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Lessons I’ve Learned as Chair

Being a recent graduate just entering the professional stage of one’s career is an especially turbulent time. This is magnified for ones that had a prolonged academic journey, such as advanced medical training, pursuing master’s/doctoral degrees, and any other unique situation that can lead to a long journey of being an official student on paper (because unofficially we’re all students of life, until the end!).

However long and winding road one takes, there comes a time when the stage is set to exit being a student and enter the professional field. This stage is simply known as Early Career (using the naming convention most widely used, including at the American Heart Association). This part of a career journey has the uniqueness of blending learning many new life skills, and professionally performing up to the standards expected from achieving the academic endpoint one has reached (MD, PhD, or any other).

One way a young professional can advance their learning curve and become professionally savvy and focused is by seeking and actively participating in committees within organizations related to their working field. Committees provide a platform where members interact regularly, discuss and plan actions related to the work environment, provide community-building opportunities, and essentially expose their members to a variety of learning experiences that are highly beneficial, both directly and indirectly, in progressing their early career professional journey.

Here I present my personal experience as an example. I have recently concluded my term as Chair of the trainee committee in my institute, and have recently been granted full employment status as part of the reorganization of the employment structure here. I’m now exactly placed in the “Early Career Professional” stage of my journey.  Being part of a committee provided me with many extra layers of understanding on how everything functions within the institution. My long academic stage provided me with skills and experiences within the realm of science, laboratory research and academic scholarship, but precious few glimpses of structures and professional actions outside the lab and classroom settings.

(Image from Pixabay.com CC0)

Working within a committee, and chairing a committee in my personal example, comes with its own learning curve, which can be a daunting thought for an already overwhelmed young professional (or senior student or trainee). But the rewards are plenty, and the effort is worth it at the end. Committee membership can be a rich source for personal and professional education. Some lessons are generalized for everyone to gain, other lessons are more individually centered, for each person to uniquely grow from. Some of the many lessons I’ve learned recently I’ll share here.

I’ve learned how a budget in an institutional structure is managed (which is different from how a personal household budget is done). I’ve learned the names of so many other professionals within the organization outside of my daily interactions. I’ve learned more about the administrative structure of the place where I work in. I sat in meetings that shape the direction of the future of the institution. I learned about leadership, and even more about teamwork. I learned the great value and appreciation for creating a close-knit community within a professional organization. As human beings, we have been creating and living in villages for thousands of years, and nowadays the professional network one works in can be part of that village. Here as well is where one can find opportunities to increase the equity, diversity, and inclusiveness of the professional community within the institution or organization. I had first-hand experience in this. Providing support and a platform for the under-represented can create an entry point for the larger effort required within the whole organization, institution and wider society. We should use all the tools at our disposal (and create new tools when necessary) to continuously provide better results for members of our community that are under-represented or marginalized.

My pitch here at the end to you is to seek out, create when possible, and accept opportunities, to be active in your work organization, and professional societies, during your early career stage (and moving forward). My personal endorsement goes to being an active member of a committee at your institution, and then to expand into national and international societies that exist in your professional field. There is much to learn, a community to join, to build, and a lot to gain towards advancing your professional path, and maybe, the society as a whole.

“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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Taking a public stand for social justice

My heart is broken after the recent events and the loss of George Floyd’s life in Minneapolis, my beloved home over the last couple of years, along with many other recent tragedies that highlight the racial injustices in the United States. Like many, I hope that these events will lead to fundamental changes and improvements in our society.

I admire the institutions, organizations, companies, leaders, and my colleagues who are making public statements in support of efforts to lead to social justice. I think that it is important to acknowledge that as a society, we are now expecting many organizations, institutions, companies, and leaders (political, academic, organizational, etc.) to take a public stand against racism, a topic that many organizations and businesses previously shied away from making public comments on. This is a positive shift in our culture. One of the initial ways to lead to long-lasting change is to acknowledge that there is a problem. My home institution, the University of Minnesota was quick to make a public statement condemning racism and social injustices after George Floyd’s death. As researchers and healthcare providers, we know that there are health inequities, magnified by the COVID-19 pandemic which my fellow AHA blogger, Dr. Anika Hines (@DrAnikaLHines) recently discussed.

Furthermore, as healthcare providers and researchers, we are often leaders in our communities and are able to provide a voice to those who are disadvantaged. Another fellow blogger, Dr. Elizabeth Knight (@TheKnightNurse) recently wrote about the importance of advocacy by healthcare providers. Racism and social inequalities are public health issues. Many organizations that we are a part of have made public statements for social justice. The American Heart Association and American College of Cardiology have made a joint statement with the Association of Black Cardiologists against racism and social inequities. Similarly, the American Medical Association and Association of American Medical Colleges have also made public statements condemning racism and advocating for change. Additionally, many healthcare providers across the country have kneeled and protested for #WhiteCoatsforBlackLives over the last couple of days. When the organizations and institutions that we are a part of take a public stand against racism and social injustices, we then feel supported in our efforts.

I encourage trainees to pay attention to which organizations and institutions are making statements against racism and social injustices and are committed to making changes.

Be an active ally. Listen and learn. Be kind. Be safe.

“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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Scientific Sessions during the pandemic

I didn’t know what to expect when I logged in to the American Heart Association’s Quality of Care and Outcomes Research Scientific Sessions earlier this month but having attended I’m definitely a fan of this new virtual format. As a trainee, the largest barriers to attending conferences are usually finding the funding and arranging the time off from work. Not having to worry about missing work on Friday and the cost of a roundtrip flight and hotel for the weekend was a huge positive.

In the couple of weeks since the conference, it’s also been great having access to sessions I missed. With so much going on during the live scientific session, it’s easy to miss a lot of really interesting new research being presented. Being able to go back a couple of weeks later and look through the content has made it much more digestible and eased any fear of missing out I had.

It did take me a little bit to get comfortable navigating the HeartHub (https://www.hearthubs.org/qcor), but then again I usually get turned around at in-person conferences too. Once I was in virtual sessions, I was surprised by how interactive the chats were and how relaxed they felt. Not sure why it felt less formal than an in-person conference but “attending” while having a coffee in my living room, rather than wearing a suit in a conference room sure didn’t add any stress.

Looking forward to #AHA20 online!

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

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The Importance of Maintaining the Public’s Trust in Science and Medicine

Often, and especially during the COVID-19 pandemic, there is a plethora of misinformation that is spread. We have all probably seen at least one scientific publication, news article, social media post, or YouTube video that is spreading information that is not accurate. Every day, I am bombarded by conspiracy theories or unfounded scientific claims while skimming through social media. During a time when information is rapidly disseminated through the internet, it is often difficult to extinguish a lie.

Sometimes, misinformation is inadvertently spread by well-meaning individuals who have not had the time or energy to confirm or critically appraise the information shared. “Liking”, “retweeting”, and/or sharing a post from a colleague/friend/relative is facile. We have all probably “retweeted” or shared certain articles and posts that we did not completely critically assess before sharing. Sometimes dissecting truth from fallacy is difficult, especially when information is disseminated widely. Our current technological advances with the internet and social media magnify opinions, good and bad. Occasionally, one may think, if multiple people I know and/or respect are sharing certain information and the number of posts about the false information outnumber those on the truth, then the misinformation must be true.

Occasionally, misinformation about science or medicine is shared by members of our own scientific and/or medical communities, which can sometimes be more damaging to our profession. For example, more assumed credibility may be given to a scientist or healthcare provider, even if his/her expertise is not in the area that is commented on. Conspiracy theorists may continually reference these “experts” to support their arguments. Sometimes, refuting incorrect information requires massive efforts but may never eliminate the long-lasting negative effects of the misinformation. For example, Andrew Wakefield’s infamous, now retracted scientific article that was published in The Lancet and falsely claimed an association between the measles, mumps, and rubella vaccine with autism is unfortunately still being referenced to support arguments against vaccinations even though multiple studies have overwhelmingly refuted the claims made in the retracted article.

With less malicious intent, some misinformation may be spread by the media or others in reference to research articles. Certain conclusions of research papers are sometimes not justified by the data presented due to inadequate sample size, biases, issues with the experimental design, etc. During a pandemic, since rapid dissemination of scientific and medical information is needed, there is frequently a tradeoff with the scientific rigor and reproducibility of the results. Since access to papers in preprint servers are available to the public, the media and public figures may tout certain research findings as truth when they have not been vetted by the peer-review process. A fellow AHA early career blogger, Dr. Allison Webel (@allisonwebelPhD), recently wrote an outstanding blog discussing the importance of the peer-review process (https://earlycareervoice.professional.heart.org/in-defense-of-peer-review/). Of note, even peer-reviewed articles are not free from research misconduct and incorrect conclusions. There are many articles retracted from high impact journals. Before the development of the internet and social media, critiques and feedback of research findings were typically only discussed at scientific meetings or at other selective venues (e.g., local conferences/presentations, journals typically not viewed by lay people, etc.). Now, these debates occur in the public arena with beneficial and negative aspects and frequently with nonexperts. These public debates may dilute the truth when unfounded comments are perpetuated.

What should we do about the spread of misinformation? Propaganda and false information are always going to be spread but we should try to mitigate their breadth and potential damage. On an individual level, researchers should thoroughly assess their results and determine whether their data are valid and whether the claims they make in publications are justified by the data before presenting the findings to the public. Limit overreaching conclusions. Scrutiny of results by authors and the research community is essential to the scientific process. Developments and advances in science often occur when findings are reproduced either within a specific lab/group or by other labs/groups and this is especially important to realize during a time when a deluge of single-center, small sample size papers are published about the COVID-19 pandemic. Dr. Elizabeth Knight (@TheKnightNurse), another fellow AHA early career blogger, recently calls to attention the scientific lessons learned from the current pandemic (https://earlycareervoice.professional.heart.org/evidence-whats-good-whats-good-enough-whats-dangerous-lessons-for-now-and-later/).

How do we influence other people’s opinions? Internal changes are often easier to make than changing other people’s opinions. However, we are all likely an influential source of information within our own social circles and networks. We may feel more comfortable directly communicating with people we know to correct misinformation. Altering the opinions of people who we do not personally know is more challenging. At minimum, as researchers and healthcare providers, we should not intentionally try to deceive the public. Flagrant dishonesty from researchers and/or healthcare providers may erode the public’s trust in our profession, possibly to a greater extent than a nonexpert’s comments. We all make mistakes and honest misunderstandings and misinterpretations can affect all of us. However, deliberately lying and abusing the influence of one’s position as a scientist or healthcare professional is more offensive. I do not know how best to address colleagues who blatantly mislead the public. If an individual we personally know is deceiving others, we can directly communicate with him/her about the impact of the misinformation. Depending on the extent of the damage created by an individual in our professional community who is propagating false information, should we review his/her ability to maintain as a member of our profession?

What are your thoughts on how we can preserve the public’s trust in science and medicine?

“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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Evidence: What’s good, What’s good enough, What’s dangerous? Lessons for now and later.

COVID-19 has created a complex environment for health research. In an evidence vacuum with a clinical imperative to act, we have few choices. They include relying on analogues (such as SARS or MERS), trying treatments based on theoretical biological plausibility, relying on anecdotal evidence and case reports, and rushing evidence from small studies that may have significant limitations into print. There is a need for answers that are definitive but also rapid: a condition that science as we currently practice it can’t satisfy. Additionally, peer review relies on content-area experts, which are hard to find for a rapidly evolving area when potential experts are also stretched thin with clinical and research roles. The result is that evidence may look different from what we are accustomed to.

Some healthcare practitioners and scientists have reacted with alarm when low-quality studies have been published by normally meticulous journals. Are we abandoning the RCT, they ask? Is appropriate statistical analysis no longer required? Does the name of a prestige journal no longer guarantee rigor? Is low-quality evidence worse than no evidence at all? Is it wise to publish clinical observations in a newspaper rather than a medical journal? Who is responsible when a public (or public official) not equipped to recognize the limits of early evidence spreads misinformation? Are resulting adverse events or medication shortages partially the responsibility of the publication? The researcher?

These are debates worth having, and there will be compelling arguments on both sides. No matter your stance, though, there will be an impact on the future of science.

Lessons include:

  • Critically reading studies and understanding their strengths and limitations remains a valuable skill. Just because something is in print doesn’t mean it should be in practice. Scientific education in all disciplines needs to continue to focus on this skill.
  • Perhaps the standard glacial pace of evidence dissemination can, in fact, improve. Faced with undeniable urgency, the mechanisms of publication are adapting. Turnaround time measured in days or weeks rather than months or years is possible.
  • Lots of content related to COVID-19 from academic and lay publications alike is open-access— because it is seen as for the public good. Perhaps that perception can broaden, and alternative payment structures will make science more accessible.
  • The translation of basic science to clinical application (bench to bedside) can move rapidly when needed. As my fellow blogger Sasha Prisco has noted, there are currently administrative barriers that hinder this work, and their long-term necessity may need to be reevaluated.
  • Real-time information sharing and collaboration occurs through multiple channels beyond academic journals, including social media sites.

Have you considered the potential impact of this pandemic on the future of scientific publication and knowledge dissemination? Has it changed your ideas about publishing, research, evidence-based practice?

“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 defense of peer review

The generation of knowledge, through rigorous, established systematic methods has informed much of our progress in the past few centuries. Science guides all aspects of healthcare today including how we develop the new medications, therapeutic procedures, and non-pharmacological interventions that have improved the quality and duration of human life. Many of the crucial gates in the scientific journey- funding, ethical approval, and dissemination- are guarded by the process of peer review; a process that is increasing under attack in our current hyper-reactive, digital, media cycle.

Peer review is the critical appraisal of a scientific work by those who have requisite knowledge to evaluate one or more aspects of the work. It is a panel of experts in the related field who understand the importance and novelty of the questions under consideration and the rigor and trustworthiness of the methods proposed or employed to answer that question.

Peer review takes time. Time to find agreeable reviewers with the right expertise, time to review and think about the science, and time to determine how to weigh those critiques against the community’s need for information. From the early days of the novel coronavirus pandemic, this balance of time needed for peer review and unquenchable public thirst for rigorous information has been dominating the conversations at leading medical and scientific journals around the world. To better understand how these decisions are made and what we as clinicians, scientists, and health care consumers need to consider when reading and sharing emerging science, I spoke with Dr. Joseph Hill, the Editor in Chief of Circulation one of 12 AHA Journals.

Even though peer review is an established practice, it is important to start by questioning why we should even do it. Unquestionably, the value of thoughtful peer review is that it enhances the quality of the science. “We [the AHA journals)\] handle approximately 20,000 manuscripts a year and with extraordinarily rare exceptions, the paper always gets better with peer review”.

Having now published many of my own scientific manuscripts, I know the pain of peer review well. “They” missed that detail on line 176. “They” clearly lack the expertise to evaluate my work. “They” kept this manuscript for 8 months before sending their disposition! However, I also know that some of the best revisions to my papers have come from generous peer reviewers. Reviewers who volunteered to spend their time reading my papers and think deeply about my findings in the context of larger literature. While painful, the constant assessment and evaluation of our science is critical to improving the quality and impact of our work.

Prior to the coronavirus outbreak, up to 10 experts, including peer reviewers, statisticians, and editors, would review a manuscript for Circulation. But the need for up-to-date information about the epidemiology, pathophysiology, and treatment of COVID-19 challenged Circulation’s editorial team to move fast. While recognizing that it’s “hard to do good science in a war zone”, the quality of published science cannot be compromised in times of crisis. Dr. Hill continues, “We are walking a fine line between trying to get the information out as quickly as possible but we recognize that [in clinical science] we could make it worse and could do harm. So we have to maintain our high standards but function at a high velocity.”

High velocity seems an understatement. After an initial call for high-quality COVID-19 related papers, the editorial team has done over 300 fast track reviews, contributed to a curated coronavirus and cardiovascular disease collection, and conducted 17 interviews with experts working on the front line around the world. All in the past month. This work is exhausting but done with great energy by a team inspired to advance “cardiovascular science for the good of humanity, especially during these times of urgent challenge, anxiety, and forthright resolve.”

Peer review is the best process we have for evaluating science; but peer review is done by peers- busy, human, distractible peers- who will make mistakes. This is why many reputable journals require an editorial screen and at least two peer reviews before it can make a decision on a manuscript. Scientific volunteers do this work. Which brings us to what you, as an early career professional can do. Peer review relies on us—all of us—to sign up to review, accept the invitation to review, and spend the time carefully doing the review. You may wonder if you have the expertise to peer review for Circulation or another AHA Journal; you likely do and you should. Dr. Hill remarked that “some of the best reviews I’ve seen are from early-career scientists”.  If you are interested in helping to contribute to peer review and the sharing of good cardiovascular science, considering signing up to be a journal reviewer in your AHA Science Volunteer Form or emailing Dr. Hill your interest in reviewing for Circulation.

 

“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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COVID-19 Pandemic: 5 lessons about the way we (should) debate in medicine

In my previous blog, I shared five lessons about the way we practice medicine, which I believe were highlighted by the unprecedented circumstances of the COVID-19 pandemic. I would like to share five more COVID-19-inspired reflections, but this time it’s about the way we, as physicians, debate our medical opinions and the thought processes through which we form these opinions to begin with. While these thoughts came as a result of following scientific debates on social media, I believe they apply to all sorts of debates in other contexts as well:

  1. Opinions are not principles.  Principles are ethical codes we live by and cherish for our whole life. Opinions, on the other hand, are impressions and ideas that we make as we go, based on information that is available to us (with some emotional influences as well). That being said, while it might take a major life event for someone to change their principles; opinions can, and should, change quite often. There is nothing wrong about changing one’s opinion based on new information or on changing circumstances. In fact, this only reflects a healthy and dynamic thought process. Keeping that in mind makes it easy for us to admit when we’re wrong and to accept that others are allowed to change their position without being accused of hypocrisy.
  2. Debate is not an aim. With the urge to prove our point and support our convictions, we often forget the real aim of any debate; reaching the truth through exploring alternative interpretations. Social media has opened unprecedented venues for endless debate, and the field of medicine has remarkably caught up to this. Unfortunately, we sometimes forget that proving our point often gets in the way of actually finding the truth.
  3. Absence of evidence is not evidence of absence. As physicians, we adopt a scientific thought process. We always strive to find evidence to support any medical claim. Nonetheless, it is important to remember that just because something is not supported by evidence, it does not necessarily mean that it’s not true. It often only means that “we don’t know”. In the midst of scientific debates, we tend to forget this simple fact and start to proclaim that a certain medical intervention doesn’t work simply because it hasn’t yet been assessed by clinical trials. The more accurate way to address this is to say that we don’t know if it works or not, otherwise, we would be committing the same error we were criticizing in the first place.
  4. Bias is vulnerability. Bias and prejudice are human flaws. And we are all human. We tend to be a lot less rigorous in our scrutiny of the methodology and the validity of the results of an article (scientific or otherwise) when the findings are consistent with our own bias. We tend to drop our most important defense mechanism against gullibility—our ability to think systematically and to critically appraise the evidence. This becomes particularly obvious on social media where we are quick to enthusiastically share (and sometimes praise) studies that support our viewpoints, without properly examining the content. Eliminating this bias requires a conscious effort when assessing data that align with our opinions to be even more careful.
  5. We know very little, so be humble. Every day, nature shows us that no matter how much our medical knowledge increases over time, we still know relatively very little about the world we live in. COVID-19 is just another reminder. It’s true that some of us know more than others, but in the big scheme of things, none of us is in a position to brag or be condescending. So no matter whom or what we’re debating, let’s remember to be humble, be kind, and be respectful.

 

“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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How a Pandemic Worsens Overall Cardiovascular Health in the U.S.

The novel coronavirus pandemic, currently holding the global population hostage in their homes, has killed over 150,000 people and infected over 2 million. The US leads all nations in both categories. One only needs to look out the window, or visit the local grocery store, to understand the overwhelming sentiment amongst the people.

Afraid.

Lonely.

Stressed.

In a pre-COVID blog post, I reviewed a paper by Brewer et al. that investigates the deleterious affects of chronic stress, minor stresses and major life events on one´s overall cardiovascular health, as determined by the AHA´s Life´s Simple 7 initiative.1 In summary, the authors found that the study participants performed worst in diet, BMI, physical activity and smoking metrics. They reference research studies of depression, CVH and smoking when proposing a theory as to why this profound correlation exists. The studies identify binge eating and smoking to be adverse behavioral responses to psychosocial stress, as well as decrease in physical activity.

The current pandemic is an acute stressor, and major life event, for us all. Unemployment claims in the U.S. have topped 20 million, stock prices are 40% lower than their 2019 highs, one third of the world´s school-aged children are home, local and international businesses are closed, flights are grounded and this graduation/wedding season will be like none we´ve ever witnessed. Psychiatric telehealth consultations are at an all-time high because this is not our steady state; we are social by nature. The current pandemic´s acute stress on our society will inevitably affect its overall cardiovascular health.

I like this illustration of the effects of psychosocial stress on the hypothalamic-pituitary-adrenal axis, and how that translates to increased cortisol level and the subsequent worsening of many cardiovascular risk factors.2

When juxtaposed with the graphic below, illustrating AHA´s Life´s Simple 7, it is quite clear that our current state of stress is antithetic to our goals of reducing cardiovascular death and improving cardiovascular health by 20% by the end of 2020.

With no clear end in sight, but promising figures showing flattening of the disease curve, we must begin tackle the deleterious effects of this acute but soon to be chronic stress on our patient population. Otherwise, we will awake from this pandemic with clinics full of less healthy patients at higher risk of succumbing to an already deadly disease.

At home strategies for exercising, healthy eating, meditation etc will be discussed in my next blog post. For now, be safe, stay home and keep hope alive!

References:

1) Brewer LC, Redmond N, Slusser JP, Scott CG, Chamberlain AM, Djousse L, Patten CA, Roger VL, Sims M. Stress and Achievement of Cardiovascular Health Metrics: The American Heart Association Lifes Simple 7 in Blacks of the Jackson Heart Study. Journal of the American Heart Association, 7(11). doi:10.1161/jaha.118.008855

2) Iob, Eleonora & Steptoe, Andrew. (2019). Cardiovascular Disease and Hair Cortisol: a Novel Biomarker of Chronic Stress. Current Cardiology Reports. 21. 10.1007/s11886-019-1208-7.

“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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Changes to CPR and Response to Cardiac Arrest with COVID-19

When it comes to survival of out of hospital cardiac arrest (OHCA), many advances have been made over the years, 1 early and high-quality chest compressions and defibrillation are key components of this. However, even prior to coronavirus and COVID-19, many bystanders are still hesitant to perform CPR for a variety of reasons; fear of litigation, fear of causing harm, or due to concerns about infectious disease transmission.2 In the new age of social distancing and a highly infectious disease causing stress on our world, the hesitancy may increase. In addition, many programs who have been key in providing education, such as CPR training, have come to a halt during this time.

CPR is generally considered an “aerosolized” procedure, 3 a procedure conveying high risk of transmission of disease via respiratory droplets. Resuscitation efforts in and out of hospital require multiple people in close proximity to each other to respond. In addition, COVID-19 has been reported to cause myocardial injury and ventricular arrhythmia that may predispose someone to cardiac arrest, 1 and despite a pandemic, sudden cardiac arrest and other causes of death do not decline. A concern rising in the medical community since shelter-in-place laws and changing stresses on our medical system, is a notable decrease in visits to the Emergency Departments for common complaints and concerns, such as chest pain, syncope and other things that may dispose someone to a cardiac arrest. We need to be aware of this happening in the community and the potential need for lay and EMS response in these situations.

Lay persons and dispatchers play a key role in survival efforts such as initiating CPR and early defibrillation. There has been documented success with telephone CPR and CPR guidance by dispatchers. An important component of ensuring the best survival of the community and those with COVID-19 or potential COVID-19 is communication and a well-developed community plan to ensure timely and quality resuscitation to patients while protecting rescuers. Recently, Circulation has released Interim Guidance and Advanced life Support in Adults, Children, and Neonates with Suspected or Confirmed COVID-19,1 a quick review is here. Resources from King County EMS in Washington are available for establishing a community response and plan here.

Overall, the common themes are aimed at adequate personal protective equipment (PPE), reducing the number of people responding to an event, and in the case of OHCA for lay people, focusing on hands-only CPR.

For lay persons, the majority of SCA occurs at home. The likelihood of already being exposed to a household contact is high and should be considered when responding to an arrest; for adults hands-only CPR with high-quality compressions is encouraged with early activation of EMS and defibrillation(not an aerosolizing procedure), if available. In the case of pediatric resuscitation, due to the high likelihood of respiratory arrest causing cardiac arrest, it is advised that if willing, after weighing the risk and benefit, that rescue breaths are provided along with compressions. You may use a cloth or mask covering over the victim’s mouth to help reduce transmission in the event it is not a household member.1

For EMS providers, dispatch is crucial in screening calls for any possible risk of exposure to COVID-19, based on symptoms in the victim or any recent contact or household members, and advising whether doing PPE is recommended to the EMS team.1 In Seattle, they have shown a very low rate of transmission to EMS providers when wearing the appropriate PPE.4

For in-hospital cardiac arrest, it is again important to reduce the personnel involved in the resuscitation, close the door when possible, and consider adding PPE to the code carts.  It is also important to use HEPA filters and closed circuit ventilation strategies when it comes to ventilation. The guidance also encourages early intubation by the provider with the highest qualification with the best chance for successful intubation, and use video laryngoscopy when able to minimize aerosolizing the virus while securing a closed circuit airway. The guidance also suggests that if patients are prone and intubated to perform CPR without moving the patient in the standard T7-10 vertebral bodies, however, if they are not intubated to attempt to place them supine and proceed with resuscitation.1

The article also discusses the importance of clarifying goals of care and advanced directives upon arrival, as well as proposes a careful evaluation in the cases of out of hospital cardiac arrest with inability to obtain ROSC, suggesting in some cases, this may be a reason to avoid transport to the hospital due to low likelihood of survival. However, it is important to take into consideration with the benefit, risk and ethics involved.1, 3

Another important update is in regards to maintenance of certification such as BLS/ACLS/PALS. As of March 13, the AHA has offered a 60 day extension for instructor cards and also recommends extension of provider cards for the same length, this allowance is open to be extended based on the evolving threat and CDC/public health recommendations, read the statement here. 5

Many people are looking for things to do in this time of sheltering in place, perhaps this could be an opportunity for education and learning on CPR and AED’s. There are many online resources available, and with the advent of telemedicine, zoom learning and video visits increasing, perhaps we could use this as an opportunity to increase our virtual presence for CPR education.

If you’re interested in some online resources, check out the ILHR website, or your local education center’s website.

  1. Edelson, Dana P, et al. “Interim Guidance for Life Support for COVID-19.” Circulation, ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.120.047463.
  2. Scquizzato, Tommaso, et al. “The Other Side of Novel Coronavirus Outbreak: Fear of Performing Cardiopulmonary Resuscitation.” Resuscitation, vol. 150, 2020, pp. 92–93., doi:10.1016/j.resuscitation.2020.03.019.
  3. Defilippis, Ersilia M., et al. “Cardiopulmonary Resuscitation During the COVID-19 Pandemic: A View from Trainees on the Frontline.” Circulation, Sept. 2020, doi:10.1161/circulationaha.120.047260.

“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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How is the COVID-19 pandemic affecting cardiac patients and the cath lab?

Amongst the uncertainty of the future and how this pandemic will end, there comes a huge responsibility on all healthcare workers to care for the sickest patients while staying safe, to lead their healthcare systems and to come together as one unit against this crisis. Seeing how this pandemic has affected our healthcare system, from the evolving utility of telehealth to canceling elective procedures in multiple specialties, I decided to share a few thoughts on COVID-19 and the cardiovascular manifestations associated with this infection and how COVID-19 has affected our approach to commonly performed procedures in the cardiac catheterization lab.

Cardiovascular manifestations of COVID-19

Although coronavirus predominantly affects the respiratory system, causing a variety of symptoms from flu-like symptoms to acute respiratory failure requiring intubation, it can affect other organs, and patients may present with non-respiratory complaints [1]. The cardiovascular manifestations of COVID-19 have a wide range of clinical presentations (Figure 1), from pericarditis, myocarditis, pericardial effusion, and decompensated heart failure to tamponade, cardiogenic shock and ST-elevation myocardial infarction (STEMI) [1-2]. In addition, right ventricular strain should raise suspicion for pulmonary embolism as these infected patients tend to be hyper-coagulable with a high incidence of venous thromboembolism for currently unclear reasons. It is important to recognize these cardiovascular manifestations of COVID-19, as it is thought that cardiovascular involvement is associated with a worse prognosis [1].

Figure 1: Potential risk factors and cardiovascular manifestations of COVID-19 patients.

Approach to Acute Coronary Syndrome (ACS) and Structural Procedures in the Cath Lab in COVID-19 Pandemic

Like any procedural field, interventional cardiology has been affected by this pandemic. All elective procedures are being postponed until the crisis settles down per recommendations from the Centers for Disease Control and Prevention (CDC), with emergent, urgent, time-sensitive procedures still being performed, in an attempt to preserve hospital beds and personal protective equipment (PPE) for COVID-19 patients [2]. This pandemic has led to several changes in the ACS approach across the world, with the main goal of reducing un-necessary exposure to health care workers and limiting the spread of this highly contagious disease [1,2].

To summarize, some of the key changes many hospitals have applied in their approach to some of the most commonly performed percutaneous cardiac procedures in COVID-19 patients:

  • ACS patients
  • Thrombolytics are considered standard therapy in many hospitals for many STEMI patients with symptoms <12 hours and no contraindications: signs of success are resolution of symptoms and/or >50% decrease in ST elevation. If thrombolytics fail, coronary angiogram and percutaneous coronary intervention (PCI) should be considered in an isolated cath lab (Figure 2) and the benefit versus the exposure risk should be carefully evaluated.
  • For patients with low risk Non-ST elevation myocardial infarction (NSTEMI): medical therapy is reasonable. For those with high risk NSTEMI or failure of medical treatment, coronary angiogram and/or PCI should be performed. These coronary procedures are usually performed in isolated cath labs with only limited staff in the cath lab room, to avoid unnecessary exposure (Figure 2).
  • Structural heart disease patients
  • For patients who are unstable and have severe aortic stenosis (AS), balloon aortic valvuloplasty (BAV) should be performed emergently to stabilize the patient if this is thought to be the cause of the hemodynamic instability. For those who develop significant aortic regurgitation after BAV, transcatheter aortic valve replacement (TAVR) should be performed.
  • Patients with severe symptomatic AS, TAVR is considered a time-sensitive procedure. The benefit of TAVR and risk of infection exposure should be discussed.It is important to note that this change in policy, in part, could explain the decrease in cath lab activation rates for STEMI during this pandemic [2]; as many STEMI patients are receiving thrombolytics. In addition to that, many patients are not seeking medical care, or if they do, they are presenting late, possibly due to fear from contracting the virus in the hospital, potentially leading to late STEMI complications [2]. Thus, it is important to counsel our patients in our virtual clinic visits that if significant symptoms develop, they should seek medical care.

Lastly, I want to thank all of my colleagues and healthcare workers across the nation and across the globe for risking their lives for patients and for their continued dedication. This is a critical time for everyone in the health care system. In light of this pandemic, I hope we continue to learn and share our experiences in this global crisis in order to improve our patient’s care, safety for our healthcare workers and the dynamics of our healthcare system.

Figure 2: Simplified Set-up of an Isolated Cath Lab during the COVID-19 pandemic.

References

“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.”