aha19 – Page 3 – The Early Career Voice

How to Ensure Accurate Public Communication and Information Sharing

November 25, 2019November 26, 2019 Mo Al-Khalaf, PhD

Public communication and knowledge dissemination are often thought of as straight cut, on/off types of action, especially in medicine and the broader health sciences. However it is also very evident in our present day that miscommunication and inaccurate knowledge sharing exists, and has increasingly harmful consequences on the global population. Examples of this are plenty, such as the anti-vaccination movement, the numerous debates about food health categorization, novel diet constructions, and many others.

This year in Philadelphia, where the annual AHA meeting (#AHA19) was hosted, many relevant hot topics in medicine and healthcare were spotlighted, as is usually the case in these types of marquee events. The sense coming out of the meeting was that two major issues of discussion will have to be reckoned with:

The strong AHA call to action against the E-cigarette proliferating market, specifically in the way it targets youth and minority groups;
The global trial called ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches), with its top-line statement that there was no difference between interventionist and conservative therapies for patients diagnosed with stable ischemic heart disease.

Debates quickly flared, and the messages became misunderstood and controversial. These provide a real life test once again, on how we must optimize public communication and knowledge dissemination.

At #AHA19, the start of the #QuitLying campaign against the forces driving the steep increase in youth consumption of nicotine-containing vaping products, has garnered welcome applause and support by numerous school boards, concerned parents, and health conscious youths, former users of e-cigarettes or not. These groups are well aware of the high prevalence of use (more than 1 in 4 adolescents self report¹as e-cigarette users within the past 30 days, in 2019). Everyone is genuinely concerned about the ramifications if nothing is done. This is why the AHA has stepped up with the #QuitLying initiative to combat against the big industry players that drive the majority of the proliferation of these products within youth culture.

However when the message and information being distributed is counteracted by other sources that aim to mislead and obscure facts, public communication and knowledge sharing becomes much more convoluted and disrupted. Everyone has the right to voice their opinion, that’s not in question, and there is no way to avoid lies and deceptive facts from being shared. But there are new tools to clarify, and focus-deliver facts and evidence-based information to the public that deserves the highest quality data and analysis available to it.

The ISCHEMIA trial debate is another #AHA19 event that requires some clarification and focused-delivery of facts to the public. Some specific details of the trial are nicely outlined by my colleagues Dr. Renee Bullock-Palmer² and Dr. Adham Karim³, and the primary medical publications from the NIH database are available⁴ for review by whomever is interested in the full datasets from the sources. The issues I’m addressing here are not with the trial itself, but the resulting real world consequences that form after the debate from ISCHEMIA gets filtered thru multiple gateways, many well-meaning reporters, and some opinion dispensers that lean one way or another regarding the results of the trial.

ischemia trial

When public communication and knowledge dissemination is unidirectional and gated, patients can become misinformed and fueled with distrust towards the working relationships they have with their healthcare providers (doctors, nurses, surgeons, medical professionals and hospitals). This can lead to compromised decision making, and potentially harmful health outcomes. Optimizing communication and focused-delivery of evidence-based information are essential goals in our present day world, especially between the medical research and healthcare field, and the general public being served.

For many decades, from the initial beginnings of professional journalism and news reporting, up to the start of the new millennium, the available and universally accepted method of public communication and knowledge dissemination was a unidirectional pathway: researchers that perform primary data generation and analysis → reporting and communication by well established, reliable and accountable organizations → the public learning of new information that relates to their health and well-being. That being said, presently communication methods are not confined to the same gated, unidirectional path necessarily. The value of professionals in news reporting and communication is still high, and their existence is an asset and a necessity, especially in situations where communication has to be as widespread as possible in as short a time as is necessary. However, we need to encourage, promote, and build pathways that facilitate communication between the primary sources of data, and the general public, so that accuracy and integrity of the information is maintained, and trust is strengthened between all.

Everyone gains when public communication and knowledge dissemination is accurately spread, and trust is established and elevated when stakeholders are not walled off, so that they can be reachable and communicated with. Social media platforms, professional avenues to connect researchers to the public (like this one! The Early Career Voice) are pathways that can and should be used and widely encouraged, mainly as an effort to create a new model of communication that will reduce inaccuracy of information, increase the sense of trust between the public and those who serve it, and help us all lead a healthier life.

References:

Miech, Richard, et al. “Trends in adolescent vaping, 2017–2019.” New England Journal of Medicine15 (2019): 1490-1491.
Bullock-Palmer, Renee, MD, “My Top 10 Take Home Points from The ISCHEMIA Trial”, The Early Career Voice, November 18, 2019; (Page Link Here)
Karim, Adham, MD, “A Few Things the Critical Care Cardiologist Might Have Missed While Talking About the #ISCHEMIA Trial”, The Early Career Voice, November 18, 2019; (Page Link Here)
ClinicalTrials identifier: NCT01471522; NIH U.S. National Library of Medicine; (Link)

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.

Recent Development and Advances in Basic Cardiovascular Science Research at AHA19

November 22, 2019November 26, 2019 David Paik, PhD

This year’s #AHA19 meeting, despite its abbreviated 3-day format, delivered a fantastic lineup of basic science research sessions, comprising of presentations from trainees to early career and senior investigators. Here I review some of the major topics in basic science cardiovascular research highlighted at #AHA19! This is by no means a comprehensive list of all exciting new developments in basic science, but what caught my attention the most.

Single-cell sequencing

Advances in single-cell RNA sequencing (scRNA-seq) technologies in the past 3-4 years have had a transformative effect on biomedical research, enabling the profiling and analysis of the transcriptomes of single cells at unprecedented resolution and throughput. scRNA-seq has allowed identification of novel or rare cell types, analysis of single-cell trajectory construction and stem or progenitor cell differentiation, and comparison of healthy and disease-related tissues at single-cell resolution. These applications have likewise been critical in advances in cardiovascular research, as evidenced by the generation of cell atlases of mammalian heart and blood vessels, elucidation of cardiovascular development and stem or progenitor cell differentiation mechanisms, and comparison of healthy and disease conditions for the development of novel therapeutic solutions.

#AHA19 highlighted the use of scRNA-seq in a truly wide gamut of applications, from cardiac development to cardiovascular tissue atlas to understanding disease mechanisms at the single-cell level. On Saturday Dr. Eric Olson opened his “Science Catalyst Keynote” by discussing scRNA-seq data of neonatal mouse cardiac regeneration, where his team identified intercellular crosstalk among various cell types and revealed the role of cardiac macrophage-specific Ccl24 in cardiomyocyte proliferation. In “Arrhythmia Research Summit: New Arrhythmia Concepts” session, Nathan Tucker from Massachusetts General Hospital showed his single-nuclei RNA-seq data of the four chambers of the human heart. During the “Abstract Rapid Fire Oral” sessions in Zone 1, Yifei Miao at Stanford University showed scRNA-seq data of human cardiac tissue with hypoplastic left heart syndrome.

On Sunday, during the “Mom, Where Do Baby Cardiac Myocytes Come From?” session, Fabienne Lescroart at Universite Libre de Bruxelles and Enzo Porrello at the University of Queensland displayed the use of scRNA-seq and lineage-tracing models to better understand cardiomyocyte division and proliferation during cardiac development in various model organisms. During the “Main Session”, Kory Lavine at Washington University School of Medicine discussed his scRNA-seq data that elucidated the cellular and molecular events of cardiovascular inflammation. Furthermore, the newly added “Single-Cell RNA Sequencing Bootcamp”, led by Jennie Lin and Nathan Tucker, was a major success with an enormous number of attendees. It was clear that such bootcamp events should be employed at other AHA subspecialty conferences, perhaps with a larger room and a longer session period to accommodate the full coverage of essential topics in the ever-evolving single-cell sequencing technology today. In the “Frontiers in Cardiovascular Target Discovery”, I myself shared unpublished data from our laboratory at Stanford Cardiovascular Institute in identifying organ-specific transcriptomic features of endothelial cells from the Tabula Muris dataset.

On Monday, the increasing use of single-cell sequencing in clinical and preclinical studies was evident. Anne Cornelissen from CVPath Institute discussed single-cell heterogeneity of endothelial cells post balloon angioplasty and stent implantation, and Man Rao from Fuwai Hospital in Bejiing, China showed scRNA-seq data in dissecting the cell type-specific molecular changes in heart failure.

Consequently, single-cell sequencing, in particularly those enabled by the microdroplet-based method, has become an essential tool in understanding cardiovascular biology. In addition to the heavy use of scRNA-seq, single-cell ATAC-seq is poised to become an important tool in deciphering the chromatin accessibility at the single-cell level, and spatial transcriptomic techniques for tissue- and location-specific investigation of gene expression.

A number of limitations of the technology does indeed exist, and I will discuss these in a later post. Stay tuned!

Omics

The “Omics Approaches in Cardiovascular Medicine” session on Sunday highlighted the role of multi-omics tools in basic and clinical cardiovascular research. Moderated by Sarah Franklin and Maggie Lam, the full spectrum of omics were discussed by the leaders in the field, including but not limited to: proteomics, metabolomics, epigenomics, “N of 1” personal omics, and machine learning.

With the continued efforts of the Trans-Omics for Precision Medicine (TOPMed) Initiative by the NIH NHLBI now entering Year 6, comprehensive integration and development of multi-omics tools will certainly be critical not only for advancing basic science but also in precision cardiovascular medicine.

Cardio-Oncology

Another big topic of the #AHA19 sessions was the rapidly rising field of cardio-oncology. What is cardio-oncology? I will have a blog post later dedicated to this subject. #AHA19 did a wonderful job of organizing a number of superb talks and poster presentations, from both the bench and the bedside. Some of the notable sessions included: “Cardio-Oncology or Onco-Cardiology: Cardiac and Cancer Treatment in the Balance”, “Novel Concepts in Cardio-Oncology”, and “Cardio-Oncology Debates” held on Monday.

In summary, the #AHA19, to me, was one of the most EXCITING sessions in recent years, which showcased the emergence and applications of new technologies used to address the new and old questions in cardiovascular research. The conference displayed innovative and insightful research from all over the world and from scientists in all career stages and diversity backgrounds, which may not have been the case for a few of the past sessions and thus should be highly lauded. Personally, I did wish that the conference was a bit longer (e.g. 3.5-day or 4-day instead of 3), as I found numerous interesting talks occurring concurrently. In particular, a majority of basic science talks were jam-packed into Sunday, calling for #AHA20’s extra efforts to spread the BCVS talks out across the three days of the sessions.

In any case, #AHA19 in my opinion was an IMMENSE success. Philadelphia was a wonderful (first-time!) venue for the sessions. All credit goes to the organizers of #AHA19, Dr. Bob Harrington, and the BCVS Council led by this year’s Chair Dr. Joseph Wu and Vice Chair Dr. Elizabeth McNally. I cannot wait to come back for #AHA20!

Late Breaking Science DAPA-HF: SGLT-2 inhibitors might influence Cardiovascular outcomes—- Benefits extend above and beyond HbA1c.

November 22, 2019November 26, 2019 Noora Alhajri, MD, MPH

The DAPA-HF trial was definitely the highlight of the scientific sessions at the AHA19 conference. I’m fascinated by the interesting outcomes and keen to learn more about the effect of SGLT-2 inhibitors on heart failure (HF) patients with preserved ejection fraction (HFpEF). In the next few lines, I’m going to briefly discuss the significant findings of DAPA-HF that were presented at AHA19, and will sooner nor later change the guidelines for management of patients with HFrEF.

Sodium-glucose cotransporter-2 inhibitor (SGLT-2 inhibitor) are relatively new class of drugs that act on inhibiting glucose reabsorption from proximal tubules, and thus decrease serum blood glucose concentrations.¹ They are commonly prescribed to treat T2DM patients who have poor glycemic control. However, new data are emerging in large support of the beneficial effects of SGLT-2 inhibitors not just on diabetics but also on non-diabetic HF patients. The data is big and clear as presented by Dr. John McMurray at AHA19 and it is expected to list SGLT-2 inhibitors such as dapagliflozin (Farxiga) as guideline directed medical therapeutics (GDMT) in 2021 for HF patients.

In the DAPA-HF, McMurray and colleagues enrolled 4,744 patients with heart failure characterized by reduced ejection fraction (defined as left ventricle ejection fraction of 40% or less) from 20 different countries. There were 2,139 patients diagnosed with diabetes who were more likely to have HF etiology of ischemia when compared to non-diabetic patients with HF. The study population consisted of high risk middle aged patients with a mean LV ejection fraction of 31%. The primary end point was a composite outcome consisted of cardiovascular death, HF hospitalization and urgent HF hospital visits over an average of 18 months. As for diabetics in the DAPA-HF trial there was a 25% reduction of CV events (HR 0.75, 95% CI 0.63-0.90) when comparing dapagliflozin against placebo. While, there was a 27% reduction among those who did not have diabetes (HR 0.73, 95% CI 0.59-0.91).²

“The relative and absolute risk reduction in death and hospitalization were substantial, clinically important and consistent across the age spectrum and baseline health status in both patients with or without diabetes”, McMurray noted.

The mechanism by which dapagliflozin provides the cardiovascular benefits that has been documented in the DAPA- HF trial remains to be unclear. It is plausible that SGLT-2 inhibition modifies many CV risk factors such as BP, visceral adiposity, arterial stiffness, hyperinsulinemia, albuminuria, circulating uric acid levels and oxidative stress. These factors are involved in several pathways related to the cardiorenal outcome, where SGLT-2 inhibitors regulate the glucose and sodium excretion and therefore modify the factors in these pathways.

Below is an illustration that explains the proposed pathways involved in cardioprotective role of SGLT-2 inhibitors³

dapahf

In conclusion, dapagliflozin offers new approaches to the treatment of HF with reduced ejection fraction (HFrEF) in patients with or without diabetes. Data from the DAPA-HF trail provides robust support for the initiation of SGLT-2 inhibitors in patients who either have an established CVD or at risk of developing CVD, and HF in particular, or at risk for renal decline and progression into chronic kidney disease (CKD).

References:

Mcmurray, John J. V., Demets, David L., Inzucchi, Silvio E., et al. A trial to evaluate the effect of the sodium–glucose co‐transporter 2 inhibitor dapagliflozin on morbidity and mortality in patients with heart failure and reduced left ventricular ejection fraction (DAPA‐HF. European Journal of Heart Failure. 2019;21(5):665-675. doi:10.1002/ejhf.1432
Packer, Milton. Lessons learned from the DAPA-HF trial concerning the mechanisms of benefit of SGLT2 inhibitors on heart failure events in the context of other large-scale trials nearing completion. Cardiovascular diabetology. 2019;18(1):129. doi:10.1186/s12933-019-0938-6
Ali, Amar, Bain, Steve, Hicks, Debbie, et al. SGLT2 Inhibitors: Cardiovascular Benefits Beyond HbA1c-Translating Evidence into Practice. Diabetes therapy : research, treatment and education of diabetes and related disorders. 2019;10(5):1595-1622. doi:10.1007/s13300-019-0657-8

#AHA19 – “I want to be in the room where it happens”

November 19, 2019November 26, 2019 Mirvat Alasnag, MD

This year’s scientific sessions of the American Heart Association (AHA) have been disruptive to common dogma. The Presidential Address was preceded by select songs from the Broadway musical, Hamilton. Not surprising, one of the song’s lyrics, “I want to be in the room where it happens,” caught my attention. We all want to be where the discussions are happening and that is precisely what the current President of AHA was keen to ensure. There was diversity in the program and faculty. In particular, early career professionals and women were well represented and had a seat at the table. More than that, conventionally, AHA focused on basic sciences. This year there was emphasis on clinical cardiology as well with the presentation of much anticipated late breaking clinical trials (LBCT) like ISCHEMIA, Impella and IABP in acute myocardial infarction and shock, GALILEO and RECOVERY studies.

The details of these trials were divulged through multiple platforms including social media, blogs and society websites. We read commentaries from reputable thought leaders such as the statement released by the President of the Society of Cardiovascular Angiography and Interventions (SCAI) regarding the ISCHEMIA trial. Each of these LBCT, however, heralded another important concept that Dr. Bob Harrington highlighted in his speech, evidence matters. For a change, filling in the evaluation forms at the conclusion of the sessions meant something more to me as a clinical cardiologist and weren’t just part of the routine to obtain my CME credits.

ISCHEMIA Trial: $100 million was spent to tell many of us what we already knew. Revascularization in stable disease does not reduce hard endpoints. So, why spend all that money? The answer was simple. We now have robust evidence to quote to referring physicians and patients telling them that optimal medical therapy (OMT) works just as well. Central to this are the numerous referrals to revascularize coronary arteries in otherwise asymptomatic patients before non-cardiac surgery. It also brought into focus the meaning of OMT which extends beyond anti-angina. It should include disease modifiers like more stringent lipid lowering agents, antiplatelet agents and better control of diabetes. Examining the data furnished by the investigators, it was disappointing to learn that OMT outside North America was in fact poor. Finally, core lab adjudication of every piece of information from EKG to angiograms set a new standard for research.
IMPELLA vs IABP in Acute Myocardial Infarction with Cardiogenic Shock Study: I was trained in Michigan, hometown to General Motors and CHIP (Complex High Risk Percutaneous Interventions). My patients often need mechanical circulatory support. Yet, reviewing the results of this observational study that extracted data from the NCDR registry revealed more bleeding and deaths in the Impella arm. I want to help my patients as do all other CHIP operators. Given these results, I had to question practice not guided by evidence. At this point the nuances of registry data don’t permit solid recommendations. It may help. It may harm. We are in desperate need for a well-executed and funded randomized study.
GALILEO Trial: This trial examined the role of Rivaroxaban comparted to dual anti-platelet therapy in patients who have undergone trans-catheter aortic valve replacement (TAVR). There were higher bleeding events and higher thromboembolic events in the Rivaroxaban arm. With the premature termination of this trial, we are at a loss to what the ideal treatment of patients after TAVR. The data behind the use of dual anti-platelet agents is weak. We know all novel anti-coagulants are safer than the vitamin K antagonists, but we don’t know if we can use them for atrial fibrillation in patients post-TAVR. Why? The most notable difference is the mean age in GALILEO was 80 years which is much higher than that in ROCKET AF. Once again, we need the evidence to guide practice in the elderly which is lacking on many fronts especially with regards to anticoagulation.
RECOVERY Study: This study demonstrated an improved survival out to 8 years in those with asymptomatic very severe aortic stenosis who undergo surgical aortic valve replacement. Can these results be extended to TAVR? I remain optimistic, but I know we need the evidence and that is expected to reach completion in 2021.

Finally, I am a clinician. I want to be in the room where it happens for my patients. They deserve best practices guided by evidence…Yes Mr. President, evidence matters.

Stress and Cardiometabolic Health Among Sexual and Gender Minorities

November 19, 2019November 26, 2019 Carl G. Streed Jr., MD, MPH, FACP

stress response Research continues to mount showing that stress affects our health and well-being. The various daily experiences we face that lead to stress set off a cascade of physiological responses that, when experienced over a lifetime, can lead to diabetes, hypertension, and eventually heart attack and stroke.

The effects of stress experienced over a lifetime are especially apparent for any individual who experiences discrimination or trauma due to identifying as a member of a minority group. The Minority Stress Model detailed in racial and ethnic groups and further expanded to include sexual and gender minorities (i.e., lesbian, gay, bisexual, transgender, and queer [LGBTQ] individuals) posits that LGBTQ folks and other minority groups are at greater risk for health problems, especially depression, because of the stigma, discrimination, and victimization they experience over their lifetime.

Experiences of minority stress stem from expectations of rejection, concealment (if possible) of one’s minority status, internalized homophobia and/or transphobia, and experiences of physical, mental and social harm. Concealment of one’s minority status is particularly unique to sexual and gender minority populations, who may also experience other forms of minority stress based on race/ethnicity, gender, and social class. Evidence linking minority stress and physical health outcomes is somewhat mixed, but in SGM populations the findings (especially for depression and other mental health problems) are fairly strong.

While minority stress may be more distal (timing of exposure happens earlier in life), there is likely a cumulative effect over the life course given everyday experiences of discrimination that could result in a greater risk for cardiovascular disease and other co-morbid conditions later in life.

Several studies have recently highlighted the measurable effects of stress among sexual and gender minorities:

At the AHA Scientific Sessions, Billy Caceres PhD similarly outlined these effects in his presentation “Minority Stress, Social Support, and Cardiovascular Risk Factors in Transgender and Gender Nonconforming Persons.” Using cross-sectional data from Project AFFIRM, which consists of a diverse sample of transgender people recruited from three cities, Dr. Caceres and colleagues examined the association of minority stressors, social support, and gender-affirming hormone use with self-reported cardiovascular risk factors (i.e., tobacco use, risky drinking, short sleep duration, physical inactivity, and body mass index [BMI]) adjusted for demographic characteristics. They then examined whether social support moderated the association of minority stressors and CVD risk factors. They found that experiences of discrimination were associated with higher rates of risky drinking and lower rates of adequate sleep duration. Internalized transphobia was associated with lower rates of physical activity.

Utilizing the Minority Stress Model to identify potential interventions to reduce the harmful effects of discrimination and subsequent stress, a recent study explored the effects of support for sexual minority youth (i.e. lesbian, gay, bisexual, queer):

Father support is protective against the negative effects of perceived discrimination on CRP among sexual minorities but not heterosexuals.

Researchers used data came from Wave IV of the National Longitudinal Study of Adolescent to Adult Health (Add Health) and created stratified linear regression models examining if father and mother support moderated the association between discrimination and inflammation (i.e. CRP) among sexual minorities and heterosexuals. What they found was that father support significantly moderated the association between discrimination and CRP among sexual minorities but not heterosexuals. Sexual minorities with higher father support and who experienced discrimination had lower CRP as compared to those with lower father support and who experienced discrimination; mother support did not moderate the association between discrimination and CRP among either sexual minorities or heterosexuals.

The research findings fit the current Minority Stress Model, demonstrating that father support may mitigate the negative effects of stress from discrimination on subsequent inflammation among sexual minorities. Future research ought to examine additional protective factors that could inform the development of interventions mitigating the harmful effects of discrimination and stress on subsequent cardiometabolic health.

Dr. Caceres’ research presented at AHA Scientific Sessions similarly found that social support (i.e., friends and family) moderated (weakened) the association between discrimination and adequate sleep duration, suggesting that social support is a resilience factor.

CALL TO ACTION:

Consider a stress-/trauma-informed approach to your clinical care and research agenda. Identifying and measuring stress and experiences of trauma as researchers will allow us to begin to work with our patients and communities to craft specific interventions to improve their health and well-being. Acknowledging trauma will allow us as clinicians to provide tailored care for our patients and their families.

References:

Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5):674-697.
Meyer IH. Minority stress and mental health in gay men. J Health Soc Behav. 1995;36(1):38-56.
Meyer IH, Dietrich J, Schwartz S. Lifetime prevalence of mental disorders and suicide attempts in diverse lesbian, gay, and bisexual populations. Am J Public Health. 2008;98(6):1004-1006.
Frost DM, Lehavot K, Meyer IH. Minority stress and physical health among sexual minority individuals. J Behav Med. 2015;38(1):1-8.

Lick DJ, Durso LE, Johnson KL. Minority Stress and Physical Health Among Sexual Minorities. Perspect Psychol Sci. 2013;8(5):521-548.
Williams DR, Yu Y, Jackson JS, Anderson NB. Racial differences in physical and mental health socioeconomic status, stress and discrimination. Journal of health psychology. 1997;2(3):335-351.

From across the Atlantic: making the most of your conference trip as an international delegate

November 18, 2019November 26, 2019 Aaysha Cader, MD, MRCP

Approximately 30-40% of AHA Scientific session attendees are from outside of the United States. Taking a couple (or more!) of flights, landing in a new city after a 23-hour trip from across the Atlantic and functioning at optimum levels during a meeting of such magnitude may well be a formidable task, particularly when it’s a short trip and you want to get the most of it.

While each person has their own mechanisms of adapting, here’s some derived from my relatively short experience:

Optimize the long flight hours: I personally feel that sleep makes for the finest use of flight time, particularly on long-haul flights and red-eyes. There are others, however, who might opt to use this time to fine-tune presentations and prepare points for posters. A good rest in flight also helps you adapt and combat jetlag optimally, allowing you to function at maximum efficiency.

Get the mundane things over with: Make sure you’ve sorted (and preferably pre-paid for) accommodation, figured out airport to hotel commutes, activated international roaming allowing for sufficient data/connectivity and downloaded offline maps of the city, just in case. Accommodation within walking distance to meeting location is convenient, allowing for a later wake-up (if you’re not an early riser like yours truly!) but most importantly obviating the need for figuring out taxis/ tube maps/traffic navigation when you’re very likely to be in a rush.

Pack light but pack smart: International transfers can be unpredictable; I always factor in lost/delayed bags and pack an entire day’s conference wardrobe into my hand luggage. The importance of comfortable shoes cannot be understated, especially if you’re trying to do a superspeed Flash act between meeting rooms. I also carry a large bag at meetings, one that would accommodate a fully-charged laptop and power banks, phone charger with universal adapter (absolute essential!) and a light jacket for a cold meeting room. Also, any additional space is more than welcome for journals and other print material you might pick up.

Plan your itinerary right: Basically, be in the room where it happens. Even with the most efficient meeting app, chances are you’ll have multiple overlapping sessions bookmarked. Keeping in mind the genre of sessions one might not always have access to back home, I would opt to attend late-breaking science, live cases and interactive sessions by experts, over, say, seminars and updates on more general topics.

Use social media: It’s a formidable accessory to derive the maximum conference experience. Apart from the obvious pluses of rapid access to scientific content and networking, a twitter update might even alert you to a session you intended on attending but somehow missed bookmarking.

Avail opportunities for networking: Most of conference science can now be accessed online post-conference but, one cannot put a price to the value of face-to-face networking or comparing notes with peers from across the globe, potentially even leading to collaborations. And let’s not forget the opportunities to literally pick on the brains of global experts at dedicated sessions, such as those offered at the FIT lounge.

It’s not all about the science: Make use of the additional programming. The Women in Science mentor-mentee session I had Saturday morning with Dr Noel Bairey Merz, even before I attended my first scientific session, provided a wonderful opportunity to discuss research and career with a prominent woman in cardiology (WIC).

Take breaks: Go to exhibition halls and training pavilions; If you’re super-saturated with all the scientific content, visiting booths at exhibit halls are actually a great way to take a breather, caffeinate, pick-up some new literature or check out the new tech.

Get involved: At various levels in one’s career, there are many ways international members can get involved, perhaps by joining one of the AHA’s 16 scientific councils, for a start. The Early Career Blogging program is a fantastic project: apart from the remarkable learning and networking opportunities it affords, you can’t beat the incredible perks of front row seats at the Presidential Session, including a performance by the cast of Hamilton!!

Embrace the different perspectives but apply them locally: While these meetings provide the international attendee a much-needed global perspective on a variety of aspects pertaining to cardiology, it’s also equally important to appropriately apply what you learn, taking into account local culture and tailoring it to the norms of practice back home.

Enjoy the break from work: Last but not least, even with the busiest of itineraries, international meetings offer what can sometimes be much-needed downtime and a break from work. There is no joy like that of exploring a new city, so even if it means taking an extra half day, use that “me” time to good effect. Carpe diem!

A Few Things the Critical Care Cardiologist Might Have Missed While Talking About the #ISCHEMIA Trial

November 18, 2019November 26, 2019 Adham Karim, MD

The ISCHEMIA trial definitely caused quite a chatter, and congratulations to the authors on a thought provoking and interesting study. I’m fascinated and can’t wait to do a deep dive on my own time. BUT, that’s for stable ischemic heart disease. There’s a time and a place for that, but that place is certainly not the ICU.

With that in mind, I’m going to briefly highlight a few presentations at this year’s AHA conference, and throw out a few breadcrumbs to pique your interest and hopefully encourage you to look into the primary literature.

Utilization and Outcomes of Impella vs IABP Among Patients with AMI Complicated by Cardiogenic Shock Undergoing PCI

In this talk, Dr. Sanket Dhruva and friends took data from the NCR CathPCI Registry, and created a linked cohort with the Chest Pain MI Registry. Out of 28,304 patients with AMI and CS, 8,471 received IABP only, 1,768 received Impella only. They were able to propensity match 1,680 (95%) of the Impella patients to IABP patients. The results were staggering: 45.0% mortality rate for Impella vs 34.1% with IABP. Major bleeds (as defined by the NCDR) occurred in 31.3% of Impella and 16.0% of IABP patients. They also stratified the patient event rates for pre and post-PCI initiation of mechanical circulatory support. Study perior was 10/2015 – 12/2017

Pre-PCI initiation of MCS:

Mortality 45.6% vs 36.8% Impella vs IABP
Major bleeding 27.4% vs 16.6% Impella vs IABP

Post-PCI initiation of MCS:

Mortality 44.0% vs 32.2% Impella vs IABP
Major bleeding 34.4% vs 15.7% Impella vs IABP

ischemia

Comments:

This was a historical cohort, this is observational data, and I think this highlights a need for a prospective RCT looking at the use of Impella vs IABP in patients with AMI and cardiogenic shock. Because of the nature of the dataset, the definitions of events were standardized across the board. I will also add that these patients were not stratified using the SCAI schema for cardiogenic shock (hard to use it when it wasn’t released during the study period!). Is it possible that the sicker patients got Impella more frequently? Sure, but, Dr. Dhruva noted that most of the Impella devices used were the small 2.5, and not the 5.0. A study I was a part of looking at trends in utilization and mortality with MCS published earlier this year also found similarly increasing trends in utilization of MCS, but no difference overall with regards to mortality. That paper, too, performed retrospective data analysis, and carries many of the same limitations as this study.

1 year outcomes of the COACT: Coronary Angiography after Cardiac Arrest Trial

You are the physician on-call at your ICU. You hear of a patient who had an out-of hospital cardiac arrest, the rhythm was VT, ROSC was obtained in the field, and the post-ROSC ECG showed no STEMI. Do you take them to the cath lab, or do you just focus on targeted temperature management & stabilize the patient? What if it was an electrically silent MI!?

This study sought to provide some guidance for scenarios such as the one above. Followup was assessed at 90 and 365 days for the 538 patients enrolled in this study.

Exclusion criteria was STEMI, obvious non-coronary cause of arrest, delivery of electric shock

Inclusion criteria: Initial shockable rhythm, comatose after ROSC (GCS < 8) , and no ST elevation on post-ROSC ECG.

End-result, 61.4% of patients in the immediate angiography and 64.0% in the delayed angiography group were alive 1 year post-arrest. No significant difference in rates of revascularization, MI, or hospitalization for heart failure or ICD shocks between either group.

Comments:

Looking at the details, I saw roughly similar rates of PCI in both groups, I am curious if PCI utilizing FFR would have had different results in the delayed angiography group. Overall, I think this provides solid evidence to support the importance of focusing on stabilizing the post-cardiac arrest patient, and looking for other, non-cardiac causes of the arrest (assuming no obvious signs of MI).

Session on Hemodynamics in Cardiogenic Shock

This has a lot of buzz words that I like, and I’m a huge geek for physiology, so I basically camped outside the room in anticipation of this session.

The speakers were an all-star lineup, including Dr. Hall from Baylor University, Dr. van Diepen from University of Alberta, Dr. Wong of the University of British Columbia, Dr. Kapur from Tufts, and Dr. Thiele from the University of Leipzig.

My breadcrumb summary:

The old definition of cardiogenic shock is not very helpful (sustained SBP < 90 mm Hg for at least 30 minutes and CI < 1.8 L/min/m2 along with elevated fillings pressures of LV, RV, or both).
The newly released scheme from the SCAI is more useful, and helps to better standardize and stratify patients across the spectrum of CS (and this was already validated in a huge cohort).
The duration and type of CS matters! Cardiogenic shock in a patient with ADHF is different than the patient with acute myocardial infarction!
When considering what device to use for MCS, it is important to consider a few things, namely, what is your center most familiar (and therefore best) at doing? How much volume/flow do you anticipate needing?
The existing literature regarding MCS and CS associated with AMI is lacking in sample size, and we need more data.

Neurologic Function and Outcome After Cardiac Arrest

I’m not an expert, so I’m going to shamelessly regurgitate what the experts said. Namely, multi-modal imaging approaches can, with good specificity (but poor sensitivity), prognosticate poor chances of neurologic recovery 0 a very meaningful endpoint for these patients.

Similarly, there are a few biomarkers that may serve as standard serum measurements in the future, as we study them more.

Lastly, intranasal evaporative cooling (sounds super cool doesn’t it?) is a method of targeted temperature management that can improve neurologic outcomes after cardiac arrest.

summary

Check my references below for more reading, I highly recommend doing a deep dive, as I could not possibly do these excellent physicians justice on their expert summaries.

References:

Dhruva SS. Utilization and outcomes of Impella vs IABP among patients with AMI complicated by cardiogenic shock undergoing PCI. Presented at: AHA 2019. November 17, 2019. Philadelphia, PA.
Panhwar, Muhammad Siyab, et al. “Trends in the Use of Short-Term Mechanical Circulatory Support in the United States–An Analysis of the 2012–2015 National Inpatient Sample.” Structural Heart (2019): 1-8.
Lemkes J.One Year Outcomes of Coronary Angiography After Cardiac Arrest. Presented at: AHA 2019. November 17, 2019. Philadelphia, PA.
Lemkes JS, Janssens GN, van der Hoeven NW, et al. Coronary Angiography After Cardiac Arrest Without ST-Segment Elevation. N Engl J Med 2019;380:1397-407.
Schrage, Benedikt, et al. “Impella Support for Acute Myocardial Infarction Complicated by Cardiogenic Shock: Matched-Pair IABP-SHOCK II Trial 30-Day Mortality Analysis.” Circulation10 (2019): 1249-1258.
Thiele, Holger, et al. “Intraaortic balloon support for myocardial infarction with cardiogenic shock.” New England Journal of Medicine14 (2012): 1287-1296.
Van Diepen, Sean, et al. “Contemporary management of cardiogenic shock: a scientific statement from the American Heart Association.” Circulation16 (2017): e232-e268.
Baran, David A., et al. “SCAI clinical expert consensus statement on the classification of cardiogenic shock: This document was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), the Society of Critical Care Medicine (SCCM), and the Society of Thoracic Surgeons (STS) in April 2019.” Catheterization and Cardiovascular Interventions(2019).
Jentzer, Jacob C., et al. “Cardiogenic shock classification to predict mortality in the cardiac intensive care unit.” Journal of the American College of Cardiology17 (2019): 2117-2128.
Nordberg P, Taccone FS, Truhlar A, et al. Effect of Trans-Nasal Evaporative Intra-arrest Cooling on Functional Neurologic Outcome in Out-of-Hospital Cardiac Arrest: The PRINCESS Randomized Clinical Trial. 2019;321(17):1677–1685. doi:https://doi.org/10.1001/jama.2019.4149

My Experience at AHA19 Scientific Sessions

November 18, 2019November 26, 2019 Lina Ya'qoub, MD

#AHA19 was an amazing meeting in all aspects!! I totally enjoyed every moment and definitely recommend all fellows and early career cardiologists to attend and participate in this important meeting. I will share my experience and highlight important sessions fellows and early career colleagues should not miss.

The fellow-in-training (FIT) and Early Career Lounge

The FIT/Early Career Lounge is always open and welcoming to all fellows. There were amazing sessions throughout the meeting guiding fellows in issues that matter to them at their current level of training or practice. There were great talks by experts in the field for those who were interested in scientific writing, pursuing a career in interventional cardiology, electrophysiology, heart failure, imaging…etc These sessions were packed with fellows and early career colleagues from all over the world. After each session, there were productive discussions between the audience and the speakers, that helped further make it extremely useful sessions to attend.

The Go Red Women in Science and Medicine Lounge

The Go Red Women in Science and Medicine Lounge was also packed by great talks and tips by amazing women leaders in the field. Topics ranged from time/priority management, collaborations between scientists and MDs in clinical practice, and how to advocate for women in our exciting cardiovascular field. Similarly, each session was followed by extremely helpful tips and discussions that is very relevant to all of us, regardless of our level of training or career level.

The AHA Presidential Session

The AHA Presidential session was one of a kind! Dr Robert Harrington shared his inspiring journey how he became involved in AHA and scientific research, emphasizing why evidence matters and how we all can contribute to this amazing cardiovascular field. We were all very excited and delighted by the Hamilton performance as well!!

Late Breaking Trials

Needless to say, the late and non-late breaking trials at #AHA19 were very relevant to our clinical practice, from ISCHEMIA, ISCHEMIA-CKD, GALILEO, COLCOT, RECOVERY, DAPA-HF and many other trials. These results were released in packed halls with standing attendees, showing the importance of these trials to our daily practice.

Technology/Simulation Hall and Poster Sessions

Moreover, there were concurrent sessions throughout the meeting for those of us who like to practice and use their hand skills in the technology and simulation hall, where you get to use the most up-to-date tools and equipment, including wires and simulation devices. In addition, the poster sessions were a great opportunity to engage in basic and clinical science and exchange ideas with researchers across the globe.

In conclusion, AHA19 was a great meeting that combined both basic and clinical sciences with emphasis on one goal: Evidence Matters for Better Patient Care. I look forward to AHA20 in Dallas, Texas on November 14-16!!

The Power of Storytelling: Where Personal and Professional Truths Meet

November 18, 2019November 26, 2019 Anika Hines, PhD, MPH

I’ve always been invested in lived narratives of others. Whether through a PhotoVoice project of patients with hypertension in Baltimore or people I meet in passing, I’ve never taken the presentation of a person or their behaviors at face value. As in my chosen field of inquiry—studying mechanisms underlying racial/ethnic disparities—each person I encounter presents a series of new questions providing revelation to some truth at his/her core. It’s this curiosity that has drawn me to qualitative methodologies that place the perspectives of study participants at the center of understanding their health and building sustainable interventions.

During these AHA Scientific Sessions, I’ve met people on buses, at lunch tables, or through formal mentoring sessions, who were unsurprisingly, in some way, just like me. This could be a reflection of certain similarities in personality, passion, or interest that draw individuals to a convention. Conversely, it could be that I immediately found our areas of convergence, because subtly, or even subconsciously, I was seeking it. (After all, we always like people who are like us and I like liking people—a blessing or a curse depending on who you ask). How might we envision the world to be if we each sought to find something “likeable” about the people meet—in our professional roles or otherwise? How might healthcare transform if every physician assumed they had some experience or value in common with a seemingly “different” person encountered face-to-face in clinic? What might that mean for health equity? Our stories help us to connect.

Our personal stories, as do other truths, will always find their way to the light. We can offer them up courageously, thoughtfully, and readily, or have them seep out through our conversations and actions (often inconveniently). When Dr. Harrington, President of the AHA, stood on stage after Hamilton performers and mentioned his experience as a first-generation college graduate, my heart soared, “me, too!” When he spoke of the loss of his mother, grief gently warmed my face as I was reminded of my own who succumbed to a heart attack just last year. Immediately, I felt seen. It was a connection that, on the surface, our phenotypical differences might’ve masked (see below).

dr harrington Anika Hines

Of the myriad duties that we’re challenged to perform in our roles as clinicians or researchers, “seeing” other people (and being seen), is arguably one of the most important and impactful. That’s not to say we should bare our souls at every turn—that would be unwise. However, we should probably consider not guarding our personal and professional boundaries so aggressively. Authenticity in our human-to-human interactions—with patients, study participants, collaborators, mentors, and mentees—is where we all learn. The sweet spot lies where we can embrace and respect our diversity without discounting our shared human experiences.

Public Service Announcement: Guidelines Are NOT Merely Suggestions

November 18, 2019November 26, 2019 Nasrien E. Ibrahim, MD

We are doing a pretty poor job of getting our patients with heart failure with reduced ejection fraction (HFrEF) on the appropriate guideline-directed medical therapies (GDMT). It is the talk of the town (and by town, I mean Twitter- and if you are not following Gregg Fonarow, MD @gcfmd on there, you need to because he Tweets almost daily science-backed sermons about how bad we are at this).

It is time; it has been time.

We are doing our patients a huge disservice by not optimizing GDMT to reduce morbidity and mortality for a complex disease with an enormous societal burden. I say this all the time, GDMT are low hanging fruit with significant impact. We are not talking about cracking chests open and implanting mechanical pumps or new hearts; we are talking about medications that in some cases cost patients nothing. I am keenly aware that co-pays can be unaffordable, but the reasons for non-adherence to GDMT are not always financial in nature and include complex patient, physician, and systems issues including therapeutic inertia.

The data is clear, we have so much work to do. The Change the Management of Patients with Heart Failure (CHAMP-HF) registry included outpatients in the US with chronic HFrEF receiving at least one oral medication for management of HF and told us just how bad we are. Over 1/4 of eligible patients are not prescribed an angiotensin converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor (ARNI); over 1/3 are not prescribed a beta blocker; and over 1/2 are not prescribed a mineralocorticoid receptor antagonist. Additionally, less than 1/4 are on target doses of GDMT and sadly, only 1%, ONE PERCENT, are simultaneously on target doses of all 3 classes.

It is time to implement the guidelines for our patients’ sake. Let us get comfortable with the 3-class approach now because as The Godfather of Heart Failure himself, Clyde Yancy, MD @NMHheartdoc, suggested at his provocative talk at AHA.19, sodium-glucose cotransporter-2 inhibitors in non-diabetics and de novo ARNI may just make an appearance on the 2021 HF guideline update. Brace yourselves.

And if we are not putting our HFrEF patients on the appropriate GDMT, we need a really good reason why. And the excuse, “well, my patient feels fine”, is not good enough, because we have more than enough data to tell us we are reducing long term bad outcomes with GDMT and “feeling fine” does not tell us who will die of sudden cardiac death and who will not.

As we go into the new year, let us make a commitment to optimize our HFrEF patients on GDMT. We owe it to them to provide the best care available to them. Be creative- technology, remote monitoring devices that keep getting better, phone calls, emails, telehealth, and HF nurses are all our friends. A navigator-led remote optimization of GDMT program like the one presented by Akshay Desai, MD at AHA.19 give me hope that creativity can improve adherence.

This is a team effort that will certainly pay off.

#GDMTWorks