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Advancing Cardiovascular Health for All

Finally, some excellent news in a year ravaged by innumerable tragedies, the first Black Indian American woman, Kamala Harris, is vice president-elect of the United States, and the American Heart Association has made a commitment to advance cardiovascular health for all-; what a great start to November 2020. I got to attend the American Heart Association’s news conference on the organization’s Call to Action: Structural Racism as a Fundamental Driver of Health Disparities, and unlike many of the committee, workgroup, and taskforce meetings I have attended or the emails and newsletters I have read since the newfound interest in structural racism, this felt real.

The American Heart Association’s Impact Goal read: As champions for health equity, by 2024, the American Heart Association will advance cardiovascular health for all, including identifying and removing barriers to health care access and quality. What struck me was the emphasis on structural racism being a major cause of poor health and premature death. Many of the other meetings I sat in on, you know, the committees, the task forces, and the workgroups, rarely acknowledged structural racism as the root cause. We cannot fix healthcare until we acknowledge that structural racism has contributed to the grave inequities in medicine.

One of the saddest things to me is that marginalized individuals may not even be aware that they are recipients of disparate care. One of my best friend’s uncles, a Black man, was turned away from an emergency department with a new diagnosis of diabetes and unrelenting nausea with some paperwork to apply for insurance coverage and died of a massive myocardial infarction at home. The patients we turn down for heart transplant or left ventricular assist devices because of lack of financial security- souls that will haunt me forever. The Black non-English speaking man who presented to an emergency department with acute myocardial infarction and then delayed in his care led to his death. I read these statistics in medical journals and saw stories on television, but when I started witnessing the injustices firsthand and became the go-to person for my Black friends who wanted assurance that their parents, grandparents, aunts, uncles, and they themselves were receiving “good” care (oftentimes they were not), I became even more determined to do my part in dismantling these oppressive systems.

And just so we are clear, dismantling structural racism does not mean adding Black and Latinx members to a committee, for example, that continues to be led by individuals perpetuating oppressive systems; it means removing the oppressors and replacing them with individuals committed to driving change. Being part of the change means looking around the spaces you are in and recognizing what the problems are, and fixing them. Everyone is responsible. Until we address societal racism, we will never address inequities in medicine. Expecting a patient who is a single, working mother, who lives in a food desert, and who did not have the privilege of going to a top-rated public school to be successful with the same tools provided an executive at a Fortune 500 company is ludicrous. We must provide each patient with the tools that will contribute to their success, but ideally, no provisions would be necessary if we lived in a just society. Justice is the overarching goal.

The highlights of the American Heart Association’s advisory are direct- 1. The ascertainment that structural racism is a current and pervasive problem, 2. The acknowledgment that structural racism is real and produces adverse effects, and 3. The burdens of mitigating the impact of structural racism is a shared responsibility. Profound. All hands on deck; the individuals that deny the pervasiveness of structural racism, and it is the root cause of healthcare inequities must be phased out. Additionally, the American Heart Association listed key areas to address to eliminate structural racism and its negative effects, including restructuring systems, implementing policies, eliminating inequities, fostering allyship, and supporting research. And allyship does not mean supporting the mission when you are around people passionate about dismantling systemic racism, allyship means looking within your own families, circles, and workplace and driving change. Allyship is not wearing a Black Lives Matter pin on your white coat, kneeling with a White Coats for Black Lives sign, sitting on a diversity and inclusion committee, or Tweeting an article on the late, great Congressman John Lewis; allyship is using your privilege and platform to drive change.

I do not claim to be an expert in racism, far from it, but I do know we each have to play a role in dismantling the oppressive systems that have left Black and Latinx patients without access to quality healthcare. For me, my contribution to driving change is mentoring and sponsoring Black women and men interested in careers in medicine so we can change the face of medicine and secondly, working to eliminate inequity in organ allocation in heart transplant by improving outreach to neglected communities and creating pre-transplant “Bootcamp” programs where, instead of turning a patient down for smoking, for example, providing them with the tools necessary to become an ideal transplant candidate. Just like transplant centers are penalized for excessive mortality, transplant centers should be penalized for not expanding outreach to BIPOC communities.

I want to end with the powerful words of Reverend Dr. Martin Luther King, Jr, may he continue to Rest in Power because I cannot end this better myself- “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” Physicians, advanced practice providers, scientists, nurses, technicians, administrators, policymakers, and anyone with a stake in healthcare- we have so much work to do, but I remain full of hope.

 

“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 will COVID-19 Affect Return to High School Sports and ECG Screening?

August is traditionally very busy month in the pediatric cardiology office; visits for “sports clearance” flood the schedule due to something picked up on a high school sports physical such as chest pain. Most of these will be non-cardiac and receive reassurance; however, the cardiac causes in the pediatric population can be quite distressing. With the current COVID-19 pandemic we are seeing many cardiac effects of the virus— myocardial inflammation, dysfunction and coronary artery dilation or MIS-C (multisystem inflammatory syndrome in children). There has also been a reported increase in out of hospital cardiac arrest in the adult population, which could be attributed to those afraid to seek care, but none the less, a concern.

Cardiac effects play an important part in the recent discussions on return to school, as eventually return to school will mean return to school sports. Sports cardiologists have been following this closely and have been working to establish a safe way for return to sports in competitive athletes who have had COVID-191(click here for recommendations and see flowchart below), which may include extensive cardiac testing of those who had symptomatic COVID-19, most of which is based on the return to play myocarditis guidelines.2 These important decisions require individualization, knowledge of risk and what is happening in the community.

So what does this mean for the high school athletes? There is no doubt that exercise is great for everyone, especially with the rising obesity and the sedentary lifestyle. Organized sports participation has shown to have a positive impact on mental and physical health that extends beyond childhood.3 Many have raised concerns about the development and health of children by not attending school, along with decrease in social interaction and activity from organized sports during the stay-at-home orders and while we work to defeat COVID-19 spread.

Prior to the pandemic, the question of universal ECG testing for high school athletes always started a conversation, but could that change? Critics say that the false positives create distress and extra healthcare cost, that follow up is problematic and that it has not been shown to change outcomes. Others argue saving one child from the devastating event of collapsing and dying on the field is worth it, and a recent study showed ECG with H&P is more likely to detect a condition associated with sudden cardiac arrest (SCA) than H&P alone, and also improved cost efficiency when interpreted in the right hands.4 All agree it is important to have a good plan in place for SCA at all sporting events, including an emergency response plan in place specific to cardiac arrest.

With so many affected by the virus, at varying severity, I can’t help but wonder if this will change the way we assess our young athletes for participation in sports when it is safe to do so. While healthcare costs are always a problem, with a new virus and unclear long-term outcomes, we must be conservative. Perhaps this may provide an opportunity to learn more about ECG screening, as we will likely see a larger amount of patients who have had COVID-19 coming to our offices for clearance. This may provide an opportunity to gather evidence on the continued debate of whether ECG screening is effective.

Until we know more, what we do know is it is safer to be conservative, to assess benefit and risk and provide appropriate counseling to families on signs and symptoms of SCA. We also must continue to reassess and stay up-to-date on new knowledge and testing related to COVID-19 recovery and sports. Most importantly, it is important that we continue to advocate for heart safe schools which include having AEDs, training in CPR, and emergency response plans related to Sudden Cardiac Arrest. With more kids participating in school from home, this could be a great opportunity to engage the whole family in CPR and AED education to improve the safety and survival of our communities and at home.

 

References

  1. Phelan, Dermot, et al. “A Game Plan for the Resumption of Sport and Exercise After Coronavirus Disease 2019 (COVID-19) Infection.” JAMA Cardiology, 2020, doi:10.1001/jamacardio.2020.2136.
  2. Maron, Barry J., et al. “Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task  Force 3: Hypertrophic Cardiomyopathy, Arrhythmogenic Right Ventricular Cardiomyopathy and Other Cardiomyopathies, and Myocarditis.” Journal of the American College of Cardiology, vol. 66, no. 21, 2015, pp. 2362–2371., doi:10.1016/j.jacc.2015.09.035.
  3. Logan, Kelsey, and Steven Cuff. “Organized Sports for Children, Preadolescents, and Adolescents.” Pediatrics, vol. 143, no. 6, 2019, doi:10.1542/peds.2019-0997.
  4. Harmon, Kimberly G, and Jonathan A Drezner. “Comparison of Cardiovascular Screening in College Athletes” Heart Rhythm, 2020, www.heartrhythmjournal.com/article/S1547-5271(20)30406-9/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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How is the AHA leading the way in Cardiopulmonary resuscitation (CPR)?

In writing this last post as a junior blogger, I decided to highlight the tremendous efforts by the American Heart Association (AHA) to improve cardiovascular care in the field of cardiac arrest and cardiopulmonary resuscitation (CPR). As we know, the AHA is a worldwide leader in first aid, CPR, and Automated External Defibrillator (AED) training – educating millions of people globally in CPR every year. Here, I will share some fun facts about CPR, and you can refer to the AHA website for further details about this important topic.

Important CPR statistics

  • Majority of cardiac arrests occur outside of the hospital, with estimated 475,000 Americans dying from cardiac arrests every year [1]
  • Bystander CPR is a key component in the out-of-hospital “chain of survival” [Figure 1] and studies have shown it improves survival in cardiac arrest [1-3].

Figure 1: The adult out-of-hospital “chain of survival”. Each link of the chain from left to right is numbered 1 through 5: 1- Recognize cardiac arrest and activate the emergency response system, 2- early CPR with high-quality chest compressions, 3- Use AED for rapid defibrillation, 4- basic and advanced emergency services and 5- post-cardiac arrest care and advanced life support [2].

  • Bystander CPR has been increasing over the recent years in both men and women. Despite that, survival improved in men only, but not women [2]. This is important as it highlights that more work is needed to identify additional predictors of survival in women with cardiac arrest.
  • Efforts mandating CPR training in high schools in multiple states [5] and availability of AED in public places, including airports [Figure 2], have helped in increasing the awareness and familiarity of bystander CPR in cardiac arrest [4].

  • Figure 2: A photo of Automated External Defibrillator (AED) in one of the airports.

Personal Experience

From a personal experience, I have visited multiple high schools in my home country as well as in the United States, and have participated as an organizer in the sessions teaching high school students how to perform effective CPR. It is inspiring to see junior students interested in learning and saving lives. The takeaway from my experience is that engagement plays a major role in spreading the word and encouraging the general public to take the extra step and learn how to perform basic and advanced life support techniques.

In conclusion, it is important to remember that the general public are oftentimes our first “link” in the chain of survival; making them an important part of our efforts to improve survival and cardiovascular care in patients with cardiac arrest. A strong chain of survival improves survival and recovery after cardiac arrest. Although there have been improvements in CPR and advanced life support, there remains room for further improvement, and perhaps we can do our part by encouraging our patients, friends and relatives to take the first step and learn how to perform effective CPR and possibly how to use AEDs!!

I have added a few online references for those interested in sharing this with their patients and encouraging them to sign up for both the online and class programs [3,6]!!

References:

  • Meaney PA, Bobrow BJ, Mancini ME, et al. Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association [published correction appears in Circulation. 2013 Aug 20;128(8):e120] [published correction appears in Circulation. 2013 Nov 12;128(20):e408]. Circulation. 2013;128(4):417-435. doi:10.1161/CIR.0b013e31829d8654
  • Malta Hansen C, Kragholm K, Dupre ME, et al. Association of Bystander and First-Responder Efforts and Outcomes According to Sex: Results From the North Carolina HeartRescue Statewide Quality Improvement Initiative. J Am Heart Assoc. 2018;7(18):e009873. doi:10.1161/JAHA.118.009873
  • CPR facts and stats:

https://cpr.heart.org/en/resources/cpr-facts-and-stats

  • Chain of Survival:

https://cpr.heart.org/en/resources/cpr-facts-and-stats/out-of-hospital-chain-of-survival

  • Mandatory CPR training in high school:

https://www.sca-aware.org/schools/school-news/mandatory-cpr-training-in-us-high-schools

  • CPR AED and first aid classes:

https://cpr.heart.org/en/course-catalog-search

“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 History of the AHA

Following up on an earlier post about the history of the NIH R01 grant, which morphed into a history of the NIH and the National Cancer Institute, I wanted to find out more about the history of the American Heart Association and the first AHA research awards.

This was much easier information to obtain! It is on the AHA website. The first award went to biochemist, Dr. Albert Szent-Gyorgyi, who was fascinating and possibly the topic of a future post. He received the first AHA grant in 1948 while he was at the Marine Biological Laboratory in Woods Hole, MA. He primarily contractile components of muscle including the heart.

Dr. Albert Szent-Gyorgyi (https://en.wikipedia.org/wiki/Albert_Szent-Gy%C3%B6rgyi)

 

The first AHA logo

The first AHA logo (https://www.heart.org/en/about-us/history-of-the-american-heart-association)

Easily finding this answer led to another question. When and how did the AHA begin in the first place? The public and physicians knew little about cardiovascular diseases in the early 1900’s when the AHA was founded. Heart disease was thought to be a slow, drawn-out death sentence. A group of 6 physicians believed that with scientific research, a cure could be found.

One of the first AHA meetings.

One of the first AHA meetings.(https://www.heart.org/en/about-us/history-of-the-american-heart-association)

 

The 6 founding members of the AHA were: Drs. Lewis A. Conner, Robert H. Halsey, Paul D. White, Joseph Sailer, Robert B. Preble, and Hugh D. McCulloch. Since the founding in 1924, the AHA’s has been primarily a scientific association. After awarding the first research grant in 1948, AHA began publishing its first journal Circulation in 1950.

From that point on, the AHA was instrumental in funding research that linked smoking and saturated fats to heart disease. AHA research was instrumental in the development of implantable pacemakers, CPR, artificial heart valves, statins, and AEDs. They also established a personal favorite of mine, the Jump Rope for Heart, which I proudly participated in as a child.

There were several changes geared toward unifying the AHA’s objectives, research standards, and guidelines through the years. In 1995, the AHA declared its strategic driving force: Providing credible heart disease and stroke information for effective prevention and treatment. The AHA still functions as a scientific organization but one that faces first and foremost on the public. The AHA’s driving force guides the scientific efforts of AHA members to public benefit.

 

Are you an AHA member and interested in applying for a research program or award?

The AHA is now accepting applications for four research programs:

  1. AHA Predoctoral Fellowship
  2. AHA Postdoctoral Fellowship
  3. Merit Award
  4. Institutional Undergraduate Program

APPLICATION DEADLINES

  • Merit Award Letter of Intent (required) – July 11, 2019
  • AHA AIREA Award – July 17, 2019
  • Predoctoral Fellowship – August 14, 2019
  • Postdoctoral Fellowship – August 15, 2019
  • Institutional Undergraduate Fellowship Program – September 18, 2019

The Grants@Heart or AHA Application Information web page will contain updates about subsequent programs and you can begin preparing your application. Email  apply@heart.org or call 214- 360-6107 for questions.