram and think through their hemodynamics imagining what their numbers would be if I had a swan. I manage shock, assess volume responsiveness and fluid status, and use inotropes a little differently given my general cardiology training. My pulmonary critical care colleagues taught me to look at the chest CT and make a mental picture of their pulmonary status and my anesthesia colleagues play with the medications differently. As a cardiologist, the critical care field is very exciting. Our older cardiac patients often have multiple organ systems involved and patients in the other units have more cardiac disease.  This year has been an amazing journey as I go around the other units and look at them from different perspectives, critical care cardiologists fill a gap that was missing.

Why did you choose to stay at the University of Minnesota for cardiac critical care training?
There are three main reasons I wanted to stay here. First and foremost is mentorship. The field of critical care cardiology is newer and having someone to guide me and to aspire to was very important to me. Here I had the opportunity to train with great people who since the early stages of my training pushed me to think out of the box and practice independently, transforming me into a better person and doctor.  The second was the patient population. The University of Minnesota has a great resuscitation team, and we see a multitude of cardiac arrest patients many of whom are treated with VA ECMO. I wanted to have the first-hand experience treating these patients since I believe this is the future of cardiology. And lastly, the research experience. I had protected research time last year which was important to me as I wanted to stay at an academic center and wanted to start building my portfolio in critical care given that my prior research experience had been focused on electrophysiology. Overall, it has been a great experience and I wouldn’t do it any other way.

What are some of the unique aspects of cardiac critical care and general cardiology training at the University of Minnesota?We are lucky enough to have a lot of exposure to mechanical circulatory support. During our general cardiology training, we have several rotations in our intensive care units with our cardiac structural and interventional team which includes our post-arrest patients and the heart failure service with LVAD and transplant patients. We are given a lot of independence with these very sick patients, and I believe that this is what taught me the most and reinforced my decision to pursue critical care. Our cardiothoracic surgeons are very approachable and wonderful team players which makes work so enjoyable and patient care seamless.

What is the balance of your time during your first faculty position (e.g. how many weeks are you on service, do you get protected academic time, etc.)?
I am very excited about starting my first job. I think the balance is perfect for me to start my career. My appointment is 80% clinical and 20% academic. I will have around 13 weeks of service and will be only in the intensive care unit while on service. On my time off service, I will be in the echocardiography lab and will have some clinic. With this, I hope to have a great balance between the sick patients in the ICU and the more relaxing setting  of imaging and general cardiology.

What were you looking for when you were searching for your first attending position?
It was very important for me to be in an academic institution. I like clinical research and the idea of furthering the field is fascinating to me. I was looking for a place that would push me in terms of clinical experience to continue learning and had challenging patients yet provided support and mentorship. The University of Minnesota seemed like the perfect fit. I truly think that what I will be part of, will change the field of resuscitation and save lives, that is why we all signed up for medicine.

What advice do you have for other early career cardiologists?
I think the most important thing is to find and do what makes you happy. If the days are long and tiring but you feel fulfilled at the end of the day, then that is what you should be working for.

Thanks so much for the great advice, Dr. Gutierrez-Bernal!

 

“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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An Experiment with an A.I. Blogging Partner!

This week I wanted to try some new ideas for a blog. Instead of writing it myself, I wanted to test out a new class of artificial intelligence that’s already available, and rapidly expanding in the domain of online media writing. As a blogger, I think it is important to demonstrate what this space is going through in terms of evolution. Therefore, for this monthly blog post, I will be using one of the relatively new Artificial Intelligence (AI) writing generators.

These are applications built on algorithms requiring you to only input a few keywords, or sentences, and then clicking a button and letting the AI generator initiate its programming. The AI will spend some time (only a handful of minutes) and search all over the internet for data, producing a 100% guaranteed unique written article. This type of technology is right now in its infancy stages, and is useful in a limited capacity. But in the next five to ten years, AI of this sort will be immensely more integrated, not just in blogging, but in all types of professional fields.

As a biomedical scientist, I can imagine using an AI generator as an assistant in writing scientific articles that I aim to publish when I generate new research, finalize studies, and have results to share. A medical doctor could use AI writers to assist in composing case reports, as well as discussing details of specific medical treatments, or any other writing task. It’s not hard to imagine a future where many professionals, within academia, or the healthcare system, will be using AI generators to assist them in enhancing, and speeding up content sharing while reducing the time consumption required for writing reports, articles or any other original content.

This is an exciting new technology to embrace as an early career professional. Knowing that my readers (as always, thanks for reading!) are mostly early-career scientists and professionals, I think it’s prudent for me to expose and bring awareness to this emerging technology. With that, I will now share the stage on this blog with the artificial intelligence writing generator called Writesonic. This specific AI generator was picked by me because of its simplicity and affordability. The application only requires me to provide a few keywords, and then provide it time to search and produce a short article that is guaranteed to be unique. There is no “copy-pasting” from somewhere else. And it’s up to me to accept it, and make any changes necessary.

The keywords I provided to seed Writesonic are Heart disease burden novel treatments & prevention strategies. The primer intro I was prompted to provide was this: Heart disease is the number one cause of mortality worldwide. The burden of this disease is set to increase in the coming decades due to longer lifespans, more prevalent sedentary lifestyles, as well as the changing type of diet and food choices that the global population is adapting to. Research towards new preventative measures, as well as new treatment options is of great importance in order to reduce the burden of heart disease on the overall society.

Let’s see what Writesonic produced:

[New Treatments And Prevention Strategies For Heart Disease: A Comprehensive Update

Heart disease is the number one cause of mortality worldwide. The burden of this disease is set to increase in the coming decades due to longer lifespans, more prevalent sedentary lifestyles, as well as the changing type of diet and food choices that the global population is adapting to. Research towards new preventative measures, as well as new treatment options is of great importance in order to reduce the burden of heart disease on the overall society.

What is heart disease?

Heart disease is a term that is used to describe conditions that affect the heart and its chambers (cardiac chamber). Heart disease can be classified as either coronary artery disease or ventricular heart disease. Coronary artery disease is the narrowing of the coronary arteries and the accumulation of plaque, which can lead to a heart attack. Ventricular heart disease is the weakening or malformation of the chambers that give the heart its ability to pump blood, leading to a similar heart attack or a stroke. Approximately 50% of heart disease is due to coronary artery disease. Of this group of diseases, only 50% will progress to cause a heart attack. The remainder are considered non-major conditions, but the symptoms and outcomes can be much worse.

Prevention Strategies

Heart disease is often prevented in its early stages, where the average life expectancy is around 5 years. The first step in the prevention strategies is to prevent a number of risk factors that can cause heart disease, such as high blood pressure, obesity, diabetes, smoking and an unhealthy diet. Some of the proposed strategies for the prevention of heart disease are: Studies show that the common components of heart healthy diets include: vegetables, whole grains, fruit, nuts, low fat dairy products, tea and coffee. Progression to clinical cardiovascular disease can be delayed and even reversed if found in the earlier stages of the disease. Weight gain to obesity may cause a number of health problems, Weight loss is the most important factor in the prevention of heart disease.

Diagnosis and treatment

Heart disease is a major risk factor for death, in both men and women. It is also considered a major cause of morbidity and mortality. Heart disease encompasses all types of conditions in which the heart is significantly damaged. Conventionally, the most common approaches for the treatment of heart disease are drug therapy and surgical intervention. In general, heart disease is caused due to a build-up of atherosclerosis.

Conclusion

Heart disease is a major cause of death worldwide. New therapies and preventative strategies are being developed to reduce the risk of heart disease, as well as new targeted therapies to treat certain forms of the disease. Heart disease is highly complex and the available knowledge and research on the condition is constantly changing.]

 

Alright, I’m back! Here’s my review: Writesonic is one of the better, but not top of the line, expensive options, so presumably there is a level of competence above what we saw here. The user-friendly and low threshold to entry and use of this AI content generator is very attractive. It allows folks like us, outside of the daily need for such a product, to actually jump in and try this stuff out. The actual end-product, the content, is however way below our “subject matter experts” viewpoints, and for many of us, our “technical precision” will quickly find the overly generalized way the AI writes leaves a lot to be desired.

Without burdening you with another example, I did the same exercise with a different AI writing generator called Rytr, which functions similarly to Writesonic. The final content output was remarkably similar in length and depth of information. This research provided me with enough data to understand where the technology has broadly reached. I see no way for these AI assistants and algorithms to be sufficiently up to date with scientific literature and novel science at this moment. Being able to scan and extract information from original research articles and academic publications is a step (or a mile) out of the general AI writer mandate, for the time being (but surely in a few years this will not be the case).

So, in the end, I’ll say this: AI writers have a great potential to be useful in fields of research and medical writing, but for now, they’re a few years away from that utility. Having said that, for early-career professionals, I say keep an eye on this, you’ll probably be using it by the time you’re at a later stage in the career path you’re on currently!

 

“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.”