AHA18

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Live Streaming AHA18 – My First Experience

Daniel Tyrrell, PhD

The American Heart Association’s Scientific Sessions 2018 concluded this past Monday. Unfortunately I was unable to attend in-person, but I was able to catch some of the events virtually online via Scientific Sessions Live Streaming. While I have been to other scientific meetings hosted by the AHA, I have yet to attend the main event – Scientific Sessions. By live-streaming some of the sessions at the event, I was still able to hear about breaking scientific advances.

If you’ve ever felt like all of your colleagues were at a conference and you should have been there, but were prevented for whatever reason, that’s how I felt. Live-streaming some sessions at Scientific Sessions was a last-minute decision for me, but well worth it. I was able to watch Dr. Paul Ridker’s presentation at the AHA Distinguished Scientist Lecture. Not only did that provide the opportunity to hear Dr. Ridker’s update on new and exciting findings coming out of the CANTOS trial, I had never heard him speak until that moment. This was an opportunity I did not want to miss.

Another great opportunity that Live Streaming provided was the opportunity to connect in real-time with attendees who were at the Scientific Sessions in-person. As part of AHA’s Early Career Blogger team, I was able to live-tweet during the session and connect with other’s in the audience. It was a really great way to hear and feel connected to the cutting-edge science without being physically present.

This is my first blog post for the AHA Early Career Blogging team, so thanks for reading. My other posts will focus more on science in the fields of vascular biology and atherosclerosis, so if you’re interested, please stay tuned.

 
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Live Streaming, Cardiovascular Disease, and Violence: What I Learned at Scientific Sessions 2018

Jacqueline Leachman

Take a trip back down memory lane to your glory days as a happy and shiny nine-year-old. If your childhood was as amazing as I remember mine to be, then you spent your days running outside with friends, making mud pies, and then fabricating methods by which you could trick your little sister into eating said mud pies. Now even though life is all spick-and-span for you at that age, imagine that you have a close friend whose parents are experiencing some domestic problems – so bad in fact, that it results in the mother attempting to commit suicide by ramming the car, full speed, into a cement block with your friend and his/her two other siblings inside. In your present day and age, can you even begin to fathom the degree of trauma that this past event brought to your friend? Now, would you believe me if I say that if undealt with, your friend may not only experience mental health issues but also cardiometabolic problems? While this may not be your first thought, it is now becoming more widely known that violence (or stress) is an independent risk factor for adverse cardiovascular health. This story may seem just a tad over the top; however, this was the topic of discussion for the session titled Unpacking the Cardiovascular Biology of Violence at Scientific Sessions 2018 and was the eye-opening account given by physician Marjorie Fujara from Chicago during her presentation.

As a new graduate student, this was my first time experiencing Scientific Sessions and I was completely taken aback by the various works discussed. Presentations that I was luckily able to witness via Live Streaming. Yes, you read correctly, LIVE STREAMING. Complete transparency here, I definitely opened my iPad with the preconceived notion that I would not be as engaged watching from my tiny screen in comparison to what I would experience being presented live and in-person. However, from the comforts of my own home, I found myself unreservedly hooked on the late-breaking science from researchers across the country. From the new Physical Activity Guidelines, to the nature versus nurture of cardiovascular disease, it was without a doubt an exciting weekend for science!

Considering the variety of disciplines at the conference, there were a number of ways to personally connect to the science presented. For example, my lab studies the effects of early life stress (or adverse childhood experiences) on the development of obesity and its related diseases later in life. As a result, the cardiovascular biology of violence talks were the ones that resonated with me the most because of its applications to my own research and personal interests.

During the discussion on the connections between heart health and trauma exposure, one panelist considered the case of primordial violence on developmental programming. Key points stemmed around the idea that excessive punishment led to increased levels of circulating cortisol. This then results in damage to the hippocampus (memory and learning), amygdala (emotions), and frontal cortex (reasoning). This data has led to the implementation of “No Hit Zones” in various hospitals. At the genetics level, however, what makes the people who experience increased levels of violence different from the rest of the population? When considering the epigenetics of the situation, violence in one’s life results in alterations in DNA methylation patterns (either hypo- or hyper-) and eventually leads to a higher cardio-metabolic risk. During the discussion, it was mentioned that for a child, just hearing about violence in one’s own community resulted in a difficulty concentrating for periods ranging from two days to an entire month. You can easily begin to wonder, “What does this mean for children living in areas with high homicide rates?” Overall, people exposed to trauma, and are not properly dealing with it, are predisposing themselves to diastolic elevations much earlier in life consequenting in early onset of cardiovascular disease.

The question is now, “What interventional methods can we use to better help people who are experiencing cardiac alterations due to increased stress exposure?” One solution discussed is the Bright Star Community Outreach program. Bright Star is a nonprofit aimed at using science and research to aid members of the south side Chicago community in recovering from the trauma of violence. By confronting the trauma, instead of bottling it away, they hope to help people to end the cycle and limit violence-induced early cardiovascular insults.

As the reader, and possibly someone who was unable to attend (or live stream) AHA Scientific Sessions 2018, what else do you think can be done clinically to better serve this group in terms of cardiovascular health? Do you think they will need different pharmacological interventions compared to the “traditional” hypertensive patient, for example?

 

Disclaimer

“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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Women in the New Lipid Management Guidelines

Mirvat Alasnag, MD

The American Heart Association‘s annual meeting, Scientific Sessions, remains a Mecca for cardiologists worldwide. Those of us who were unable to attend in person followed the scientific discussions virtually through the Live Streaming option.  This year the much anticipated update to the Lipid Management Guidelines were presented at the meeting.  A focus on women as a special population was addressed separately by Dr. Lynne Braun. As cardiologists, we are not trained to search for atherosclerotic cardiovascular disease (ASCVD) enhancers specific to women, namely premature menopause (less than 40 years old), pregnancy associated disorders such as preeclampsia, gestational diabetes and preterm labor. Moreover, we often fail to discuss pregnancy and contraception with women of childbearing age who require statin therapy based on their ASCVD risk assessment. The majority of our key performance indicators in a cardiac unit or clinic require that patients are discharged on a statin if they are at risk. Yet, women should be advised to discontinue statin therapy 1-2 months prior to attempting pregnancy. It seems counter-intuitive to discuss discontinuation of statin therapy in a system that measures performance by the intensity of the prescribed dose. This in itself requires retraining of cardiologists and the AHA offered a unique opportunity to highlight its importance during Dr. Braun‘s presentation.

Another related topic addressed extensively at this year’s meeting was the role of calcium scoring (CACS) in risk stratification in the new lipid management guidelines. It is noteworthy that several large studies demonstrated that CACS improves risk assessment when combined with the conventional risk parameters.1-3 Women often have lower CACS compared to age-matched men. A meta-analysis by Kavousi et al in 2016 examined 5 large cohorts of women with an ASCVD risk <7.5% (low risk by current guidelines).4  CACS was identified in 36% of the women which led to a 2-fold increase risk of ASCVD. Ensuant to this discussion, is the topic of a coronary artery calcium score of 0 that denotes a very low risk, ie 1.1–1.5% 10-year risk of ASCVD events. This is commonly referred to as the power of zero calcium.5  The latest guidelines suggest CACS may assist in further stratifying women particularly those in the intermediate and borderline categories of risk given the older age of onset of ASCVD in women. It may also assist in the shared decision making with women of different ages and women with additional risk enhancers as discussed above.

As this year’s meeting drew to a conclusion, I’m grateful I could keep pace with the discussions on lipid management in women from the other end of the globe. More importantly, as a woman cardiologist, I was able to go to work the next morning and reevaluate the discussions I have with my female patients. For the first time, I tailored my discussion on statin therapy to the woman sitting across from me, my patient.

 

References:

  1. Paixao, A.R., Berry, J.D., Neeland, I.J. et al. Coronary artery calcification and family history of myocardial infarction in the Dallas heart study. JACC Cardiovasc Imaging. 2014; 7: 679–686
  2. Elias-Smale, S.E., Proenca, R.V., Koller, M.T. et al. Coronary calcium score improves classification of coronary heart disease risk in the elderly: the Rotterdam study. J Am Coll Cardiol. 2010; 56: 1407–1414
  3. Arad, Y., Goodman, K.J., Roth, M., Newstein, D., and Guerci, A.D. Coronary calcification, coronary disease risk factors, C-reactive protein, and atherosclerotic cardiovascular disease events: the St. Francis Heart Study. J Am Coll Cardiol. 2005; 46: 158–165
  4. Kavousi, M., Desai, C.S., Ayers, C. et al. Prevalence and prognostic implications of coronary artery calcification in low-risk women: a meta-analysis. J Am Med Assoc. 2016; 316: 2126–2134
  5. Nasir, K., Bittencourt, M.S., Blaha, M.J. et al. Implications of coronary artery calcium testing among statin candidates according to american College of cardiology/american heart association cholesterol management guidelines: MESA (Multi-Ethnic study of atherosclerosis). J Am Coll Cardiol. 2015; 66: 1657–1668
  6. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol
    • Scott M. Grundy, Neil J. Stone, Alison L. Bailey, Craig Beam, Kim K. Birtcher, Roger S. Blumenthal, Lynne T. Braun, Sarah de Ferranti, Joseph Faiella-Tommasino, Daniel E. Forman, Ronald Goldberg, Paul A. Heidenreich, Mark A. Hlatky, Daniel W. Jones, Donald Lloyd-Jones, Nuria Lopez-Pajares, Chiadi E. Ndumele, Carl E. Orringer, Carmen A. Peralta, Joseph J. Saseen, Sidney C. Smith, Laurence Sperling, Salim S. Virani, Joseph Yeboah
      Journal of the American College of Cardiology Nov 2018, 25709

 
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Yoga CaRe: When Evidence-Based Science Meets Ancient Wisdom

Abhishek Sharma, MD

Yoga can be vaguely defined as group of ‘mind-body’ exercises. Though exact timing remains debatable, origin of yoga can be traced back to more than 3,000 years ago when it was first mentioned in ancient Indian text ‘Rigveda’. Yoga is among one of six fundamental ‘Darshanas’ of Hindu philosophy. Various yoga practices were integral part of Indian sages’ routine, who taught and propagate various yogic practices across ancient India.

In western society, yogic practices involving ‘Asanas’ (stretching/body posture), ‘Pranayama’ (breathing exercise), and Meditation have become popular as mean of reducing stress and improving physical well-being.  Several small studies have reported beneficial effects of yoga in primary and secondary prevention of cardiovascular disease (CVD) [1-3]. Yoga based cardiac rehabilitation program post coronary artery bypass graft surgery has been reported to be associated with improvement in left ventricle function, lipid profile, stress reduction and quality of life [1, 2]. However, studies reported beneficial effects of yoga have been limited by small sample size, lack of adequate control, and non-uniform methodologies. Thus, utility of yoga based rehabilitation program in patients with pre-existing CVD remains uncertain.

Against this background, group of Indian physicians conducted a multi-center randomized controlled trial, to evaluate effectiveness of yoga-based cardiac rehab (yoga-CaRe) in patients with acute myocardial infarction. Dr. Dorairaj Prabhakaran from Center for Chronic Disease Control (New Delhi, India) presented the results of this study in a late-breaking science session at the American Heart Association 2018 Scientific Sessions. Study randomized 3,959 patients with acute MI patients from 24 Indian centers to 14 weeks of either Yoga-CaRe or enhanced standard care (ESC). Patients in Yoga-CaRe group underwent 13 sessions of yoga (3 health rejuvenating exercises, 15 postures, 5 breathing techniques & 5 meditative techniques) under trained yoga instructor guidance. ‘Asanas’ (body posture) in Yoga-CaRe group were carefully selected to avoid significant tachycardia.  ESC was comprised of 3 educational sessions (before discharge from the hospital and subsequently at weeks 5 and 12) and printed leaflet delivered by nurse or another member of cardiac care team either individually or in groups to avoid contamination. At 42-month follow up, compared to ESC, patients in Yoga-CaRe had numerically fewer composite endpoint events (death, nonfatal MI, nonfatal stroke, or emergency cardiovascular hospitalization) in the intention-to-treat analysis; however this difference was not statistically significant. The secondary endpoint of self-rated quality of life, and rate of patient return to pre-infarct daily activities were better in Yoga-CaRe group at three months. As per Dr. Prabhakaran ‘.. it (yoga) improve quality of life and made patient return to pre-infarct activities as quickly as possible….wherever people adhere to yoga i.e they attend more than 10 sessions there was reduction in composite end point particularly in death..’

Despite been a class I recommendation cardiac rehabilitation remains highly underutilized in post MI patients.  Situation is even worse in underdeveloped countries where structured cardiac rehabilitation post MI is almost nonexistent due to limited resources. In this context, results of this study are very relevant as yoga is relatively inexpensive and can be delivered by trained instructor to group of patients without further straining already overburden health care system. As pointed out by Dr. Prabhakaran ‘Yoga is feasible, and it can be ambitiously scaled up in term of cardiac rehabilitation..’. This could have far reaching benefits in low- and middle-income countries with limited health staff and resources, and high CVD burden.

However, due to lack of standardized physical exercise component in control arm of Yoga-CaRe trial, it remains unclear if yoga offers any additional benefits over traditional exercise performed for equal duration. Further, Yoga-CaRe enrolled relatively younger patients (mean age ~53yr) and predominately males (>85%). Thus, potential role of yoga in post MI elderly and females patients remains unexplored. Future, large-scale studies addressing these limitations and evaluating yoga based cardiac rehab in other CVD like heart failure would be useful in testing utility of these age old ‘mind-body’ exercises in modern world.

 

References:

  1. Raghuram N, Parachuri VR, Swarnagowri MV et al. Yoga based cardiac rehabilitation after coronary artery bypass surgery: one-year results on LVEF, lipid profile and psychological states–a randomized controlled study. Indian Heart J. 2014 Sep-Oct;66(5):490-502.
  2. Amaravathi E, Ramarao NH, Raghuram N et al. Yoga-Based Postoperative Cardiac Rehabilitation Program for Improving Quality of Life and Stress Levels: Fifth-Year Follow-up through a Randomized Controlled Trial. Int J Yoga. 2018 Jan-Apr;11(1):44-52.
  3. Yeung A, Kiat H, Denniss AR, Cheema BS et al. Randomised controlled trial of a 12 week yoga intervention on negative effective states, cardiovascular and cognitive function in post-cardiac rehabilitation patients. BMC Complement Altern Med. 2014 Oct 24;14:411.
  4. Prabhakaran D, et al “Effectiveness of a yoga-based cardiac rehabilitation (Yoga-CaRe) program: a multi-centre randomised controlled trial of patients with acute myocardial infarction from India” AHA 2018.

 
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MINOCA – The New Unique Type of Myocardial Infarction

Sivabaskari Pasupathy, PhD

Myocardial infarctions have been claiming lives since ancient times, yet we are still understanding the condition itself. With the emergence of acute coronary angiography in the 80s, it became evident nearly 90% of myocardial infarctions are associated with occluded coronary arteries. This led to the advances in clinical approaches to reduce the myocardial damage by reopening the obstructed coronary arteries as quickly as possible with the aid of mechanical and pharmacological interventions. Among all this, a distinctive form of myocardial infarction have been silently increasing in prevalence over the years without drawing much attention. This subtype of myocardial infarction has recently been named “myocardial infarction with non-obstructive coronary arteries’ or ‘MINOCA’. As the name implies, it refers to patients presenting with myocardial infarct symptoms without obstructive coronary artery disease. The lack of obstructive coronary artery disease in this group often leads clinicians to disregard them as “false-positive presentations” and patients are discharged with “it doesn’t seem like there is anything wrong with you and there is not much I can do about it at this stage.” Despite a myocardial infarct presentation, patients are discharged to home with minimal to no medical management and no explanation. With the widespread use of coronary angiography and the advance of more sensitive cardiac biomarkers, the MINOCA presentations have started to gain attention among cardiologists and researchers in recent years.

This year at Scientific Sessions 2018, Dr Jacqueline E. Tamis-Holland and Dr Harmony Reynolds addressed MINOCA and the existing knowledge gap. Here is a summary of the key points discussed at the meeting:

 

What is MINOCA?

Approximately 5-10% of myocardial infarct presentations are suspected as MINOCA and available data suggests that they are likely be younger, females and have lower cardiovascular risk factors than myocardial infarct patients with obstructed arteries. The recent 4th universal definition of myocardial infarction published in 2018 highlighted that the diagnosis of MINOCA indicates that there is an ischemic mechanism responsible for the myocyte injury. Therefore, the MINOCA diagnosis is not applied to patients with clinical evidence of aberrant troponin changes as a result of non-ischemic or non-cardiac causes such as myocarditis or pulmonary embolism.

 

What causes MINOCA and what are the additional recommended tests?

The dilemma with treating MINOCA is delineating MINOCA presentations from those with troponin rise and/or fall due to non-ischemic and non-cardiac causes as this not feasible based on the presentation itself. When a patient is suspected as MINOCA following coronary angiography, the patient should be clinically re-evaluated with multiple potential causes in mind. The following are the key underlying causes and corresponding diagnostic investigations.

 

 

Prognosis of MINOCA

The available literature demonstrates that overall suspected MINOCA patients have a favorable prognosis compared to those with the classic myocardial infarction (associated with obstructive CAD). However, careful examination of literature shows suspected MINOCA patients have the equivalent 12-month all-cause mortality to those with myocardial infarction associated with single- or double-vessel coronary artery disease. However, the prognosis associated with MINOCA with only ischemic mechanisms in mind is yet to be studied.

 

Treatment for MINOCA

There are no randomized trials addressing this question. However, a recent publication by Lindahl and colleagues stemming from the SWEDEHEART (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapy) registry provides the first insights into potential long-term prognostic benefit of medical therapy in the management of MINOCA. The authors have showed benefits of statins, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and beta-blocker therapy in MINOCA cohort.

The MINOCA BAT Trial (Randomized Evaluation of β‐Blocker and Angiotensin‐Converting Enzyme Inhibitor/Angiotensin Receptor Blocker Treatment in MINOCA Patients) is the first randomized clinical trial initiative in MINOCA patients and expected to begin enrollment in Australia and Europe in 2018 and also plans to expand enrollment to the United States and Canada in the next year. This will be a pragmatic prospective, randomized, multicentre, open-label clinical trial, with 2×2 factorial design. All outcomes will be analyzed using the intention-to-treat principle. The study aims to determine whether oral beta-blockade and/or ACEI/ARB impacts on MACE in patients discharged with MINOCA, where MACE is defined as the 4-year composite endpoint of all-cause mortality or hospital admission for AMI, ischemic stroke or heart failure.

As evident from Scientific Sessions 2018, the current available MINOCA literature demonstrates the importance of diagnosing and treating patients with MINOCA, although substantial knowledge gaps exist that require future research to identify optimal management.

 

Key points about MINOCA

  • MINOCA is not uncommon occurring in approximately 5-10% of patients.
  • MINOCA indicates that there is an ischemic mechanism responsible for the myocyte injury.
  • MINOCA diagnosis is not applied to patients with clinical evidence of aberrant troponin changes
  • There are various etiologies for MINOCA and it is important to perform a careful evaluation to identify the cause
  • Treatment will vary depending on the underlying cause but there may be some role for cardioprotective therapies in MINOCA
  • The prognosis of MINOCA is not benign, once again emphasizing proper diagnosis and aggressive treatment for this condition

 

“The good physician treats the disease; the great physician treats the patient who has the disease” – William Osler

 

Do you have any thoughts on MINOCA?

 

 
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Late Breaking Science Trial: ORBITA Debate at Scientific Sessions 2018

Saurav Chatterjee, MD

“Life is like riding a bicycle. To keep your balance you must keep moving.” -Albert Einstein.

There may scarcely be any other sphere of medicine than interventional cardiology where the quote is more applicable. In 2017, the paradigm shifting ‘Objective Randomised Blinded Investigation With Optimal Medical Therapy of Angioplasty in Stable Angina’ – ORBITA  trial was presented and published.The results of this trial indicated that among patients with stable angina, percutaneous coronary intervention/PCI does not result in greater improvements in exercise times or anginal frequency compared with a sham/placebo procedure. This was despite the presence of anatomically and functionally significant stenoses. PCI did however resolve ischemia more effectively, as ascertained by follow-up stress.

This was clearly a landmark trial, but several issues were put forward as limiting factors. The trial was well conducted, with careful assessments of ischemia pre- and post-procedure, and appropriate use of antianginal medications-which unfortunately has been hard to replicate outside of the controlled setting of a trial, in the tribulations of real-world medical practice. Although powered for exercise treadmill-based endpoints, the trial has been noted to be too small to address a question of clinical benefits with PCI. Moreover, changes in Duke treadmill score and exercise time were both numerically higher in the PCI arm, and it is unknown if a larger sample size would have detected more modest improvements in exercise capacity.

The controversies and ‘buzz’ had prompted me to follow the data as a early career interventionist-and I cued in keenly for the short debate session on the same at the Annual Scientific Sessions of the American Heart Association 2018 (#AHA18) .Dr. Brahmajee Nallamothu, Editor of the Circulation: Quality and Outcomes and a Professor of Medicine at the University of Michigan- speaking in favor (PRO) of the findings from the ORBITA trial mentioned that while the myth that percutaneous coronary intervention’s prolong the life has long been debunked, a commonly held notion, and indeed one of the main reasons for performing PCI was to improve the quality of life in patients with significant coronary artery disease and symptoms. And ORBITA actually indicated that in a relatively healthy patient population, in a carefully conducted placebo controlled trial, the postulated benefits imparted with PCI were likely minimal. He went on to note that the trial was representative of a “real world” population of middle-aged patients with symptomatic coronary artery disease and  also referred to images from the original Lancet publication which indicated that the lesions that were treated appeared quite significant indeed. He concluded that in spite of  ongoing debates, results from ORBITA changed the way he discussed planned coronary intervention with his patients where he has changed his practice by incorporating a more tempered discussion on anticipated benefits with PCI, and has had greater conviction in advocating for more aggressive “medical” therapy.

Dr. Jay Giri from the University of Pennsylvania next took the stand in presenting the antagonistic (CON) version of the debate. Vying away from the anticipated track of discussing largely well publicized limitations of ORBITA, Dr. Giri took an innovative approach in going back to the fundamentals of the expected benefits from PCI. He presented data from recent studies which showed that PCI did reduce symptoms in patients with significant ischemia to a greater extent than optimal medical therapy alone. He also pointed to the fact that PCI reduced ischemia as well, and based on current understanding may mean favorably impacting future risk of subsequent adverse cardiac events including spontaneous myocardial infarctions (although that hypothesis is under evaluation with the on going ISCHEMIA trial). He honed in on the fact that the results from ORBITA had been sensationalized in both directions by ardent proponents and the media alike, while the “reality” was probably in between. With ongoing sub group analyses from the ORBITA trial itself, as well as follow-up studies being conducted, this is a rapidly evolving arena- and trainees /early career interventionists would do well in keeping themselves abreast of the nuances of the evolving data.

 
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The 2023 Cholesterol Guidelines

Akl Fahed, MD, MPH

A few days ago, the long-anticipated 2018 AHA/ACC Cholesterol Clinical Practice Guidelines were released at the American Heart Association Scientific Sessions 2018 in Chicago.

The update from 2013 was viewed favorably in the cardiology community, as it reflected a large body of evidence that has accumulated since, specifically the recommendations for targeting LDL< 70 mg/dL in secondary prevention and using non-statin lipid-lowering medications (ezetimibe and PCSK9 inhibitors) with proven incremental reduction in cardiovascular events. In primary prevention, the recommendations for the use of coronary calcium score to decide on statin therapy in intermediate risk patients and the use of several ASCVD risk enhancers in borderline risk patients also reflected a decade of accumulating evidence.

In fact, many cardiologists feel that the new 2018 guidelines finally reflect what they already practice or would like to practice. I definitely feel this way, but are guidelines always meant to come that late after the evidence? Also, should guidelines be static documents at specific time intervals? When writing guidelines that will be used by millions around the globe, it is crucial to strike the right balance in being timely in providing guidance for clinicians but also cautious in not providing premature recommendations based on low levels of evidence, which could result in harm. This is not an easy job and the authors of the current guidelines successfully achieved this balance, in my opinion.

At Scientific Sessions 2018 where the new guidelines were released and made headlines in the morning, new science was being presented in the afternoon showing that these guidelines might already be outdated! The REDUCE-IT trial, which showed that icosapent ethyl 4g/day reduced major adverse cardiovascular events by 25%, was only one example.

I could not but reflect: What will be in the next cholesterol guidelines? How outdated will our current guidelines be if we wait another five years? And if new treatments will target triglycerides and inflammation, should we even change the name to “Atherosclerosis Management Guidelines”?

Here are my predictions for the next set of guidelines:

  • The LDL target cutoffs will be shifted downwards by 20-30mg/dL. In the highest risk patients we will be talking about LDL targets of <50mg/dL for secondary prevention and <70mg/dL for primary prevention. There is accumulating evidence that “lower is better” and that very low LDL (~20mg/dL) is safe, so as we become comfortable with targeting <70mg/dL in the coming few years, it would be reasonable to move the needle even lower.
  • Polygenic Risk Scores (PRS) will be used to risk-stratify patients <40 years of age and target a fraction of the population with high polygenic risk score who would benefit from statin therapy despite their LDL not being  >160mg/dL. The predictive ability of the polygenic risk score for CAD is already established and retrospective data show that statin therapy can attenuate the risk of CAD in those with highest polygenic risk score. Establishing the value of implementing PRS in clinical practice will require prospective randomized trials, and we are likely to see that in the near future.
  • New non-statin therapies to target ASCVD will emerge and have a major role in treatment. Icosapent Ethyl is leading the way, but other triglyceride lowering agents are also promising, specifically inhibitors of Angiopoietin-like 3 (ANGPTL3) and Apolipoprotein C-3 (APOC3). Antisense oligonucleotide inhibitors of  apolipoprotein(a) successfully reduced Lp(a) levels in a Phase 2 trial presented at this year’s scientific sessions. Future phase 3 trials will test whether lowering Lp(a) will reduce CV events. If proven, we might see more emphasis on Lp(a) screening and treatment cut-offs in the next guidelines. Finally and most importantly, the role of heightened inflammation in ASCVD risk is clear. While low-dose methotrexate did not reduce ASCVD outcomes in the CIRT trial, targeted anti-cytokine therapy with canakinumab did improve outcomes in the patients selected for high hsCRP in the CANTOS trial. The next guidelines will likely recommend routine hsCRP screening in secondary prevention to identify patients with residual inflammatory risk (high hsCRP, low LDL) who could benefit from anti-cytokine therapy.
  • And then there’s the atherosclerosis vaccine! A “Cutting Edge in Cardiovascular Science” presentation at Scientific Sessions 2018 by Dr. Klaus Ley highlighted that this is possible in mice. Will it be possible to safely manipulate the adaptive immune system in humans to  create an atherosclerosis vaccine? The answer is probably yes, but it would be wishful thinking to hope for it in the next guidelines.

 

Those are my predictions. What are yours?

 
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So Far, Yet So Near – Live Streaming Scientific Sessions 2018

Saurav Chatterjee, MD

This year I had to miss the Annual Scientific Sessions of the American heart Association #AHA18 due to a recent addition to the family. Through the generosity of the American Heart Association and the Early Career Blogging Program, I was offered an opportunity to be able to participate “virtually” in the meeting through Live Streaming and was offered a complimentary pass for streaming specific sessions. I gleefully excepted the offer and made full use of it over the weekend of the meeting intermittently between sessions. I had envisioned attending a meeting of this nature in the past when I had written a prior blog post on Cardioexchange.com in 2014. It seems a wonderful idea to be able to assimilate all the knowledge on offer from the comfort of one’s home. This year at the American Heart Association  Scientific Sessions 2018, I intended to fully experience and ‘test drive’ such a opportunity.

Just based on back of the envelope calculations, attending a meeting remotely is definitely a more cost efficient and pragmatic option. The ‘Sessions OnDemand’ was available for $299 (for the online-only version) and $399 for those requiring recorded sessions on a hard drive. When compared against the full registration fee, usual airfare on the weekend, at least a night’s hotel stay at premium rates at the time of a national conference, and add-in some commuting and ancillary expenses – it all adds up to significantly higher expenses compared with the remote access options, and it would have been a no-brainer if the remote options offered a comparable experience. And with the dwindling healthcare dollars everywhere, more and more programs are streamlining the educational benefits and leaves extended to fellows and early career professionals for attending conferences.

However in its current form, I think the remote option still has a fair bit of catching up to do with the live attendance format. While the streaming for individual presentations were quiet spot on and seamless, the options for discussing the same were limited. There was a ‘pop-up’ window to ask questions of panels/presenters, but the couple of questions I posed remained unanswered or unclear if the panelist/presenter even viewed them. For the “bigger” presentations like the Late-Breaking Clinical Trials or the new guideline releases, the sheer energy and ambiance of a room full of learned audience was also lacking. And of course the opportunities of networking in person, grabbing a coffee with a prospective collaborator, and plain-and-simple catching up with friends and ex-colleagues had to be passed on. Add on the fact that one’s study at home is hardly sacrosanct from interruptions from a young family! So, while the remote meeting at present has a cost-effective alternative, probably the experience of attending a live meeting especially for a relatively recent graduate/early career professional has yet to be matched by the virtual experience.

 
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The Evolution of Cardiac Care- “Moving the Needle from Predominantly Treatment to Additional Prevention of Cardiovascular Disease”

Renee Bullock-Palmer, MD

Cardiovascular disease (CVD) remains the number one cause of mortality for both men and women in the United States1. Although CVD related mortality is decreasing with advanced diagnostic testing and therapies of CVD, the prevalence of this disease remains high including in the younger aged population younger than 55 years of age1. This suggests that as providers we have done a successful job at treating CVD however there remains a lot of work to be done with regards to preventing this disease.

 

Moving the Needle

The prevention of CVD disease requires effort not just at the individual provider- patient level, but requires effort at the professional organization/societal and legislative level. The focus of the recent 2018 American Heart Association Scientific Meeting on several areas of Preventive Cardiology  such as the recently released 2018 Cholesterol Practice Guidelines as well as the recently released Department of Health and Human Services Physical Activity Guidelines for Americans indicates that there is some momentum and interest in moving the focus of health care from solely treating CVD to also preventing CVD in addition to treatment. The 2018 Cholesterol management guideline document has indicated that assessment of CVD risk begins as early as 20-39 years of age and this provides an opportunity to counsel these patients on heart healthy lifestyle modification to improve their cholesterol profile and therefore decrease their CVD risk2. The cholesterol guidelines also focus on the fact that the lower the cholesterol level the lower the CVD risk2.

It has been shown that most individuals in the United States do not report enough physical activity to meet the American Heart Association physical activity guidelines1. The recently released Department of Health and Human Services Physical Activity Guidelines for Americans also indicates that there is also legislative support for increasing physical activity in an effort to improve the cardiovascular health of Americans3.

The Million Hearts 2022  national initiative that is co-led by the Centers for Disease Control and Prevention and the Centers for Medicare & Medicaid Services is also another effort in the prevention of CVD. The goal of this initiative is to prevent 1 million heart attacks and strokes in 5 years through focused partner actions on several priorities selected for their impact on heart disease, stroke, and related conditions.

These initiatives indicate that there is an effort to move the needle of healthcare to preventative medicine. This plays an important role in decreasing CVD prevalence and will therefore lead to improved CVD outcomes for the United States population.

 

Impact on our Patients

A heart healthy diet and a physically active lifestyle has been shown to decrease the risk of developing CVD disease1. Counselling patients on a heart healthy lifestyle positively impacts our patients as it raises their awareness of the impact of lifestyle on overall cardiovascular health and also encourages them to adopt a heart healthy lifestyle.

 

More Work to be Done

Adequate training in Preventive Cardiology for fellows has been lacking as many of our trainees are not being taught the required amount of preventive cardiology during their General Cardiology fellowship training4. A survey in 2012 indicated that only a quarter of the surveyed General Cardiology fellowship training programs met the Core Cardiology Training Symposium (COCATS) guidelines recommendation of a dedicated 1 month rotation in preventive cardiology. In view of this, many Cardiologists in practice do not include nutritional and physical activity assessment as a part of their clinical evaluation. As a result, counselling on a heart healthy lifestyle as a part of preventive cardiology is not practiced by many Cardiologists. This void in training and experience in preventive cardiology provides an opportunity for us to assess and improve our own practice in this area as Cardiologists and also provides an opportunity to develop formal training in Preventive Cardiology for our cardiology fellows.

 

Despite the fact that CVD disease related mortality is decreasing in the United States, the prevalence remains high1. This indicates that providers within the Cardiovascular community have done a great job in treating CVD disease but there is still a need to improve our practice with regards to preventing CVD. The movement by the American Heart Association,  Centers for Disease Control and Prevention and the Centers for Medicare & Medicaid Services in focusing on areas of lifestyle medicine and preventive cardiology indicates that there is an effort to shift the needle from not just treating CVD disease but also preventing this disease. This movement therefore provides an opportunity for the Cardiovascular community to improve our practice in this area and to equip our cardiology fellows with adequate training in Preventive Cardiology to become better practitioners in this area in their future role as Cardiologists.

 

References:

  1. Benjamin EJ, Virani SS, Callaway CW, sChamberlain AM, Chang AR, et al. Heart Disease and Stroke Statistics—2018 Update: A Report From the American Heart Association
  2. Grundy SM, Stone NJ, Bailey AL, Beam LT, Birtcher KK, et al. 2018AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol. JACC Nov 2018, 25709; DOI: 10.1016/j.jacc.2018.11.003
  3. The Physical Activity Guidelines for Americans: THe HHS Roadmap for an Active Healthy Nation. Second Edition. ADM Brett P. Giroir, MD
  4. Pack QR,Keteyian SJ, McBride PE, Weaver WD, Kim HE. Current status of preventive cardiology training among United States cardiology fellowships and comparison to training guidelines. Am J Cardiol 2012;110:124-8.

 
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New Guidelines on the Most Effective, Most Accessible Health Intervention on the Planet Released at #AHA18

Elizabeth Knight, PhD, DNP

The new physical activity guidelines from DHHS were released, not coincidentally I suppose, on “Sneaker Day” at #AHA18. I walked up the 5th floor of McCormick place to hear Adm. Brett Giroir, MD, Assistant Secretary for Health present the update. I was excited to see this one, because I’m a lover of activity— running, yoga, strength training, dance, martial arts, hiking, swimming, etc. Activity makes me feel good, and I’ve seen the change in other people (friends, patients) who’ve become active. And because, as a clinician who works with underserved people, I love health promotion activities that are free.

I was curious to hear what the approach would be. Much of the “big news” at AHA is related to drug and intervention trials. Physical activity is a different kind of topic— one that isn’t necessarily the primary domain of many of the attendees. How would this group from HHS fit in? Giroir said, “Our overarching goal is to transform the current sick-care system into a health-promoting system.” Here, here! Not only is this intuitively appealing, but it better aligns with value-based payment systems that are coming down from on high. We’ve heard a lot about trying to align financial incentives in less perverse ways, so let’s keep a watchful eye on that. I like interventions that are free— but there’s a big machine out there that doesn’t agree, and it can be hard to get the same kind of traction.

So that said, what’s in the new guidelines? There aren’t big shifts in the actual recommendations, but there’s an important change in the messaging.

  • First, the guidelines address the need for activity in all people, including toddlers (for the first time), people with chronic illnesses, pregnant and post-partum women, and older adults. Message: activity matters for everybody.
  • The next key point is that all activity counts— it doesn’t need to be in designated sessions and it doesn’t matter if it’s just a few minutes at a time. The target numbers haven’t changed– but the message now includes that people should “move more and sit less” throughout the day, and any activity is better than none. As physical therapist Dr. Kelly Starrett says, the best position is the next position. This messaging also suggests that not only is activity healthful, but sedentary time is detrimental to health. It’s a two-sided coin, and it’s important to think of it that way. We’ve heard “sitting is the new smoking”– and the evidence here suggests that’s not off the mark. The key message is that activity that’s part of the day-to-day way we live is important to our health. I’ve said this a lot to patients, but it’s great to have the guidelines– and evidence– back it up. The recommendation to get activity throughout the day should strengthen support for programs that encourage movement in all kinds of contexts.
  • The last major theme is that activity is even better for us than we previously knew. Much of the evidence reviewed isn’t about what to do, or how, or even how much— but rather, that any and all activity is healthy in ways we hadn’t previously described and measured. Health benefits are immediate, and include lower anxiety, lower blood pressure, better sleep, and better insulin sensitivity. Long-term benefits include reduced cancer risks (including types for which the benefits were previously not described), better brain health, less weight gain, and fewer risky falls. For those with chronic illnesses, it can reduce pain, symptoms, and disease progression and improve cognition. It’s a testament to our physical activity research community (including lots of great work presented this week!) that we have all this data. Can we turn this data into action? We can’t do it exclusively in a clinical setting, despite our best intentions. We’ll need implementation studies. We’ll need CBPR. We’ll need policy advocacy.

 

Just 26% of men and 19% of women meet the current guidelines. The bar in these guidelines isn’t high. This tells me that we need to work on systems. Schools, workplaces, and public spaces are low-hanging fruit. Chapter 8 of the guidelines also touches on faith-based settings and mass media campaigns. Dan Buettner’s The Blue Zones is an example of a program that’s ahead of the curve, working with communities to tweak infrastructures and build social communities to keep activity in the fabric of life. Michelle Obama’s “Let’s Move” project took a stab at the public messaging approach. What else could we try? In a Viewpoint article for JAMA, Giroir & Wright make some systems suggestions, and also touch on the potential for wearable tech and workplace initiatives to move the needle. These are well-trodden paths, and we’re still waiting for strong evidence of efficacy. Personally, I’d like to see rules and norms encourage activity-friendly clothing and footwear in professional settings (#SneakerDay every day!?). Can we make it “OK” to stand for a bit when our tracking devices remind us that we’ve been sitting for an hour? Can we support activity with locker rooms at work? Better and more accessible training for healthcare workers on exercise prescription? More clarity on the roles and qualifications of fitness professionals? #AHA18 had a heart failure “Hackathon” this year to generate novel ideas– can we come up with some innovative ways to improve implementation of the cheapest, most effective treatment we have for poor health?

 

 

 

References:

U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans, 2nd Edition. Washington, DC: U.S. Department of Health and Human Services; 2018.

Giroir BP & Wright D. (2018). Physical activity guidelines for health and prosperity in the United States.  JAMA, published online 11/12/18.