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Cardiovascular diseases in women: the heart of the matter

It was 4 am one winter night on call when I got paged:

“Youngish diabetic female, mid-thirties, chest pain for a few hours. Unremarkable ECG. Let me send troponins and see. Doesn’t seem cardiac.”

“Doesn’t seem cardiac”

Dismissed, just like that, because she was young, and because she was a woman.

A proper listen to her symptoms revealed that this could indeed, be cardiac. She was admitted, her troponins were raised, a coronary angiography done a few hours later showed an occluded principal obtuse marginal branch which was stented. She was symptom-free the same day.

Fortunately for her, a definitive culprit lesion in her coronaries could be identified, that was amenable to stenting and thus treated. For the majority of women with non-obstructive coronaries, presenting with myocardial infarction with non-obstructive coronary arteries (MINOCA)1 or ischemia with no obstructive coronary arteries (INOCA), investigations would very likely have stopped right there, with that normal coronary angiography. Dismissed.

CVD in women

Cardiovascular disease (CVD) is the number one cause of mortality among women across the globe.2 Despite improved treatment algorithms and the enormous strides made in cardiovascular care, women continue to have worse clinical outcomes than men, partly owing to them being underdiagnosed, understudied and undertreated.

One size does not fit all: A spectrum of differences

The inherent biological differences between men and women, in addition to the socio-cultural attributes of gender, mean that women have very different characteristics of ischemia in terms of symptoms, triggers, and aetiologies.3

Symptoms: While chest pain is the predominant presenting symptom in both men and women in acute coronary syndrome (ACS), historically, women have been known to present with more “atypical” symptoms such as neck pain, fatigue, dyspnea or nausea, often triggered by emotional stress but even this time-honored notion has been challenged by a recent study that found that typical symptoms were more common among women and have greater predictive value in women than in men with myocardial infarction.4

Co-morbidities: Women with ACS are known to be older, with a clustering of risk factors and greater prevalence of co-morbidities.3  Particularly, diabetes, smoking and a family history of ischaemic heart disease have been shown to have a stronger impact on event rates among women.3 Younger women with ACS have been found to have a worse pre-event health status (both physical and mental) in comparison to men.5

The age paradox: Premenopausal women are thought to be relatively protected against CVD compared to similar-aged men, owing to favorable effects of estrogen on cardiovascular function and metabolism. Intriguingly though, recent studies report an increase in hospitalization rates of ACS among young women, despite a decline among younger men. The mechanisms behind these differences remain a fairly understudied area.

Delayed presentation: Women are also known to present later, frequently attributing their symptoms to a non-cardiac-related condition such as acid reflux, stress, or anxiety.2,3 This inaccurate symptom attribution, in addition to a lack of awareness of risk, and barriers to self-care in general, lead to a delay in seeking treatment, contributing to poorer outcomes.

Different etiologies: By virtue of an obstructed coronary artery, my patient got lucky in terms of prompt diagnosis and treatment. In about 10% of all patients, and in about a third of women, such a culprit coronary lesion cannot be identified on angiography.2,3 Furthermore, microvascular angina affects close to a half of patients with non-obstructive coronary arteries.7 This coronary microvascular dysfunction (CMD) is defined as the presence of symptoms and objective evidence of ischemia in absence of obstructive coronary artery disease, with blood flow reserve and/or inducible microvascular spasmAngina with no obstructive coronary arteries is twice as prevalent in women as in men, 7 and might also contribute to the pathogenesis of heart failure with preserved ejection fraction (HFpEF), which is also more commonly observed in women.9

Women are still under-studied in clinical trials

In the face of such a formidable gender disparity in CVD, women continue to be under-represented in some areas of cardiovascular clinical trials, particularly in ischaemic heart disease and heart failure drug trials, the most common cardiovascular conditions affecting women. In fact, a number of pivotal cardiovascular drug trials of 2019 had less than a quarter of women enroll.12-15 Interestingly, the PARAGON-HF trial, where 51.7% of patients were women, found a heterogeneity in treatment response: women with HFpEF responded better to valsartan-sacubitril, with a 28% reduction (rate ratio 0.73) in the primary endpoint.

In a compelling 2018 editorial, doctors Pilote and Raparelli explore the practical reasons for under-enrollment of women in cardiovascular drug trials, notably male-patterned inclusion criteria and gender-related barriers to screening and participation in trials, such as caretaking roles and low socioeconomic status. While proposing interventions to mitigate this issue (childcare and such support for women during time spent as a research participant, inclusion criteria that consider sex differences in pathophysiology, prespecified subgroup analyses, etc.), they warn that such under-representation of women could lead to sex-biased outcome measurements and missed opportunities to transfer results in clinical practice.

The issue, in essence, is not just about researching CVD in women: even within this large cohort, differences in symptoms, presentation and outcomes, heterogeneity related to age, ethnicity and geographic locations exist. Why younger women with ACS tend to have unfavorable prognoses is an as-yet unanswered question, with huge scope for research, as is microvascular dysfunction, known to be more prevalent among women.

What can be done?

With February being national heart month, and the American Heart Association’s #GoRedForWomen campaign soaring at its highest, it seems like a good time to reflect on what can (and should) be done for women with CVD. Because there is plenty left to do.

Raise awareness: It’s vital that both women and men are aware that heart disease is as big a killer in women as in men. The AHA’s signature women’s initiative Go Red for Women (https://www.goredforwomen.org/) and the sub-initiatives of Wear Red Day are great platforms dedicated to increase women’s heart health awareness. The Women’s Heart Alliance (https://www.womensheartalliance.org/) is another organization working to promote gender equity in research, prevention, awareness and treatment.

Enroll more women in clinical trials: it’s important to identify barriers accounting for the low inclusion of women in clinical trials, and actively intervene to overcome them.

Women’s Heart Health Clinic: a number of programs have successfully initiated women’s heart health clinics, exclusively catering to the diagnosis and treatment of this often-underestimated patient group.

Get more women involved: at every level, be it as clinical trialists, advocates, physicians, nurses or other health-care providers.

As physicians, perhaps the best thing we can do for our female patients is to pay more attention. Don’t dismiss a symptom, because nothing should “not seem cardiac” until proven otherwise.

So, yes:

Listen to her.

Diagnose her.

Investigate her.

Study her.

Treat her.

And don’t just #GoRedForWomen in February. #GoRedForWomen throughout the year.

 

References

  1. Pasupathy S, Tavella R, Beltrame JF. Myocardial Infarction With Nonobstructive Coronary Arteries (MINOCA): The Past, Present, and Future Management. Circulation. 2017;135(16):1490-1493.
  2. Mehta LS, Beckie TM, DeVon HA, Grines CL, Krumholz HM, Johnson Mnet al; American Heart Association Cardiovascular Disease in Women and Special Populations Committee of the Council on Clinical Cardiology, Council on Epidemiology and Prevention, Council on Cardiovascular and Stroke Nursing, and Council on Quality of Care and Outcomes Research. Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association. Circulation. 2016;133(9):916-47.
  3. Haider A, Bengs S, Luu J, Osto E, Siller-Matula JM, Muka T, et al. Sex and gender in cardiovascular medicine: presentation and outcomes of acute coronary syndrome. European Heart Journal (2019) 0, 1–14.
  4. Ferry AV, Anand A, Strachan FE, Mooney L, Stewart SD, Marshall L, et al. Presenting Symptoms in Men and Women Diagnosed With Myocardial Infarction Using Sex-Specific Criteria. J Am Heart Assoc. 2019 Sep 3;8(17):e012307.
  5. Dreyer RP, Smolderen KG, Strait KM, Beltrame JF, Lichtman JH, Lorenze NP, et al. Gender differences in prevent health status of young patients with acute myocardial infarction: a VIRGO study analysis. Eur Heart J Acute Cardiovasc Care 2016;5:43–54.
  6. Arora S, Stouffer GA, Kucharska-Newton AM, Qamar A, Vaduganathan M, Pandey A, et al. Twenty year trends and sex differences in young adults hospitalized acute myocardial infarction: the ARIC Community Surveillance Study. Circulation. 2019;139:1047–1056.
  7. 037137Jespersen L, Hvelplund A, Abildstrom SZ, Pedersen F, Galatius S, Madsen JK, et al. Stable angina pectoris with no obstructive coronary artery disease is associated with increased risks of major adverse cardiovascular events. Eur Heart J 2012;33:734–744.
  8. Ong P, Camici PG, Beltrame JF, Crea F, Shimokawa H, Sechtem U,et al. International standardization of diagnostic criteria for microvascular angina. Int J Cardiol 2018;250:16–20.
  9. Srivaratharajah K1 Coutinho T, deKemp R, Liu P, Haddad H, Stadnick E, et al. Reduced Myocardial Flow in Heart Failure Patients With Preserved Ejection Fraction. Circ Heart Fail. 2016;9(7).
  10. Scott PE, Unger EF, Jenkins MR, Southworth MR, McDowell TY, Geller RJ, et al. Participation of Women in Clinical Trials Supporting FDA Approval of Cardiovascular Drugs. J Am Coll Cardiol. 2018;71(18):1960-1969.
  11. Pilote L, Raparelli V. Participation of Women in Clinical Trials: Not Yet Time to Rest Our Laurels. J Am Coll Cardiol. 2018;71(18):1970-1972.
  12. Mehran R, Baber U, Sharma SK, Cohen DJ, Angiolillo DJ, Briguori C, et al. Ticagrelor with or without Aspirin in High-Risk Patients after PCI. N Engl J Med. 2019;381(21):2032-2042.
  13. McMurray JJV, Solomon SD, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA, et al; DAPA-HF Trial Committees and Investigators. Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction. N Engl J Med. 2019;381(21):1995-2008.
  14. Schüpke S, Neumann FJ, Menichelli M, Mayer K, Bernlochner I, Wöhrle J, et al; ISAR-REACT 5 Trial Investigators. Ticagrelor or Prasugrel in Patients with Acute Coronary Syndromes. N Engl J Med. 2019 ;381(16):1524-1534.
  15. Presented by Dr Judith S. Hochman at the American Heart Association Scientific Sessions (AHA 2019), Philadelphia, PA, November 2019. https://www.ischemiatrial.org/system/files/attachments/ISCHEMIA%20MAIN%2012.03.19%20MASTER.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.”

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Recognizing Congenital Heart Disease (CHD) as an Important Part of #HeartMonth; Important Considerations for Healthcare Providers

Congenital Heart Disease (CHD) is a diagnosis that often causes confusion, concern, and fear, not only for family and patients but also for healthcare providers who are not exposed to them frequently. February is Heart Month; it is important that we take time to recognize the youngest of our heart patients, as well as those who are now adults living with Congenital Heart Disease.

CHD is the most common congenital malformation in newborns and there are great than 1 million adults now with CHD in the United States,1 which makes it important for every health care provider to know about; it requires understanding of sometimes complex physiology, a high index of suspicion, and most importantly a multidisciplinary approach to care with the patient and often parent at the center. For a review on CHD you can click here3, but below are some important things to consider:

  • CHD does not always present at birth and can be missed on routine prenatal obstetric ultrasound, fetal echocardiogram, and the neonatal pulse ox screening. Fortunately, not all CHD requires surgery or intervention at all.
    • General OB ultrasounds and fetal echo will likely catch major congenital heart disease, but there are some smaller lesions that are difficult to diagnose due to normal fetal circulation, which is abnormal after birth.
    • The pulse ox screen was initiated in 2011 to improve detection and outcomes in critical congenital heart disease that could cause hypoxemia and a higher risk of death early on; these lesions are typically prostaglandin dependent and outcomes can be improved if addressed early on.2
    • CHD is often associated with extreme clinical situations, but many infants with CHD will not present this way and may not require surgery at all. They still require follow up with a pediatric cardiologist.
  • CHD is not always “cured” but often palliated, and these patients can have different hemodynamics to consider as a result.
    • While many patients receive surgery to create a “normal” heart, many infants born with complex congenital heart disease will require multiple surgeries, termed palliation, that create a new way of circulation (such as the Fontan Procedure4). Altered hemodynamics(blood flow) are important to understand and it is important to know what surgeries have been performed.
    • Some surgeries, while restoring normal or near-normal can still put patients at risk for long term issues that need to be followed closely such as heart failure, hypertension, valvar issues or arrhythmias.
  • There are now more adults living with CHD than children.
    • Thanks to advances in medicine and surgery, adults now represent the largest population of patients with CHD. While many of these patients are healthy and can live normal lives, they still need lifelong care with providers who specialize in CHD.
    • It is important to encourage adolescents with CHD to learn about their diagnosis early on and take their health into their own hands. The transition to an adult congenital heart disease (ACHD) provider is something that needs to be encouraged not only by pediatric cardiologists but primary care physicians and adult cardiologists
    • Most CHD patients can, and should be encouraged to, participate in a healthy lifestyle including exercise; however, this should be in discussion with a CHD provider to help provide guidance.
    • Click here5 to find an ACHD specialist near you.
  • CHD parents and patients are great resources of knowledge and want to be heard.
    • CHD parents and patients are their best advocates and are often the most knowledgeable about their heart and what they have been through. It is important to take their complaints and concerns seriously. Do not be afraid to ask them questions and learn their history.
  • CHD requires a multidisciplinary approach; CHD providers are willing to answer a call and collaborate.
    • CHD patients may be at higher risk for psychological issues such as depression and anxiety related to living with chronic disease.6 They are also not free from other cardiovascular problems that are not necessarily congenital, such as coronary artery disease and stroke1, which is why collaboration amongst specialties is crucial.
    • If you have a question, concern or need more help; never hesitate to reach out to your hospital or patient’s CHD specialist. We are here to help, educate and provide the best care for our patients.

CHD represent a population of heart patients that is consistently growing with continued advances in medical care. Everyone in healthcare is likely to be exposed to these patients during their career, therefore a multidisciplinary, patient-centered approach is important to continued success in the field.

 

  1. Wang, Tingting, et al. “Congenital Heart Disease and Risk of Cardiovascular Disease: A Meta‐Analysis of Cohort Studies.” Journal of the American Heart Association, 9 May 2019, ahajournals.org/doi/10.1161/JAHA.119.012030.
  2. Engel, Melissa S, and Lazaros K Kochilas. “Pulse Oximetry Screening: a Review of Diagnosing Critical Congenital Heart Disease in Newborns.” Medical Devices (Auckland, N.Z.), Dove Medical Press, 11 July 2016, www.ncbi.nlm.nih.gov/pmc/articles/PMC4946827/. Puri, Kriti, et al. “Congenital Heart Disease.” American Academy of Pediatrics, American Academy of Pediatrics, 1 Oct. 2017, pedsinreview.aappublications.org/content/38/10/471.
  3. Puri, Kriti, et al. “Congenital Heart Disease.” American Academy of Pediatrics, American Academy of Pediatrics, 1 Oct. 2017, pedsinreview.aappublications.org/content/38/10/471.
  4. “The Royal Children’s Hospital Melbourne.” The Royal Children’s Hospital Melbourne, rch.org.au/cardiology/parent_info/Information_for_patients_and_parents_about_the_Fontan_Operation/.
  5. “Adult Congenital Heart Association – Home.” ACHA, achaheart.org/.
  6. Areias, Maria Emília Guimarães, et al. “Long Term Psychosocial Outcomes of Congenital Heart Disease (CHD) in Adolescents and Young Adults.” Translational Pediatrics, AME Publishing Company, July 2013, www.ncbi.nlm.nih.gov/pmc/articles/PMC4728933/.

“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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#HeartMonth and Healthy choices

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

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

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

My son and I after his first Turkey Trot last year

References:

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

 

“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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Building an academic portfolio during medical training: Part 2 – finding your research team

In my previous blog, we discussed why it is important for medical students and trainees to consider research collaborations outside their own institutions, and what types of research studies can be performed using this type of collaboration between young researchers. In this blog, I will focus on how to find potential collaborators and/or join a multi-institutional team of young researchers.

Once you decide to explore this non-traditional way of doing research, the first challenge you will be facing is how to find potential research team members. At this point, you need to take a step back and ask yourself 2 essential questions:

  • “What area(s) of research am I interested in?” – This will largely be dependent on the particular specialty you are interested in pursuing as a career, and whether you have a general interest in this specialty or a more focused area that you would like to explore.
  • “What skillsets can I bring to the table in such collaboration?” – No matter how novice you are in medical research, you can always be a valuable team member provided that you are willing to learn, work hard and acquire new skills. But it is essential for you to know exactly what you can or cannot do, to be able to find your right position within a team. A successful research team requires a myriad of skills, some are basic, such as searching the literature or collecting data, some are more advanced, such as conception of research ideas or scientific writing, and others are specialized, such as relevant statistical knowledge and competency in using a statistical software or experience with using one of the databases that we previously discussed e.g. National Inpatient Sample (NIS).

Answering these 2 questions will help you present yourself in an honest and practical way to your potential collaborators, and will ensure that you achieve the 2 fundamental goals of any collaboration: to benefit and to be beneficial. It also gives you an idea about what potential skills you can work on acquiring to increase your value as a team member.

Now that you know what you want and what you can offer, it is time to find your collaborators. The easiest and most straight-forward way is to collaborate with people that you had previous experience with, like your medical school colleagues, or co-residents from your previous training program who have similar research interests. However, this may not be an available option to you, so what to do in this case? – If you are still taking your very first steps in the research field, you would be better off joining a team that is already established rather than building a new team. There are several ways to identify multi-institutional research teams that are already up and running:

  • Word of mouthyou may have heard about one or more resident or fellow who does this type of research, and in that case, you could reach out directly to them.
  • Medical literatureyou could search within your field of interest for recently published meta-analyses, systematic reviews, or articles that use one of the publicly available databases that we mentioned, and examine the authors’ list. What you would want to look for are articles that are authored by people affiliated with different institutions. Next step, would be to look up some of these authors on PubMed and see if that same group of authors (or some of them) publish these types of articles frequently together. Once you identify a particular group of collaborating authors, then you could look them up to check if they are mostly residents and fellows.
  • Social mediathis is another great tool for research collaboration. Twitter, in particular, is becoming an invaluable platform for sharing medical knowledge and recent research articles. Many of the currently active research groups promote their work on Twitter, and using the same process we just discussed, one can easily identify active members of these groups and reach out to them directly. Further, many researchers nowadays reach out on Twitter when they need young motivated medical trainees to help out with ongoing projects. So I would strongly encourage you to get on Twitter if you haven’t already done so and to start following people with similar research interests.

At this point, you know your research field of interest, you are aware of what you have to offer as a research team member, and you have identified potential research team(s) that you would like to be part of. You should be ready to reach out. What is the best way of presenting yourself? How can you maximize your chances of success in joining a team? This will be the topic of my next blog. So stay tuned…

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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Why Cardiology?

“Why Cardiology?” is one of the most common questions I have been asked by friends, family, interns, residents, and even the occasional stranger sitting next to me on a flight. Despite being a simple question, the answer is very complex. I initially started residency thinking I would pursue a career in pulmonary/critical care – I loved the acuity, broad differential diagnoses, and the bond created with families. However, after my first month in the unit, I quickly abandoned this career path for multiple reasons. Shortly thereafter, I did my first rotation on the cardiology wards service with Dr. Matthew McGuiness (who is still one of my closest mentors) and I saw the light.

The month on the cardiology wards service is best described as “finding the missing piece of the puzzle.” I loved the anatomy, physiology, patient population, subtle differences in presentations, and my interactions even as an intern with patients. I also loved the depth of cardiology – including both clinical and basic science research opportunities, advanced fellowships options, and the ability to create my niche in cardiology. I learned cardiologists were pursuing careers in preventative cardiology, cardio-oncology, cardiac critical care, and cardio-obstetrics. I was blown away at the possibilities of a career in cardiology and having the ability to create my perfect dream job.

As I mentioned earlier, I was very interested in critical care when I started residency but did not want to be in the medical ICUs. The cardiac intensive care units were much more interesting to me with advanced hemodynamics, malignant arrhythmias, various mechanical circulatory devices, and seeing how quickly the realm of the cardiac ICUs were changing. The CCUs are no longer filled with patients who have had a STEMI requiring a week-long admission, but rather those with decompensated heart failure/cardiogenic shock requiring mechanical circulatory support (MCS) with LVADs, Impella, or ECMO.

I am now combining all of my loves – cardiology, critical care, and obstetrics (yes, I at one point wanted to go into OBGYN) for my job as an attending. With the help of my mentors, I have been able to combine all my passions into one. I will be attending in the cardiac intensive care unit and have a predominantly general cardiology clinic with a focus on cardio-obstetric patients. And the best part, every cardiology fellow can create his/her dream job.

A few key questions to ask yourself are:

  • Do I see myself as someone who enjoys the in-patient or the out-patient setting? This will help focus career options and set the stage for your career.
  • Am I a proceduralist or not? For me, I hate wearing lead, so it was a simple decision to not go into interventional or EP.
  • What type of patients do I get the most joy of taking care of. In my case, it was the critically ill and women who are pregnant with cardiovascular disease.
  • Who is 5-10 years ahead of me career-wise and has my ideal job? This has helped me be more active with research, clinics, conferences, and improve my fund of knowledge. It also gave me a roadmap to follow – no need to reinvent the wheel.

Of course, these are starting points and it’s a vast topic that takes time to explore. My journey of “why cardiology” has been filled with highs and low, but with the help of various mentors I have a clear vision of what I envision for my future career.

 

“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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Support Starts at Self

Last month I wrote about how trainees and early career professionals should approach the New Year with a focus on mentorship (from multiple sources when possible!) as a priority to advance their careers. The input we can accumulate from individuals that have the ability to “teach us the ropes”, and expose us to some new tool or perspective to enhance our professional growth and advancement, is essential. This input carries value that fuels the propagation and elevation of society upward and forward. Today I want to discuss what I envision to be the “other side of the coin” to mentorship, the way in which an individual can advance by an “output” effort, in complement to the “input” that mentors provide. Namely what I’m referring to is advocacy. Trainees and early career professionals tend to under-appreciate 2 main truths with regards to advocacy efforts:

1- We are prone, primed and sometimes advised to shy away from advocating for our own causes.

2- We underestimate our ability to advocate and support others within our professional communities.

I’ll start with the case for self-advocacy. It can be hard to dissociate the idea of being self-advocating from being self-absorbed, and that is the root cause for why most well-meaning, humble folks avoid the issue altogether. Seeming selfish or self-centered is of course a bad trait, a noxious attitude that most trainees and early career professionals want to avoid at all cost. Selfishness will lead to career derailment and loss of support from other members in the community. But self-advocacy on the other hand, stems from hard work, a desire for just outcomes, as well as confidence and pride in one’s workmanship and abilities. To advocate for yourself, you must first believe and prove that what you’re advocating for is a just and worthwhile cause.

When there is evidence to support the self-promotional effort, individuals can and should be empowered to advocate for themselves. A quick and easy framework to approach self-advocacy could flow like this:

The first step towards justified self-advocacy is identifying and analyzing the reasons why one should or should not pursue the cause. This can sometimes be difficult, we might not be the best judges of our own efforts, sometimes it helps to have “peer-reviewers” to help us assess the need for advocacy or not. Family, friends, partners, colleagues, and specialized professionals (referees, counselors, etc), are all individuals that could supply viewpoints that help us understand and decide on whether self-advocacy is warranted at present, or if there still is some distance to cross before we get to that point.

Once justified, championing your own causes has become in fact necessary in a world where competition is present, and alternatives are available, at every stage in a career, most evidently in the early career segment of professions. This necessity also brings nowadays a level of expectation from decisions makers, who may see and value self-advocacy efforts as positive traits in individuals seeking professional advancement. This is the clearest reason why one should acquire and optimize the skills needed to become a just self-champion. Of major importance in this discussion is to note that the way in which one is doing what’s needed to advance, is doing so in a manner leading to an overall benefit, and no harm to anyone else (being a champion for one self can also equal being a champion “for the greater good”).

The second point mentioned above, specifically referring to advocating and supporting others within the shared professional community, also warrants a closer look. A strong and advancing community can promote growth for everyone within it, creating momentum and a sense of altruistic advocacy that is much easier to root for and accept without any hesitation or fear of negative feedback. When professionals in a shared community see the advancement of peers as a strength and growth for the whole group, a collective effort to support and promote one another is created, and a positive feedback loop is fueled.

This is significantly more important when the community can have individuals that face some deliberate, or blind forces, that work against their growth and advancement (such as minorities, persons with disabilities, sex and gender systematic biases, and other forces that do exist in many ways). Whenever there exists a gatekeeper with unjust (knowing or blind) motivation that hinders the advancements within a professional community, it is strongly desirable (and necessary) for a whole group effort to champion and advocate for the fair advancement of the affected individuals within this community. Everyone would gain at the end. A strong community would be built and a momentum for “paying it forward” will start.

As mentioned initially in this post, early career professionals have the unique space to be very highly invested in optimizing the “input” provided to them (mentorship), and the “output” they require (advocacy, both self and community oriented). As we progress in our personal and professional journeys, we must aim to maximize the ways in which mentorship and advocacy can help us achieve the goals we aim to accomplish, both for our own benefits, and the benefits of the communities that we are a part of.

 

“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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Dear Kobe

 

Dear Kobe,

Thank you for inspiring all of us in medicine too.

Sincerely,

The future of medicine.

From Los Angeles to Manila, sports fans and people that know nothing about sports were shattered by the deaths of Alyssa, John, and Keri Altobelli, Gianna and Kobe Bryant, Payton and Sarah Chester, Christina Mauser, and Ara Zobayan aboard that helicopter on Sunday January 26, 2020 in Calabasas, California. We all knew exactly what we were doing when OJ was found not guilty, when we realized Prince would never perform Purple Rain again, when Whitney was found in her bathtub, and when we found out Robin Williams would never star in a Broadway play of Patch Adams. Kobe’s death will be no different. I was sitting on my couch watching reruns of a show on BET with one of my best friends. We sat there stunned for several hours hoping this was some sort of sick joke, but as every news outlet and social media platform picked up the tragedy, I felt sick.

Death is inevitable. It’s the only thing we know for sure is going to happen to every single one of us. But like I said in my previous blog about being on heart donor call, when the deaths are unexpected and take young people, they are shocking, they are life altering, they are gut wrenching. They remind you that life is fragile and our time here is limited.

Kobe’s legacy will live on forever through the magic he shared with people he knew directly and with people he never met, like myself, who grew up watching him, sometimes hating him because he was destroying your team. His work ethic was unmatched, and his love of the game surpassed every athlete’s of our generation.

What did and can we, as clinicians, scientists, and educators, learn from the Black Mamba?

  • To show up in every single thing we do, every single time
  • To love our family and friends and make them a priority despite how busy we may be
  • To leave the world a better place for future generations coming behind us
  • To inspire those around us to be the very best human beings they can possibly be
  • To inspire people to live their life’s purpose
  • To inspire people to live each day like it’s their very last
  • To bring grit and passion to everything we do
  • To find that fire inside and keep it ignited
  • To set monstrous goals, crush them, and then set even bigger goals
  • To find the things we love doing outside of medicine and do them with our whole heart. I mean, you won an Oscar, Kobe
  • To love deeply
  • To never take no for an answer
  • To bring heart to everything we do
  • To know when it’s time to leave the stage
  • That without obstacles there is no growth
  • That we can be fierce AND kind
  • That there are no ceilings
  • That records are made to be broken
  • That one human being can indeed have a profound impact on the entire world
  • That when we feel like quitting, we should ask, what would Kobe do?

May you, your daughter, and all the passengers aboard that helicopter RIP. Your legacy will live on through all of those you touched. There are no words to express how grateful we are to have been touched by your magic.

So, what legacy are you going to leave behind?

 

“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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Civility in Scientific Debate

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

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

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

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

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

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

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

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

#scicomm #supportwomen

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

 

 

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Bigger Isn’t Always Better: My 3 Tips on Maximizing the Small Conference Experience

In my March blog, I wrote about a few of my tips to get involved in our cardiovascular professional societies. I received a lot of great questions and feedback from trainees across the spectrum of cardiovascular disease through Twitter, LinkedIn, and email, so I thought I would share some similar content this month.

As busy cardiology fellows in training (FIT), finding the free time to attend more than one professional conference in an academic year is tough. Trying to choose among the various local, regional, national, and international opportunities can be difficult, not to mention the financial and time commitments required to attend multiple meetings in a year. As I have become a more senior cardiology FIT, I have come to appreciate the value of attending smaller, disease or topic-specific conferences. Here are 3 of my tips to make the most of these opportunities.

MindTheGraph.com

1) Search the CME offerings of academic institutions around you: Most large academic medical centers host continuing medical education (CME) programs focused on specific topics or diseases throughout the year. They are often held on weekends but are usually less time-intensive than the national professional society meetings. Despite their smaller sizes, the organizers will still invite preeminent clinicians and scholars in the relevant fields, which make these meetings terrific opportunities for FITs to access thought leaders and craft collaborations. I recently attended a weekend-long CME course focused on hypertrophic cardiomyopathy at an academic institution in a neighboring state. At the conference, I reconnected with a long-distance mentor who was invited to give a lecture, met a junior faculty member and brainstormed cross-institutional collaborations, and learned about HCM from internationally renowned clinicians and scientists. In addition, taking a deep dive into a topic of your interest can be a welcome respite from the hectic cognitive shifting we are forced to do at larger conferences.

MindTheGraph.com

2) Find a way to participate: While smaller conferences usually do not have much room for flexibility in the programming, the organizers may allow FITs to present cases to accompany the didactics. Offer to present a case that ties into the talk of a speaker whom you are most interested in meeting. By doing so, you can “break the ice” with your case presentation and worry less about initiating interaction with the speaker. You may also have the course registration fee, if there is one for FITs, waived through participating. Along the way, stay responsive over email and telephone and obey the organizer’s deadlines for submission of your materials. If you notice that the conference does not have an avenue for FIT involvement, offer to contribute by presenting a case or submitting a poster. Last year, I advised one of my mentees to contact the organizers of a sports cardiology course she was interested in attending. Even though there were no publicized opportunities for FIT engagement, she let the organizers know about her interest in attending and enthusiasm to contribute. The organizers invited her to the course and extended discounted registration. This year, she is on the course planning committee and is spearheading the FIT case and poster presentation sessions!

MindTheGraph.com

3) Follow up after the course: Send an email to the course directors and your new contacts after the course. Let them know how much you enjoyed the experience and that you would be delighted to participate in the same or a similar conference again. Close the loop with new contacts and propose next steps to move those potential collaborations forward. Connect with each other through social media, as well.

 

What are your tips for maximizing the small conference experience? I would love to hear them over the next month – share them with other #AHAFIT and me on Twitter and LinkedIn!

 

 

 

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My Three Tips for “Getting Involved”

While we are still incorporating the knowledge from AHA Scientific Sessions 2018’s late breaking trials like REDUCE-IT and TRED-HF into our daily practices, the AHA has already started planning for Scientific Sessions 2019 being held in my current home of Philadelphia, Pennsylvania. My co-AHA Early Career Blogger, Jeff Hsu, M.D., Ph.D., and I are excited to serve as Co-Vice Chairs for the AHA’s Fellow in Training (FIT) Programming Committee, and we are hard at work incorporating feedback from AHA18 into our vision for AHA19. For a recap of the AHA18 FIT/Early Career Lounge experience, check out my November blog here and FIT Insight blogger Anum Saeed, M.D.’s January blog here.

Becoming involved in my professional societies as a trainee has been hugely rewarding for me, but admittedly, making those first breakthroughs was not easy and took a few years to accomplish. In this blog, I will share 3 of my tips that can help you seize these opportunities.

1) Seek out a well-connected sponsor: Our professional societies are very eager to involve more FITs and Early Career members in a majority of their initiatives. Often, they advertise and require an application for trainee-specific opportunities like blogging, editorial, and leadership council positions. But, there are a host of positions that are not filled via an application-based process and are frequently offered to trainees through a personal connection within the society. If you have applied to formal engagement opportunities and your application has not been selected, instead of being discouraged, seek out a well-connected sponsor within the society with whom to share your motivation. Faculty usually know of other available opportunities for trainee involvement within their own councils or committees and can connect you with other members volunteering in clinical and research areas of your interest.

 

2) Offer concrete ideas when you make contact: When you connect with a society member whether in person, via telephone, or via email, instead of just saying that you would like to “be involved,” offer a few concrete ideas for the society and its mission. By doing this, you can demonstrate your enthusiasm and establish your dedication to the potential role. Your new sponsor will be more likely to engage with you and find an opportunity for you that is aligned with your interests and skills.

 

3) Form relationships with trainee colleagues who are already involved: When societies have formal councils or committees comprised of trainees, they often rely on them to disseminate news and opportunities nationally and internationally. While tip #1 can definitely help to launch your involvement, following the same practice with your FIT and Early Career colleagues can sometimes be more impactful. Trainees’ professional networks are usually smaller than those of the faculty in society leadership positions, so when we are asked to submit names of colleagues for opportunities, our selection pools are more limited. In the AHA18 FIT/Early Career Lounge, I met multiple medical students, residents, and fellows who expressed interest in the AHA FIT program and shared their feedback with me after Sessions. In turn, when I was offered the chance to nominate FITs and Early Career members for other roles, these new colleagues were at the top of my list.

 

If you are a FIT or Early Career member, watch out for emails about AHA Scientific Sessions 2019 programming in the coming months. If you have a great idea about what you would like to see at AHA19, reach out to Jeff (@JeffHsuMD) and me (@noshreza) on Twitter!