aha19

The past few years have witnessed the emergence of many technological advances that hold promises for potentially revolutionizing the way we are treating patients with cardiac arrhythmias. Between innovative technologies for cardiac pacemakers and defibrillators, breakthroughs in ablation of atrial and ventricular arrhythmias, and boundless progress in remote monitoring of cardiac rhythm, the field of clinical electrophysiology (EP) is undergoing an exhilarating conceptual transformation.

The American Heart Association (AHA) 2019 Scientific Sessions that took place in Philadelphia last month, have dedicated an excellent session to highlight and summarize these recent EP advances. A session that brought together prominent EP leaders and innovators discussing the present and the future of the field, which, to an aspiring electrophysiologist like myself, has been one of the most inspiring sessions of the conference. The title was catchy: “Hottest New EP Advances and Connections with the Experts”, and despite being an evening session, the large conference room was packed with EP enthusiasts at different stages of their careers. It was around an hour and a half of tour-de-force presentations by an outstanding group of speakers. The amount of valuable information presented is more than what can be captured in a short essay, yet, I will highlight the most promising technologies in my humble opinion.

I will start with cardiac implantable electronic devices (CIEDs), where several technological and conceptual breakthroughs have recently made their way to clinical practice, and many more are expected to do so in the near future. The 3 most exciting frontiers are:

• The leadless intra-cardiac pacemaker system, which was approved by the FDA in April 2016. The device is the size of a large vitamin capsule, implanted percutaneously. This new technology allows cardiac pacing in the absence of intravenous leads and subcutaneous pulse generators, which not only is more convenient for patients, but also avoids lead and pocket-related complications.¹ The current commercially-available system is only capable of single-chamber sensing and pacing, however, the results of the MARVEL 2 study,² demonstrating the safety and efficacy of an accelerometer-based VDD pacing algorithm to maintain AV synchrony with the leadless pacemaker system, were just released at AHA19. Newer technologies that are expected in the next few years include atrial leadless pacemaker and leadless multicomponent systems, for instance using endocardial left ventricular electrodes as part of cardiac resynchronization therapy.
• The new subcutaneous implantable cardioverter- defibrillator (ICD) technologies. The original subcutaneous ICD was approved by the FDA in September 2012 and has been widely used in clinical practice.³ This technology provides a defibrillator option for patients with challenging anatomy for conventional intravascular ICD implantation, and with no indication for pacing. Newer promising technologies in the field of subcutaneous ICDs that are not commercially available yet include string subcutaneous ICD – with no can, hence no need for a surgical pocket – and extravascular ICD which is capable of pacing the myocardium in addition to delivering ICD shocks, while being completely extravascular. Combining subcutaneous ICDs with leadless pacemaker systems is another exciting area of future research.
• His bundle pacing and left bundle branch pacing, which are new physiological alternative to right ventricular pacing, and potentially to bi-ventricular pacing in patients with proximal left bundle branch block, through engaging the normal conductive His-Purkinje system and, therefore, avoiding the long term deleterious effects of ventricular dyssynchrony. As opposed to the above-mentioned technological breakthroughs, this is more of a slow ongoing learning process, which has been around since the early 2000’s, initially performed with the already-available standard pacing leads with reshaped or deflectable stylets, limited by technical difficulties. However, the more recent use of a solid core lead in conjunction with specialized sheaths has sparked new interests in this pacing technique, which is being increasingly adopted in clinical practice and eventually made its way to the most recent pacing guidelines.⁴ The future likely holds the development of more specialized equipment designed specifically to facilitate these pacing approaches.

Switching gears to the field of cardiac ablation, the other major pillar of EP interventions. The most promising, and potentially revolutionary advances in this area are:

• Non-invasive radio-ablation of ventricular tachyarrhythmias (VT). VT ablation is known to be associated with increased risk of procedural complications given the sick phenotype that these patients commonly present with, in addition to the length of the procedure, catheter manipulations inside the left ventricle and the need for induction of VT, which makes the procedure more challenging and more risky compared to other forms of cardiac ablation. The use of stereotactic body radiation therapy (SBRT) to ablate VT in a radiology suite, aided by non-invasive cardiac mapping using electrocardiographic imaging, is undoubtedly one of the most exciting recent breakthroughs in the field of EP. The use of radiotherapy not only mitigates the procedural risks of catheter-based ablation, but also allows reaching myocardial foci that are not accessible by conventional endocardial or epicardial approaches. Although the available data are merely preliminary,⁵ and more research is needed prior to the widespread use of this procedure in treating patients with VT, the concept is very promising and the potential implications are remarkable. The potential use of SBRT in treating other arrhythmias such as atrial fibrillation (AF) is also under investigation.
• Pulsed Field Ablation (PFA) for pulmonary vein isolation (PVI). Indiscriminate tissue destruction with potential damage to surrounding structures such as the esophagus and the phrenic nerve has been the major barrier to delivering reliable ablation lesions that ensure durable PVI in AF patients. This new ablation technology uses a process called electroporation, for which cardiac myocytes are most sensitive, potentially allowing selective cardiac ablation. The results of the IMPULSE and PEFCAT studies were recently published, and demonstrated an impressive 100% PVI durability at 3 months with this technique, with an average skin-to-skin procedure time of only 92 minutes. Importantly, there were no evidence of esophageal or phrenic nerve damage, despite the lack of use of an esophageal protection strategy.⁶ The ability to safely deliver deep ablation lesions in the atrium without damaging the surrounding extra-cardiac tissue can potentially transform the success rates of catheter ablation for AF and may expand the use of this technology to other forms of arrhythmia ablations.

Listening to world-renowned EP experts enthusiastically walking the audience through these various breakthroughs and painting a futuristic picture of how the world of EP can look like in the near future, left me thinking about how lucky I am to be starting my EP training in this exciting era of technological revolution. Witnessing the transformation of a cardiac subspecialty is exciting, but the possibility of being part of this transformation is mind-blowing!

References:

1. Reynolds D, Duray GZ, Omar R et al. A Leadless Intracardiac Transcatheter Pacing System. N Engl J Med. 2016;374:533-41
2. Chinitz LA, Khelae AK, Garweg C et al. Atrial Synchronous Pacing Using a Leadless Ventricular Pacemaker: Primary Results From the MARVEL 2 Study. Presented at the American Heart Association Annual Scientific Sessions (AHA 2019), Philadelphia, PA, November 16, 2019
3. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMA/pma.cfm?id=P110042. Accessed November 30, 2019.
4. Kusumoto FM, Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay. Circulation. 2019;140:e382–e482
5. Robinson CG, Samson PP, Moore KMS et al. Phase I/II Trial of Electrophysiology-Guided Noninvasive Cardiac Radioablation for Ventricular Tachycardia. Circulation. 2019;139:313–321.
6. Reddy VY, Neuzil P, Koruth JS et al. Pulsed Field Ablation for Pulmonary Vein Isolation in Atrial Fibrillation. J Am Coll Cardiol. 2019;74:315-326.

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.

AHA19 was a tremendous meeting for many reasons – extraordinary science, inspirational attendees, performances from the cast of Hamilton, and all in my current home of Philadelphia! Sessions 2019 was also unique for its deliberate approach to the inclusion of women in cardiovascular and neurovascular medicine. I was impressed by the breadth and depth of programming related to women and the open discussions of issues facing women in medicine. If you missed this thread of Sessions 2019, here are some highlights:

1) President Harrington’s Presidential Address: In AHA President Robert Harrington’s Presidential Address, he noted that over the last 7 years as a department and health system leader, he has become increasingly concerned with the lack of diversity in cardiovascular medicine. He also proclaimed that the male : female ratio in cardiovascular medicine is “out of whack” – a sentiment that drew rounds of applause from the audience.  He shared some startling demographic data regarding the cardiovascular workforce, including the fact that 12 states have fewer than 10 practicing women cardiologists. The AHA’s newly formed Go Red for Women in Science and Medicine Committee is tackling implicit and explicit gender biases in all of its science activities, including grant submission and peer review processes. Dr. Harrington closed this part of his speech by emphasizing the imperative upon men in power to recognize and address these disparities in cardiovascular medicine. Despite lasting less than 5 minutes, this segment of his Address was captivating, and his impassioned case for diversity and inclusion drew multiple ovations from the audience.

2) No Manels: Dr. Harrington also announced that at AHA19 there were no all-male speaking panels, or “manels”! Earlier this year, the Director of the National Institutes of Health, Dr. Francis Collins, announced that he would no longer participate in manels or other events in which “inclusiveness is not evident in the agenda.” In his statement, he challenged other scientific leaders to do the same. When Dr. Harrington announced that he, Dr. Donald Lloyd-Jones, Dr. Manesh Patel, and AHA leadership had eliminated the manel at AHA19, I felt proud to be a part of an organization that prioritized this commitment to inclusivity in the scientific program and in a public way. The AHA has now set the standard for gender representation at cardiovascular conferences, and I am looking forward to where we go from here.

3) Women Across the Program: When I searched the word “women” in the AHA19 Sessions App, I found a total of 173 abstracts, oral presentations, luncheons, dinners, and Lounge sessions spanning career development, basic, translational, clinical, implementation, and population science. Not only were women leading at the podiums and panels, but there was an explosion of featured research in women’s cardiovascular health, cardio-obstetrics, sex differences in pathophysiology, diagnostics, therapeutics, and outcomes across the spectrum of cardiovascular disease.  In addition, the Women in Science and Medicine Lounge hosted high-yield career development programming for women throughout the weekend with sessions on mentorship, sponsorship, volunteerism, social media, negotiations, storytelling, mindfulness, and more. In the AHA Fellow in Training (FIT) and Early Career Lounge, we held a fantastic session on self-advocacy as a woman in medicine with insights from Drs. Harriette Van Spall, Biykem Bozkurt, Mary Cushman, and Monika Sanghavi. In his Address, Dr. Harrington also announced a new AHA partnership called Research Goes Red, a technology platform powered by Verily and Project Baseline to engage 1,000,000 women to contribute their health data toward research into heart and brain health, with a focus on millennial women from underrepresented ethnic and racial groups.

In my advocacy work, I have learned that women are usually successful at engaging and empowering other women to support the mission of diversity and inclusion in cardiovascular medicine, but it is often easy for other populations to remain at a distance, divorced from and uninvested in these efforts. In many ways, AHA19 brought this dialogue to the center stage and demonstrated to our trainees and early career members that we are indeed making strides toward an equitable and just future for women in cardiovascular 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.

The American Heart Association’s Scientific Sessions is one of the biggest conferences in cardiology. It draws students, residents, fellows, affiliate practitioners, attendings, researchers, and so many more. Therefore, attending a conference of this caliber is a big deal! The event is full of intense information. New ideas. New contacts. New solutions. And, new found energy. Most of us are revitalized after any scientific session which I believe is due to a multitude of factors including: meeting experts in our field, seeing new clinical trials, attending small group sessions for a more intimate experience, and reconnecting with friends and colleagues. Eventually, the conference comes to an end and we go our separate ways. Seems as we get closer to home, the exhaustion from the trip and the ensuing clinical responsibilities become more of a reality. This massive surge of energy is quickly plummeting. As an early career FIT, we have several responsibilities that can quickly take away from the momentum we have built during the sessions so how do we continue to sustain it?

• Write: As soon as I get home or even every night at the conference, I jot down my thoughts. This helps me prioritize what is important for me to focus on once the conference is over.
• Speak to your program leadership: When I came back from AHA 19, I had an inform discussion with my program leadership on the entire conference and what I learned. Specifically, I used this time to discuss how I can accomplish the goals I have set forward. The leadership is well aware of the program strengths/weaknesses but more importantly, others who can help mentor me in achieving my goals.
• Debrief with your co-fellows: After the sessions, the entire fellowship class can get together to discuss ideas for quality improvement, collaborate research, or changes they would like to implement in the fellowship. This is a great way for junior fellows to start getting involved in existing projects if they feel starting one of their own will be too daunting.
• Reach out: Hopefully you were able to network while you attended the sessions. I always reach out to the people I met asking for advice or if they are looking to collaborate on projects. I’ll also reach out if I have a question regarding how to care for a complex patient – after all, the scientific sessions are a fantastic time to meet providers who are considered experts in their fields. This continues to foster a professional relationship for years to come. Conferences are a great time to see what is “hot” in cardiology and meet the individuals that are leading the charge. Take advantage of this unique opportunity to cultivate your career.
• Sign up For Another AHA Conference: Remembering how good I feel after a conference helps me stay motivated. Whenever I’m dragging my feet, I revisit the ideas I wrote down in the first point to remind myself how much I learned, wanted to accomplish, and the new network I created. Having another conference to attend helps me stay motivated and not lose steam on projects.

Hopefully, these five easy tips will help keep the momentum going strong long after the conference is over to continue to be successful.

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.

Where we live and work shapes us in many ways. Whether growing up in an urban, suburban, or rural community, our neighborhoods can have an outsized impact our hobbies, lifestyle, and health. It was inspiring to see so many investigators presenting findings on this topic today at the American Heart Association (AHA) 2019 Scientific Sessions during the “Environmental and Neighborhood Influences on Health” poster session.

W. Wyatt Wilson and colleagues at the University of Chicago presented “Spatiotemporal Association Between Violent Crime And Ambulatory Elevations In Systolic Blood Pressure”, an innovative analysis of 133,024 geo-coded violent crimes reported by the City of Chicago and home addresses of patients with blood pressure readings from 232,488 unique outpatient appointments. They found that longer duration of exposure to violent crime within 500 meters of patients’ home addresses was associated with increased systolic blood pressure (approximately 0.27 mmHg per crime) [Figure 1]¹. These results echo findings from the Jackson Heart Study published earlier this year by Tanya M. Spruill and colleagues on chronic stress and incident hypertension among black adults². This analysis followed 1,829 adults without hypertension over a median of 7 years and recorded their blood pressure and self-reported stress. After multi-variable adjustment, they found moderate or high perceived stress was associated with higher risk of developing hypertension. The chronic health effects of stress resulting from living in a neighborhood with violent crime is a newly identified and very significant externality of these crimes.

Figure 1:

Daniel W. Riggs and colleagues at the University of Louisville presented findings on the interaction between neighborhood greenness, air pollution, and arterial stiffness³. This cross-sectional study of 63 adults measured: neighborhood greenness (satellite-derived normalized difference vegetation [NDVI] index), air pollution (particulate matter [PM] 2.5 levels and ozone levels), and arterial stiffness (augmentation pressure, pulse pressure, and aortic systolic pressure in mmHg). They found among participants living in low greenness areas that air pollution was positively correlated with arterial stiffness. Further, Zachary Rhinehart and colleagues at the University of Pittsburgh presented their poster “Association of Particulate Matter and Incident Stroke in Atrial Fibrillation” which was a retrospective study of 31,414 patients at their academic medical center⁴. They found that among patients diagnosed with atrial fibrillation, living in neighborhoods with high levels of air pollution (highest quartile compared to lowest quartile) was associated with an increased risk of stroke (HR 1.50; CI 1.30 – 1.72) [Figure 2]. Given such consistent findings between air pollution and cardiovascular disease, I wonder if built environment interventions such as increased vegetation might help mediate neighborhood factors that contribute to cardiovascular disease long-term.

Figure 2:

Attending scientific sessions this year was a phenomenal experience. I came away with new insights for clinic from the late breaking trial sessions, met some incredibly smart and gifted people, and as evidenced by this specific session came away with a renewed enthusiasm to research some questions I was left with. Looking forward to #AHA20!

References:

1. W. Wilson et. al. Spatiotemporal Association Between Violent Crime And Ambulatory Elevations In Systolic Blood Pressure. Poster Presentation, American Heart Association 2019 Scientific Sessions, Philadelphia, PA, November 18, 2019 https://www.ahajournals.org/doi/10.1161/circ.140.suppl_1.17139
2. J Am Heart Assoc. 2019;8:e012139. DOI: 10.1161/JAHA.119.012139.
3. W. Riggs et. al. Effect Modification of Neighborhood Greenness on the Relationship Between Ambient Air Pollution and Arterial Stiffness. Poster Presentation, American Heart Association 2019 Scientific Sessions, Philadelphia, PA, November 18, 2019 https://www.ahajournals.org/doi/10.1161/circ.140.suppl_1.15881
4. Rhinehart et. al. Association of Particulate Matter and Incident Stroke in Atrial Fibrillation. Poster Presentation, American Heart Association 2019 Scientific Sessions, Philadelphia, PA, November 18, 2019 https://www.ahajournals.org/doi/10.1161/circ.140.suppl_1.16440

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.

I have always advocated making time to attend a talk that’s outside of your area of focus when attending a big conference. It’s a powerful way to experience new perspectives. On Monday, the last day of Sessions, there was a panel held in Main Event I— the grand stage, where the presidential session and the big-news late breakers are held— about climate change. That definitely qualifies as outside of my area. Climate change, at a cardiovascular health conference? Yes, the panelists argued, climate change is a dire threat to cardiovascular health, and we need our scientists and clinicians to address it.

Dr. John Balbus suggested several avenues through which climate impacts health, including air pollution, thermal stress and migration and conflict. These problems create cumulative physiological stress, which is a major driver of cardiovascular disease. Direct evidence of health impact can be seen. For example, during severe wildfires in California, Dr. John Balmes noted, not only did lung-related illness increase, but so did myocardial infarction.

Photo: Marcus Kauffman via Unsplash

AHA took a great step towards raising the profile of the climate problem by hosting this panel, and by doing it as a Main Event. I was dismayed, though, to see the room mostly empty.  Why does this issue not have traction? Is it “too big”— leaving folks feeling like they can’t make an impact, or any impact would be too distant to feel? Is it a question of importance vs. urgency— we see people dying vaping-related lung injuries right now, and we are facing the specter of climate-related illness less immediately? Is it that the clear lines of causation between human activity, climate change, and health problems aren’t yet clearly visible to all? I don’t know, but it is up to us as the next generation of health and science professionals to insist.

So here we are, as early career scientists and clinicians. We know there’s a problem, and we know it’s a big one. But what can we do, as busy, ambitious, career-focused young(ish) people, working in universities and healthcare organizations? Get ready to channel your inner Greta Thunberg and speak truth to power!

During the climate panel at sessions, Dr. Caren Solomon presented a framework for action with six ideas. Here’s how we can apply them to professional meetings and conferences, and maybe this will help you think about how to apply them at your home institution, as well.

• Personal Behaviors: Traveling to a meeting is resource-intensive. For the trip to Philly this year, I tried to mitigate my impact by using public transit instead of taxis or Lyft, bringing a reusable mug/water bottle, skipping daily linen changes and housekeeping at my hotel, turning down the lights and heat when I left the room, forgoing items like bags, straws, and lids that I didn’t need, and eating plant-based (that’s a topic for another post!). These changes aren’t hard, but they do require paying attention. What else could you change to reduce your impact?
• Institutional Decarbonization- Hosting organizations could focus on providing sustainable food and food packaging, reducing waste (think of all the printed papers and giveaways that wind up in the trash), or purchasing carbon offsets for meeting travel (organizations like Terrapass make this easy).
• Education: The public views physicians and nurses as trusted sources. When we are knowledgable, the potential impact is high. Professional organizations like AHA can therefore facilitate the flow of information. AHA is on the right track, including a climate panel at scientific sessions. Maybe next year, we can work to increase exposure around this issue and boost uptake: promote the issue in conference materials, schedule it at a high-visibility time, and minimize conflicting sessions.
• Advocacy: AHA recently joined a consortium of medical organizations focused on education and advocacy around climate issues https://medsocietiesforclimatehealth.org/ and @DocsForClimate). This is a great step! This group provides organization and resources to help health professionals educate local lawmakers, the press, and community groups. I’d like to see organizations do more to take up the link between climate and cardiovascular health directly, consistently, and visibly. That’s a great way to be a relentless force for a world of longer, healthier lives.
• Nonprofits and public institutions generally have their financial information available, including financial relationships with companies and other organizations. Advocating for divestment can make some waves in an organization because it’s so closely tied to the bottom line, and it often requires a very compelling case to make change. Financial relationships can conceal conflicts between an organization’s stated values and its actions effectively— and it often takes guts to challenge the apparatus. But you have guts, right?
• Protest & Non-violent direct action. We can be visible, as scientists, clinicians, and members of our professional organizations (including AHA). Speak out in public, wear your lab coat or your “Go Red” gear. Write letters to the editor. Attend a demonstration. We can leverage the respect our society affords us as health experts to encourage societal change.

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.

The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial¹ has been a landmark in clinical decision-making for patients with stable ischemic heart disease – leading to a paradigm shift in clinical care by establishing that revascularization/percutaneous coronary intervention(PCI) in patients with stable ischemia did not reduce subsequent mortality or myocardial infarction(MI) outcomes over ‘optimal’ medical therapy. There was a reduction of ischemia-driven revascularization with invasive management-which has been attributed as a ‘soft end-point’. However, there have been criticisms of the trial – one of which has been that patients had not been selected based on a significant extent or severity of ischemia. This has been fueled by a subsequent analysis from the courage trial investigators which revealed mortality/MI outcomes benefit with revascularization in patients with moderate to severe ischemia². This has led the national institutes of health(NIH) to evaluate the hypothesis of upfront revascularization with the eponymous International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) trial³-the baseline characteristics of the participants having been published recently. So, there was tremendous excitement and interest for the presentation of the ISCHEMIA trial at the annual scientific sessions of the American Heart Association (AHA) in Philadelphia in November, 2019-which I was fortunate to be able to attend in person with assistance from the AHA Early Career Blogger program.

The results⁴ validated the earlier COURAGE trial results with no significant differences overall with invasive vs conservative management strategies with cardiovascular mortality, overall myocardial infarction rates, unstable angina, heart failure, and resuscitated cardiac arrest as well as the composite, primary end-point. The presentation of the primary trial itself referred to the outstanding questions after the COURAGE trial results-namely:

• Do higher risk patients based on substantial ischemia benefit?
• Does elimination of referral bias by randomizing before cardiac catheterization cause outcomes to differ by planned strategy of management?
• Does use of newer stents and FFR as needed impact outcomes?

The mode revascularization appeared to reflect contemporary practices with 98% of patients receiving PCI being treated with drug-eluting stents and 93% of bypass surgery candidates receiving a arterial graft. The trial did show a higher risk of all cause MI (procedural+non-procedural) at 6 months with invasive management which was reversed to a significant extent by 4 years of follow-up. Additionally, patient with significant angina at baseline had improvement of their quality of life and angina symptoms with revascularization. The above findings with MI were in contradiction to the COURAGE results-which however did show improvement in angina symptoms with revascularization.

These findings made me wonder if the ISCHEMIA trial had significant differences amongst the participants compared to the COURAGE trial-other than those mandated by trial protocol? I reviewed the baseline characteristics of the participants from the index publication of the COURAGE trial for both the PCI and the OMT groups. These were then compared and contrasted against the baseline characteristics identified for the ISCHEMIA trial population³.

The baseline characteristics of the ISCHEMIA trial population appeared to mirror the baseline characteristics in the two arms of the COURAGE trial published over a decade ago with some notable differences – Table 1. ISCHEMIA enrolled more than double the number of participants of the COURAGE trial, and consequently has greater statistical power in evaluating clinically meaningful end points. In terms of demographics, ISCHEMIA has enrolled significantly higher numbers of females and those of non-white ethnicity. ISCHEMIA also appears to have enrolled a significantly higher proportion of patients with hypertension and diabetes, but a lower proportion of patients with prior myocardial infarction. There also appears to be a greater number of patients with multi-vessel coronary disease and proximal left anterior descending disease in ISCHEMIA. There is a stark contrast in the location of recruiting sites – COURAGE was entirely US and Canada-based, whereas ISCHEMIA has only enrolled 16.5% of patients in the US and Canada. Participants of the ISCHEMIA trial also appear to have a better lipid profile and lower prevalence of active smoking. In terms of the medical treatment-more patients appear to be on statins in ISCHEMIA while surprisingly the proportion of other guideline-directed medications for treating coronary artery disease like aspirin, ACE inhibitor, beta blockers and antianginals appear to be lower. And eventually, only 41% of the trial participants were considered at ‘high level’ of medical optimization⁴.

The differences in the baseline characteristics between COURAGE and ISCHEMIA may have important implications. ISCHEMIA appears to have recruited a higher risk population including more women that will evaluate clinical benefits with strategy of upfront revascularization. Less than a fifth of the population being recruited from US Canada raises the question of the applicability of the results to the general US population. It is also of interest that a lower proportion of patients were on guideline directed medical therapy excepting for statins, when contrasted against a population of a similar US-based trial published over a decade ago. In summary, ISCHEMIA has important differences in the population recruited in comparison to the COURAGE trial – and these may need to be taken into account for interpretation of the final results, when published.

References:

1. Boden WE, O’Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, Knudtson M, Dada M, Casperson P, Harris CL, Chaitman BR, Shaw L, Gosselin G, Nawaz S, Title LM, Gau G, Blaustein AS, Booth DC, Bates ER, Spertus JA, Berman DS, Mancini GB, Weintraub WS; COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007 Apr 12;356(15):1503-16.
2. Shaw LJ, Berman DS, Maron DJ, Mancini GB, Hayes SW, Hartigan PM, Weintraub WS, O’Rourke RA, Dada M, Spertus JA, Chaitman BR, Friedman J, Slomka P, Heller GV, Germano G, Gosselin G, Berger P, Kostuk WJ, Schwartz RG, Knudtson M, Veledar E, Bates ER, McCallister B, Teo KK, Boden WE; COURAGE Investigators. Optimal medical therapy with or without percutaneous coronary intervention to reduce ischemic burden: results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial nuclear substudy. Circulation. 2008 Mar 11;117(10):1283-91.
3. Hochman JS, Reynolds HR, Bangalore  S,  et al; for the ISCHEMIA Research Group.  Baseline characteristics of participants in the IISCHEMIA randomized clinical trial [published February 27, 2019].  JAMA Cardiol. doi:10.1001/jamacardio.2019.0014.
4. https://www.ischemiatrial.org/system/files/attachments/ISCHEMIA%20MAIN%2011.20.19%20with%20background.pdf  . Last accessed 11/28/2019

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.

Another successful scientific session in the books and I am already looking forward to the next one #AHA20, on to Dallas.  But first, from the City of brotherly love, these are some of the highlights.

Let the countdown begin.

5) Late breaking clinical trials

There is usually a lot of noise around these sessions. People eager to learn about the new trials that may or may not affect their clinical practice, inspire new research ideas and question prior data. In Philadelphia, it was about time the long awaiting ISCHEMIA trial results go public.  Practice changing or not? It’s coming out party was nail-biting and met all the expectations whether you think it will change your practice in the future or not. To quote Dr. Alice Jacobs in the New York Times, ISCHEMIA “certainly will challenge our clinical thinking”.  Bottom line, my take home point from the session is simply to “Get with the Guidelines”.  Adherence to GDMT is critical and presents a challenge for the best of us. Only time will tell the impact of the long-awaited ISCHEMIA results.

4) Presidential session

This year’s presidential session was mesmerizing, a bit longer understandingly so.  A lot of highlights within my top 4^th moment. Started with a piece from Broadway’s hit musical “HAMILTON”. If you wanted to be in the room where it (#AHA19) happened, Pennsylvania Convention Center was the place to be. From Dr. Harrington’s incredible speech highlighting the incredible of work of the AHA in advancing clinical research and education, he reminded us “Evidence Matters”

What came after was stand up ovation worthy. Several students from the city of Philadelphia walked on stage to share their stories and stand up against Vaping. This is also a reminder to all of us to stand up for our patients not only in clinics and hospitals but where ever we can make a significant contribution to their health and well-being.

Finally, the presidential sessions weren’t without emotions. From Dr. Harrington’s emotional speech about his life story to CEO Nancy Brown’s remembering Bernard Tyson: “Through his words, actions and the way he made people feel, he left the world of health care – and the world at large – better than he found it”. This truly is exemplary of great leadership.

3) Vaping

Again, AHA not only talks the talk but also walks the walk. The American Heart Association is truly invested in fighting for the young and against the vaping epidemic on a multi-level nationwide platform. The future is bright and #AHA knows it as it is highlighted with their #QuitLying initiative that empowers kids in their schools and communities to call out different vaping companies on their lies.

#QuitLying

2) Cardiomyopathy

[The “PechaKucha Potpourri”: The Key Things You Need to Know about Interesting Cardiomyopathies] session moderated by Dr. Sandra Chaparro was one of my favorites and highlighted key points regarding less common cardiomyopathies. Information covered was very concise and it was provided by the experts in their respective fields such as Sarcoidosis, Chagas Disease, Check Point inhibitors and Myocarditis, Hypertrophic Cardiomyopathy, Stress Cardiomyopathy, Recovered Cardiomyopathy and Peripartum Cardiomyopathy. #AHA20 needs to bring back “PechaKucha Potpourri’’.

1) Early Career Blogger
This was the first time, I attended AHA as an Early Career Blogger. This was truly a different perspective where I had a lot of fun enjoying the different sessions, twitting the different topics of interests, meeting new people and representing the #AHA19.

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.

 I have gone back and forth with attending the American Heart Association (AHA) Scientific Sessions online in 2017 (AHA17), to onsite (AHA18), and this year (AHA19) I attended online again. There was absolutely no comparison between attending AHA18 to the online versions! I was the first to say that going to conference is overwhelming because there is so much to see and so many people to meet. I have since come to appreciate the benefits to attending meetings onsite. Generally, I stay within my session [Atherosclerosis, Thrombosis, Vascular Biology (ATVB) or Hypertension (HTN)]. Attending online gives some limitations, such as being at home, work, or traveling, there is a time restraint as well as multiple distractions. I experienced them all! I was traveling to a conference that conflicted with AHA19, thus the distractions of traveling and keeping up with my meeting responsibilities was a lot to juggle. Once I was home, there was everything that goes along with getting settled back into the routine of things that gave me a distraction. This year was a beast of responsibilities, but before I discourage you from attending a meeting online, let me share some benefits and things that I enjoyed about having the flexibility of being online rather than onsite.

With all the distractions I experienced viewing AHA19 online, the main benefit was that I was able to watch sessions at my own pace as well as read the transcripts while the speaker was talking. In previous years I did not use that function; this year, I used it for almost all sessions, and it was wonderful. To be able to take screenshots of the talk and look things up later was the best tool in my toolbox. Additionally, there was a textbox that allowed viewers to ask questions to the speaker without standing in long lines and potentially not getting a response. That has happened to me more times than not because, as chance would have it, the best speakers and researchers show up to AHA meetings. These are the opportunities to get the best guidance regarding research methodology, mentoring, clinical expertise, and networking with some of the best in every discipline from around the globe.

I had the privilege of sitting in on several topics that sparked my interest. For example:

• Update in Clinical Lipidology – Aspirin: Who Needs it Anymore? Discussing what markers should be considered with prescribing aspirin; role of and how to interpret the stenosis score; and considerations of patients with diabetes, family history of nonclassified plaque
• Clinical Trials—ASPREE (JJ Mcneil, NEJM 2018; MATCH); ISAR REACT 5 Trial; and GLOBAL LEADERS)

Share some of your favorite parts of AHA19 with me in the comments or follow me on Twitter (@AnberithaT); also @ahameetings and @ATVBCouncil. Let’s keep this conversation going. Did you attend online or onsite?

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.

Mechanical circulatory support (MCS) use in cardiogenic shock (CS) in the setting of acute myocardial infarction (AMI) is one of the most controversial topics in cardiology. Despite advances in many aspects in our cardiovascular field, mortality from CS remains unacceptably high. At the most recent AHA meeting, two studies suggested the use of intra-aortic balloon pumps (IABP) in CS might result in better outcomes compared to use of the percutaneous MCS device, Impella. I wanted to share my thoughts and ideas on this topic in light on these studies.

Major Randomized Clinical Trials on MCS

There is limited evidence in the literature supporting the use of MCS in AMI-CS^1-3. There are two main randomized clinical trials in MCS devices: IABP-SHOCK II and IMPRESS trials. IABP-SHOCK II trial compared IABP with medical treatment in 600 patients with AMI-CS, and showed no difference in survival between the two groups². The IMPRESS trial compared Impella CP versus IABP in 48 patients with CS-AMI and again did not show a difference in survival between these groups³.

Summary of recently-released studies at AHA19

A study by Amin et al, which included 48,306 patients undergoing percutaneous coronary intervention (PCI) with MCS from the Premier Healthcare Database, found wide variations in the use and clinical outcomes of Impella (mortality, stroke, bleeding, acute kidney injury) across hospitals. They also found that Impella had higher odds of adverse events and higher costs compared to IABP after adjusting for hospital, patients and time period⁴.

A separate study by Dhruva et al, which included 28,304 matched patients with AMI-CS undergoing PCI from NCDR Cath-PCI registry, found that 8,471 patients (29.9%) had IABP only, and 1,768 patients (6.2%) had Impella only. In-hospital outcomes were compared; in-hospital mortality was 34.1% with IABP compared to 45% with Impella use, and in-hospital bleeding rates were also lower in IABP group with 16% versus 31.3% in the Impella group⁵.

Discussion

In light of the results of these two observational real-world studies, I think we should take these results with a grain of salt. As we know, observational data has its own limitations, including confounding bias. Patients with AMI-CS may differ significantly based on their co-morbidity profile and angiographic complexity, which could potentially influence device selection; as we expect that patients who are sicker will usually get Impella as it provides more hemodynamic support compared to IABP, making comparison between these two devices inaccurate.

Both studies have shown an increase in the use of Impella over the past years, which is an opportunity to study these devices with larger numbers in different clinical settings. Registries across the nation are being established to build databases to compare these devices. Stronger evidence and more robust data with potential randomized clinical trials are much needed to help us know how to best manage this complex patient population and select which MCS device is optimal for each of our patient populations.

I would like to say special thank you to Dr Khaldia Khaled, my friend and colleague at Louisiana State University, for helping me write this blog and for her continued support.

References 

1- Schrage B et al: Impella Support for Acute Myocardial Infarction Complicated by Cardiogenic Shock. Circulation. 2019 Mar 5;139(10):1249-1258.

2- Thiele et al: Intraaortic Balloon Support for Myocardial Infarction with Cardiogenic Shock. N Engl J Med 2012; 367:1287-1296. DOI: 10.1056/NEJMoa1208410

3- Ouweneel DM et al: Experience from a randomized controlled trial with Impella 2.5 versus IABP in STEMI patients with cardiogenic pre-shock. Lessons learned from the IMPRESS in STEMI trial. Int J Cardiol. 2016 Jan 1;202:894-6. doi: 10.1016/j.ijcard.2015.10.063. Epub 2015 Oct 9.

4- Amin et al: The Evolving Landscape of Impella® Use in the United States Among Patients Undergoing Percutaneous Coronary Intervention with Mechanical Circulatory Support.

Circulation. 2019 Nov 17. doi: 10.1161/CIRCULATIONAHA.119.044007.

5- https://www.tctmd.com/news/more-adverse-events-higher-costs-impella-new-observational-studies

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.

I left Scientific Sessions 2019 (AHA19) feeling so refreshed, empowered, motivated, and ready to rock it when I got home to Boston. I’ve been told this a lot, but I really felt it this time – that conferences serve more than just to educate and provide a venue for networking; they rejuvenate you. We all exist in our silos within our various institutions, but when we’re at AHA’s scientific conferences, we’re surrounded by people from all over the world, sharing science, friendship, and most important, hope for the future of medicine. AHA19 was particularly diverse in my eyes, I saw more people of color than I have seen at any scientific session, both attending and sharing their science.

When I’m at my institution, I sometimes forget about the world outside of it. You get caught up in the things going on at your institution and the work your research team is doing. You forget that there’s an entire world out there doing brilliant work too and that we’re all in this together – to better medicine and to open doors for the generations we will be passing the baton to. Attending conferences is one of the best ways to exit that bubble.

During the AHA President’s address, when several students from all over Philadelphia were on the stage sharing their stories as part of their ant-vaping campaign – #QuitLying Big Vape – I was assured that the future of medicine is so, so, so bright. The diversity of the students on that stage made me so proud and made me even more determined to work so hard in order to have the ability to create opportunities for the underrepresented women and men who will be our next generation’s healthcare leaders. It’s moments like these that you remember your life’s purpose.

My life’s purpose in medicine is 2-fold. 1) To make sure underserved, underrepresented, and disadvantaged patients receive world-class healthcare. Meaning, if you’re a Google executive or a school environmental services employee- you have the exact same access to healthcare, including organ transplantation. And 2) To make it to the top so that I can create opportunities for historically underrepresented women and men in medicine too. Get to the table and bring all of my friends, and by friends, I mean the women and men missed for opportunities because of the color of their skin, their religious preference or lack thereof, their sexual orientation, the way they wear their hair, their socioeconomic status, their disabilities, or any number of superficial factors that contribute to inequities in medicine.

When you identify your life’s purpose and keep it at the center of every decision you make, I can’t imagine not succeeding. We’ve been given a gift – we are scientists, academics, teachers, advocates, activists, and most important, we are healers. It’s our responsibility to pay that gift forward. Especially to those who don’t have a voice and haven’t made it through those doors yet.

I came home from AHA19 ready to crush more goals and added new ones to my list. AHA19 was literally the juice I didn’t realize I needed. I’m looking forward to AHA20 already.

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.