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#HeartFailure: Remember the hashtag #GDMTworks

I have always been fascinated by the advances in heart failure specially with the mechanical circulatory support (MSC) devices. Cardiogenic shock is no longer simply cardiogenic shock but a syndrome with a wide array of different presentations as demonstrated by the SCAI Expert Consensus on the Classifications of Cardiogenic Shock (Figure 1) or better yet as one my colleagues, Dr. Anshul Srivastava calls it “The stages of cardiology fellow anxiety”

Figure 1.

figure 1

I got the chance to be part of the AHA’s Scientific Sessions 2019 for the first time as an AHA Early Career Blogger. The first session that I attended was titled “Mechanical Hemodynamic Support for Cardiogenic Shock in the Modern Era’’

It was a good one with the experts sharing the latest on the topic and future directions. MCS devices are exciting and at times, in a close to ideal scenario, a good “last minute” resort for our advance heart failure patients either as destination therapy, and/or bridge to transplant or to recovery. However, I came to the realization that we must not forget about GDMT (guideline directed medical therapy). GDMT for chronic heart failure with reduced ejection(HFrEF) works.

They are class I and II ACC/AHA guideline recommendations for a reason. As a new early career blogger for AHA, I wanted to take the opportunity to stress how the importance of GDMT and furthermore our role in assuring that our patients with cardiomyopathy are on the correct medications at the appropriate dosages. All of us, active on social media let’s make the hashtag “GDMTworks” trend. Let’s always remember, it works. Let us constantly remind ourselves and our colleagues that this is supported by evidence.

gdmt

After starting and optimizing the medications. We must be persistent. We must not give up. We must push. It does work. And if it’s not working, we must make sure that our patients are on the optimal medications and dosages before charting “Failed Medical Therapy’’. Having said that, I will quote Dr. Everett Koop1, “Drugs don’t work in patients who don’t take them’’.

Our options for medical therapy continue to grow.  With DAPA-HF, we are possibly witnessing the recruitment of another medication joining the “GDMT” crew. The possibilities are endless and it might just be the beginning for GDMT with “Quadruple therapy in heart failure2

I chose to talk about this topic because it is in my opinion that at times we are at fault for not been aggressive with GDMT in the treatment of chronic HFrEF.  We often throw in the towel early in the game forgetting that we have another quarter to play. You got this. It’s not over yet. Start the medications. Optimize the medications, educate your patient on how effective GDMT can be. If you don’t believe it works, how will you ever convince your patient otherwise.  Most importantly, spread the word and share your stories with the hashtag #GDMTworks .

 In conclusion, to highlight Dr. Robert Harrington take away message from the presidential session “Evidence matters”. Let’s make it count and reinforce the evidence for the sake of our patients.

 

References:
1. Cramer JA. Enhancing patient compliance in the elderly. Role of packaging aids and monitoring. Drugs Aging. 1998; 12:7–15.

2. G. Michael Felker. Building the Foundation for a New Era of Quadruple Therapy in Heart Failure. Circulation. Nov 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.

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Engaging the Youth with Technology in CPR Education

You would be hard-pressed to find anyone who would counter the argument that education in Cardiopulmonary Resuscitation (CPR) is very important; you would also struggle to find anyone in the healthcare field who would not counter you if you said you said you found the experience of becoming certified and re-certified exhilarating or “fun.”

Every year the AHA Resuscitation Symposium gathers minds from around the world, researchers dedicated to the advancement and promotion of advances related to CPR and traumatic injury. The areas of interest are vast, exciting, and enough to span two full days, arguably more, bringing people from all specialties and careers. It includes up and coming updates on intra-arrest monitoring, outcomes and also research in education and retention of CPR training.

One of the constant battles in training is getting CPR education taught in schools; fraught with barriers such as cost and time, and despite mandated legislation, not always successfully implemented (Cardiopulmonary Resuscitation Training in Schools Following 8 Years of Mandating Legislation in Denmark: A Nationwide Survey)1. So what can we do to change this?

 

Make CPR training fun.

New areas of research and technology promise more realistic training; in exchange this can be more engaging. David Sarno and Dr. David Axelrod, a pediatric cardiologist at Stanford, are founders of Lighthaus Inc,2 who with the AHA, have developed VR (Virtual reality) CPR; the simulation takes VR equipment and recreates a real cardiac arrest victim, showing not only a more realistic interaction but demonstrating substantial improvement in students learning and reported more engaging and realistic learning.3

 

Use our youth to Teach CPR and teach them young.

Healthcare workers are not the only ones who can learn or teach CPR, this is not news; but how young is too young? Previous studies in Italy4 have shown success and understanding as early as primary school.

Children bring a level of excitement and offer a great module for not only testing new technology, but creating new technology. Eashan Biswa, son of UC Riverside cardiologist, Dr. Mimi Biswa, demonstrated this as a 6th grade science fair project. With support of  UC Riverside medical center and school district have they showed success teaching as young as 5th grade students CPR. They used traditional videos but also a video game developed by Eashan. They also demonstrated success in children retaining this knowledge and teaching their parents and community. You can read more about their story here: Kids as young as 12 should learn CPR.5

 

Repeat, Repeat, Repeat.

Repetition is important in CPR, as any skill, if you don’t use it you lose it. Virtual reality and early education offer great opportunities for retention and repetition and show an exciting step in the future of CPR education and learning, particularly in young kids and with opportunities for schools.

The future is bright; in order to continue to advance education of CPR we have to be creative, engage young minds, maybe even younger than previously thought, and work with new technology with the ultimate goal of continuing to spread knowledge to save lives.

 

References

  1. Malta Hansen C, Zinckernagel L, Ersbøll AK, et al. Cardiopulmonary Resuscitation Training in Schools Following 8 Years of Mandating Legislation in Denmark: A Nationwide Survey. J Am Heart Assoc. 2017;6(3):e004128. Published 2017 Mar 14.
  2. (2019). Lighthaus. [online] Available at: https://www.lighthaus.us [Accessed 17 Nov. 2019].
  3. Gent L, Sarna D, Coppock K, Axelrod D. Successful Virtual Reality Cardiopulmonary Training in Schools: Digitally Linking a Physical Manikin to a Virtual Lifesaving Scenario. Circulation 2019 Nov 11. 2019;140(A396)
  4. Beeston, A. (2019). Kids as young as 12 should learn CPR. [online] Essential Kids. Available at: http://www.essentialkids.com.au/news/current-affairs/kids-as-young-as-12-should-learn-cpr-20171113-gzk2el [Accessed 17 Nov. 2019].
  5. Calicchia S, Cangiano G, Capanna S, De Rosa M, Papaleo B. Teaching Life-Saving Manoeuvres in Primary School. Biomed Res Int. 2016;2016:2647235.

 

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

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Digital health: Four insights for early career members from Scientific Sessions 2019

  1. What is digital health? Digital health is the application of digital technology using mobile applications or wearable sensors for the betterment of health.1 This offers a distinct pathway for advancing healthcare as compared to medical devices and drugs. Digital health is uniquely positioned to tackle multiple unmet needs in healthcare such as improving medication adherence, enhancing patient experience, increasing access to care and reducing healthcare costs. The digital health sector is on track to raise over $8.4 billion in 2019.2 Riding on the winds of optimism from multiple stakeholders, digital health startups have an incredible opportunity and an equally important responsibility to deliver results. The Health Tech and Innovation Summit at the AHA Scientific Sessions 2019 in Philadelphia was the hub for thought leaders from academia and industry to build relationships and share insights on shaping the future of medicine. It offered a chance for early career members to make connections and learn about the current landscape of digital health.
  2. The need for more evidence. During his AHA presidential address, Robert Harrington, MD emphasized, ‘evidence matters’. As the number of digital health startups claiming to disrupt healthcare continues to rise rapidly, it is becoming increasingly important to ascertain the credibility of these claims. Traditionally, drugs and devices are subject to strict regulatory oversight for the assessment of clinical efficacy and safety prior to widespread use. On the contrary, digital health startups are not directly incentivized for generating evidence for the validation of their technology. Mohamed Elshazly, MD who is a cardiac electrophysiologist and health tech entrepreneur shared his experience as the founder of Ember Medical, ‘Startups have to move fast with product development to keep up with the need for raising capital.’ Clinical trials need significant time and capital expenditure which many early startups cannot afford. For instance, conducting a NIH funded randomized trial from grant application to publication takes about seven years.3 
  3. Challenges faced by startups. Startups constantly cope with the pressures arising from limited resources and considerable uncertainty about the validity of their business model. That’s why many startups embrace a hypothesis-driven approach to conduct rapid testing for pressure testing assumptions regarding their business model.4 Unfortunately, many healthcare startups end up focusing heavily on product development and underestimate the value of understanding patient preferences and physician workflows.5 Elshazly shared an important statistic to give perspective, ‘Only 5% of startups ever succeed’. Although digital health presents a challenge, there is also an extra-ordinary opportunity for early career members and startups to come together for developing groundbreaking innovations that could revolutionize the practice of medicine. ‘This is where physicians can leverage the skills acquired in an academic environment and make a broader impact’, said Bimal Shah, MD, MBA, Chief Medical Officer at Livongo.
  4. How to build a career in digital health? An important question for early career members is figuring out funding mechanisms to support themselves. Analysis of NIH funding shows that the age of obtaining the first independent grant funding is rising, while the overall funding capacity of the NIH is declining.6 Therefore, early career investigators stand to benefit from working with startups, doing clinical research and generating high quality evidence. For startups, these partnerships provide the opportunity to introduce scientific rigor in product development and conducting validation studies. It is important for early career members to be supported by senior mentors who share their vision. Maulik Majmudar, MD, medical officer at Amazon cautions, ‘It is crucial to find alignment between your personal goals and those of your organization. It is also important to show your value to the leadership by demonstrating success’. Shah shares another tip, ‘Health systems across the country are investing in creating centers for innovation. This can be another way to get support for working in this space’. In conclusion, with the changing healthcare landscape and the need for innovation in medicine, there is a need for clinician innovators. Early career investigators are uniquely positioned to lead the way in digital health. Gathering high quality evidence will be crucial to achieving the full potential of what digital health has to offer.

References:

  1. Turakhia MP, Desai S, Harrington RA. The outlook of digital health for cardiovascular medicine challenges but also extraordinary opportunities. JAMA Cardiol. 2016 Oct 1;1(7):743-744. doi: 10.1001/jamacardio.2016.2661.
  2. Digital health investments in 2019 poised to surpass 2018. Fierce Healthcare. 2019 https://www.fiercehealthcare.com/tech/4-2b-invested-digital-health-first-half-2019-as-sector-poised-to-surpass-2018
  3. W. Riley, R. Glasgow et. al. Rapid, responsive, relevant (R3) research: a call for a rapid learning health research enterprise. Clin Transl Med. 2013 May 10;2(1):10. doi: 10.1186/2001-1326-2-10.
  4. Eisenmann T RE, Dillard S. Hypothesis-driven entrepreneurship: The lean startup. Harvard Business School Background Note.812-095
  5. Why do digital health startups keep failing? Fast Company. 2019. https://www.fastcompany.com/90251795/why-do-digital-health-startups-keep-failing
  6. Rockey S. Age distribution of NIH principal investigators and medical school faculty. 2012. National Institutes of Health Extramural Nexus. https://nexus.od.nih.gov/all/2012/02/13/age-distribution-of-nih-principal-investigators-and-medical-school-faculty/

 

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

 

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AHA19: Arrhythmia and Electrophysiology Scientific Updates

This weekend, I was fortunate to attend the American Heart Association (AHA) Scientific Sessions 2019 in Philadelphia. Based on my career interest, I was keen to attend sessions related to the field of arrhythmia and electrophysiology. While late-breaking trials such as ISCHEMIA, COLCOT and DAPA-HF have appropriately and expectedly dominated the highlights of the scientific sessions, I would like to use the next few lines to talk about a few selected arrhythmia and electrophysiology studies that were presented at AHA, and have important clinical implications in my opinion.

Early morning on Saturday, Dr Larry Chinitz from New York University Langone Health, presented the primary results of the prospective, multicenter Micra Atrial tRacking using a Ventricular accelerometer (MARVEL 2) study.1 This innovative study examined the safety and efficacy of an accelerometer-based atrial sensing algorithm in patients with atrioventricular (AV) block who are implanted with a Micra leadless pacemaker. The primary efficacy endpoint (which was available in 40 patients) was the superiority of the algorithm in providing AV synchronous pacing (i.e. VDD) compared to the conventional Micra VVI pacing. The novel algorithm was successful in maintaining AV synchronous pacing (≥70% of the time at rest, during normal sinus rhythm and complete heart block) in 95% of the patients, compared to 0% in the Micra VVI pacing (P<0.001). VDD pacing was associated with 8.8% increase in stroke volume. There were no pauses (i.e. oversensing) or episodes of pacemaker-mediated tachycardia during VDD pacing. The automatic algorithm was successful in mode switching between VVI during intrinsic AV conduction and VDD during AV block. The algorithm is not commercially available yet, however, based on this exciting data, it seems that we should expect VDD leadless pacemakers to be available in the market shortly. Furthermore, the revolutionary leadless pacing technology is likely to expand in the coming few years, with potentially atrial leadless pacemakers and multicomponent systems such as cardiac resynchronization therapy with leadless left ventricular pacemaker and the possible combination of leadless pacemaker with subcutaneous defibrillator.

Later in the day, Dr Sean Pokorney from Duke Clinical Research Institute, presented the results of the RENal hemodialysis patients ALlocated apixaban versus warfarin in Atrial Fibrillation (RENAL-AF) trial.2 The study tackles a very important question regarding the safety and efficacy of NOAC (compared to warfarin) in hemodialysis patients with atrial fibrillation and elevated stroke risk (CHA2DS2-VASc score ≥2). A total of 154 patients were randomized 1:1 to apixaban 5 mg bid (N=82, 29% received a reduced dose of 2.5 mg bid due to increased age or low body weight) or warfarin with a target INR of 2-3 (N=72). At 1-year of follow up, there was no significant difference in the primary outcome of International Society on Thrombosis and Hemostasis (ISTH) major or clinically relevant non-major bleeding between the 2 groups (31.5 vs. 25.5% for apixaban and warfarin, respectively; p > 0.05). Similarly, the secondary outcomes of ISTH major bleeding (8.5 vs. 9.7%), major intracranial (1.2 vs. 1.4%) or gastrointestinal bleeding (2.4 vs. 6.9%), stroke (2.4 vs. 2.8%) and death (25.6 vs 18.1%) were not significantly different between both groups. Dr Pokorney clarified that the study was terminated prematurely due to slower than anticipated enrollment, and that the power was limited by small sample size. However, this remains the only randomized data currently available for the comparative safety and effectiveness of NOAC vs. warfarin for non-valvular atrial fibrillation in this challenging patient population that is at increased risk of both thromboembolic and bleeding events. For the time being, it seems that apixaban is a reasonable anticoagulant option for hemodialysis patients.

Last but not least, Dr Arthur Labovitz from the University of South Florida presented the Apixaban for Early Prevention of Recurrent Embolic Stroke and Hemorrhagic Transformation (AREST) trial.3 The study was a randomized, open-label, pilot trial that included patients with atrial fibrillation who had recent cerebral ischemic symptoms (0-48 hours). The patients were randomized to apixaban (to start 0-3 days after transient ischemic attack [TIA], 3-5 days after small stroke and 7-9 days after medium stroke, N=41) or warfarin (to start 7±5 days after TIA, or 14±5 days after small or medium stroke, N=47). At 180 days, early use of apixaban resulted in less fatal stroke, recurrent ischemic stroke or TIA (19.5 vs 27.7%, p=0.46) but this did not reach statistical significance. Early apixaban use was not associated with increased risk of intracranial bleeding. The authors concluded that the early use of apixaban is safe in this patient population and may be associated with improved outcomes.

Whether you are a fan of innovative technologies that revolutionize the way we treat our arrhythmia patients, or you are an admirer of rigorous clinical trials that address common challenging scenarios in clinical electrophysiology, the high-quality science presented this year at AHA will sure satisfy your taste. Stay tuned!

 

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

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My Top 10 Take Home Points from The ISCHEMIA Trial

The long awaited results of the ISCHEMIA trial were presented at this weekend’s American Heart Association’s annual scientific meeting in Philadelphia, Pennsylvania by the Principal Investigator Dr. Judith Hochman (1). This study was a randomized parallel multicenter study that had an aim to compare outcomes of patients with stable ischemic heart disease and had moderate to severe ischemia on non-invasive stress testing who underwent optimal medical therapy (conservative arm) compared with those who underwent initial routine invasive therapy (invasive arm).

 

ischemia trial

 

The clinical and stress test eligibility criteria were:

  1.  Age > 21 years
  2. The presence of moderate or severe ischemia is defined as:
    1. Nuclear > 10% left ventricular ischemia (summed difference score of > 7)
    2. Stress echo with > 3 segments with stress induced moderate to severe hypokinesis or akinesis.
    3. CMR with
      1. Perfusion > 12% myocardial ischemia and/or
      2. Wall motion > 3/16 segments with stress induced severe hypokinesis or akinesis.
    4. Exercise tolerance testing (ETT) with > 1.5 mm ST depression in > 2 leads or >2 mm ST depression in single lead at <7 METS with angina.

Ischemia eligibility was determined by sites. All stress tests were interpreted at core labs.

 

The major clinical exclusion criteria were:

  1. New York Heart Association Class III-IV functional class
  2. Unacceptable angina despite medical therapy
  3. Left Ventricular Ejection Fraction (LVEF) <35%.
  4. Acute coronary syndrome within the last 2 months
  5. Percutaneous coronary intervention or coronary artery bypass graft within the last 1 year
  6. eGFR <30ml/min on dialysis

 

The coronary CT angiogram Eligibility Criteria were:

Inclusion Criteria:

  1. > 50% stenosis in a major epicardial vessel (stress imaging participants)
  2. > 70% stenosis in a proximal or mid vessel (ETT participants)

 

Major Exclusion Criteria:

  1. > 50% stenosis in unprotected left main disease.

This study initially enrolled 8518 patients of which 3339 were excluded due to screen failure due to insufficient ischemia (N=1350), nonobstructive coronary artery disease (CAD) (N=1218) and the presence of unprotected left main disease (N=434). The remaining 5179 patients were randomized either to the conservative arm (2591 patients) or to the invasive arm (2588 patients). The study follow up was over 3 years, the mean age of patients included in the study was 64  years and the number of women enrolled in the study was 23%. Forty-one percent of the study cohort had diabetes mellitus.

 

The primary outcomes of the study were:

  1. The primary outcome of cardiovascular death, myocardial infarction, resuscitated cardiac arrest or hospitalization for unstable angina or heart failure followed over a 3 year period occurred in 13.3% of the invasive group compared with 15.5% of the conservative arm (p=0.34) and this was seen across multiple sub-groups.

 

The secondary outcomes of the study were:

  1. Rates of cardiovascular death or myocardial infarction were similar in both the invasive and conservative arms  (11.7% vs. 13.9%, p=0.21).
  2. Rates of all-cause deaths were similar in both arms (6.4% in the invasive arm vs. 6.5% in the conservative arm, p=0.67).
  3. Invasive arm was associated with a higher rate of periprocedural myocardial infarction within the first 6 months post coronary revascularization (invasive/conservative hazard ratio [HR] 2.98, 95% confidence interval [CI] 1.87-4.74).
  4. There was a greater incidence of  spontaneous myocardial infarction in the conservative arm compared with the invasive arm that was seen after 3 years (invasive/conservative HR 0.67, 95% CI 0.53-0.83).

Improvement in quality of life with regards to anginal symptoms was observed only in patients with daily, weekly or monthly angina.

 

Study Limitations

The limitations of the study included the fact that this was an unblinded trial with no sham procedure.  Based on exclusion criteria the trial results are not applicable to patients with left ventricular ejection fraction less than 35%, significant (> 50%)  left main stenosis, very symptomatic patients and patients who have had acute coronary syndromes within the previous 2 months. Trial findings may not be extrapolated to centers with higher procedural complication rates. Completeness of revascularization has not yet been assessed. The other limitation was the limited amount of women enrolled in the study (23%) as many were excluded from randomization when compared to men due to less ischemia and more non-obstructive CAD.

 

Study Conclusion

The ISCHEMIA trial concluded that patients with stable CAD and moderate to severe ischemia had significant durable improvements in angina control and quality of life with an invasive strategy if they had angina occuring daily/weekly or monthly. Shared decision-making should be done to ensure alignment of treatment with patients’ goals and preferences for patients with angina. However, in patients without angina, an invasive strategy led to minimal symptom improvement or quality of life benefits as compared with a conservative strategy.  An early invasive strategy was not associated with a significant reduction in clinical events.

 

Based on these study findings my take home messages of the ISCHEMIA trial are that:

  1. This study validates the importance of Optimal Guideline Directed Medical Therapy (GDMT) and the need to control cardiovascular risk factors and optimize anti-anginal therapy in this population. This is a potential area for improvement in daily clinical practice in caring for patients with stable ischemic heart disease. The challenges with real world clinical practice is ensuring patient compliance with medications and the patient’s ability to afford and access medical therapy. This is particularly relevant with regards to cholesterol management in patients in whom statin therapy is not sufficient in lowering cholesterol and PCSK9 inhibitors may have to be considered. It is yet to be determined if outcomes would be different with achievement of optimal GDMT.
  2. Due to the known disparities in health care with regards to race and socioeconomic status, there is a need to determine if outcomes would be similar in minority as well as underserved patient populations.
  3. Only 23 % of the study population were females as many females were excluded due to non-obstructive coronary artery disease. Therefore I believe that it is uncertain that these study findings can be extrapolated to females.
  4. It is also unclear the impact of adding cardiac rehabilitation and exercise therapy to GDMT on this study population with regards to their overall clinical outcomes.
  5. It is encouraging that 80% of the patients in the invasive arm who had moderate to severe ischemia on non-invasive stress tests  were determined to require revascularization therapy due to significant CAD indicating good accuracy rates for stress testing. It would be interesting if this could be extrapolated to real world practice. This in my mind emphasizes the need for tools in stress testing to improve and maintain accuracy such as  attenuation correction and use of prone imaging with SPECT imaging, the use of solid state CZT cameras for SPECT imaging,  the value of cardiac positron emission tomography (PET) which has been shown to have greater accuracy when compared to SPECT (2) as well as the use of artificial intelligence to improve accuracy with nuclear stress testing (3).
  6. There was an increased incidence of periprocedural MI in the invasive arm which is not a surprising finding. However, I believe that this is thought provoking as it would be interesting to determine if these myocardial infarction events were due to in-stent restenosis or due to distal embolization within the stented vessel.
  7. While it may be reflexive to consider performing only Coronary CT angiogram in these patients with chest pain to rule out LM disease and deferring stress testing before determining management strategy,  I do believe that it is important to have objective evidence of ischemia before deciding to prescribe potentially lifelong anti-anginal therapy. This is relevant for each patient as this may not align with their desires.  Additionally, this would commit them and/or their insurers to this additional expense, therefore having a clinical indication for these medications is important.
  8. A longer period of follow up could potentially have different outcomes in the treatment arms of the study and it would be interesting to determine if there will be an ISCHEMIA Extend study to evaluate this further.
  9. The completeness of revascularization in the ischemic territory is an area of uncertainty based on these study findings. Therefore, further subgroup retrospective analysis of the invasive arm will hopefully be considered by the study investigators to further study this area.
  10. Patient centered shared-decision aid tools or applications will hopefully be developed to help the physician predict individual patient’s risks and benefits for each strategy. This will facilitate the patient -physician discussion to determine the patient’s overall desires and to determine treatment goals for the patient. This is important due to the fact that what may seem a reasonable management strategy to the physician may not be acceptable to the patient based on their desired lifestyle and/or treatment goals.

Overall, I believe the ISCHEMIA trial results validates the importance of optimal GDMT as well as the importance of shared decision making between the patient and the physician based on the overall clinical risk profile of each patient and the therapeutic goals for each patient.  Hopefully, these trial results will not necessarily lead to a paradigm shift in clinical practice but will result in clinical practice improvement in delivering customized patient care based on individual patient’s clinical risks, treatment goals and patient desires.

References:

  1. www.ischemiatrial.org
  2. Takx, RAP, Blomberg BA, El Aidi H, Habets J, de Jong PA, et al. Diagnostic Accuracy of Stress Myocardial Perfusion Imaging Compared to Invasive Coronary ANgiography with Fractional Flow Reserve Meta-Analysis. Circ Cardiovasc Imaging. 2015;8:e002666
  3. Slomka PJ,Betancur J, Liang JX, et al. Rationale and design of the REgistry of Fast Myocardial Perfusion Imaging with NExt generation SPECT (REFINE SPECT). J Nucl Cardiol 2018; Jun 19:[Epub ahead of print]

 

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

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Doctor Knows Best? Trust and Empathy in Medicine

These American Heart Association Scientific Sessions have been a breathtaking representation of the diversity, potential and scientific progression of the greater cardiovascular diseases community. Among the flashing lights of landmark trials, late-breaking sessions and Cardiology fanfare, a small contingent gathered in room 202AB for a discussion on cardiovascular outcomes and improved quality of care. Titled “Peddling EBM in the Era of Fake News and Dr. Google,” Drs. Raina Merchant, Joseph Hill, Peter Groeneveld, Annabelle Volgman and Shannon Dunlay astutely presented the current landscape of healthcare delivery and the challenges of mending a broken doctor-patient relationship in an age of misinformation.

It is well known that an air of mistrust/distrust exists between the US population and the healthcare system. The 2019 Edelman Trust Barometer Report (www.edelman.com) showed that only 61% of Americans trust our healthcare system; a number that places us neck and neck with Turkey, and a far cry from the 83% boasted by India and Indonesia. This is due to a combination of our history of mistreating patients for the sake of scientific discovery, as in the Tuskegee Study of Untreated Syphilis in the Negro Male, as well as the greed of physicians who practice based on compensation rather than compassion. This is has led to a knowledge vacuum, as physician-led education of the population has been replaced by celebrity and influencer-led misinformation.

We have all walked into the room and had a patient expert waiting with pages of print-outs ready to educate you on their disease pathology. Or maybe you’ve walked in and had to convince the skeptic that rat poison will prevent them from having a future stroke. I’ve certainly had to talk a number of cyberchondriacs off of the ledge, as their Google search of “headache” resulted in a diagnosis of terminal cancer. We fail when we neglect the social, cultural and religious contexts within which our patients operate. The approach is the same for all three of the aforementioned personalities: 1) listen more than speak 2) validate their concerns 3) develop partnership/goals 4) make a recommendation.

Physicians are not inherently great at persuasion. We tend to believe that our patients (and friends/spouses/etc) think logically, and approach them as such. Aristotle used three terms to describe how persuasion or rhetoric works. Ethos or the ethical appeal, means to convince an audience of your credibility or character. Pathos or the emotional appeal, means to persuade an audience by appealing to their emotions. Logos or the appeal to logic, means to convince an audience by use of logic or reason. When your patient walks into the office, convincing them that you’re the one ethical doctor in town isn’t going to work, neither is describing the all cause mortality benefit of their new prescription.

The key to building and rebuilding this broken relationship, as well as combatting misinformation, is to appeal to the emotions (or pathos) of our patients. We must always remember that patients ultimately have 3 questions for us: do you know what you’re doing? Will you tell me what you’re doing? And are you doing it to help me, or to help yourself?1 If the answers to those questions are increasingly “yes, yes and yes” then we can look forward to a future where Medicine is once again regarded as the most noble of professions; and one where we deliver the best quality of care to our patient.

 

References:

  • Dhruv Khullar, MD, MPP. Do You Trust the Medical Profession? NY Times. Jan 23, 2018.

 

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

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Psychological and Social Influences on Cardiovascular Disease at #AHA19

Better understanding how depression, social isolation, and other psychosocial determinates of health interact with cardiovascular disease is a rapidly growing field of research. Unpacking the relationship between brain function, cardiovascular physiology, and health outcomes is no simple feat. A number of new studies presented on Saturday, November 16th at the “Depression and Psychosocial Influences on Cardiovascular Disease” poster session during this year’s American Heart Association Scientific Sessions shed new light on this topic.

Crystal Cene and her team at the University of North Carolina presented findings from the Womens Health Initiative Study (WHI) showing a correlation between social isolation and heart failure. In their analysis, they found that socially isolated woman had a 19% higher risk (HR of 1.19; CI 1.03 – 1.39) of developing heart failure over a median follow-up of 15 years1. These findings complement work published earlier this year by Anne Vingaard Christensen and colleagues at Copenhagen University Hospital2. Among 13,442 patients with ischemic heart disease, arrhythmia, valvular disease, or heart failure, loneliness predicated all-cause mortality in men (HR 2.14; CI 1.43 – 3.22) and women (HR2.92, CI 1.55 – 5.49). Given that we now have evidence that loneliness or social isolation puts patients at risk for heart failure and puts patients with heart failure at risk of all-cause mortality, there is all the more need to better understand this relationship.

simple 7Two other groups of researchers presented similar findings with depression and heart failure. An analysis of The Atherosclerosis Risk in Communities Study (ARIC) presented by Katja Vu from Brigham and Women’s Hospital found a relationship between depression and incidence of heart failure with preserved ejection fraction (HR 1.07; CI 1.02 – 1.13) among older adults (mean age 75 years) of both sexes3. However, there was no such relationship with incidence of heart failure with reduced ejection fraction [Figure 1]. Yosef Khan from the American Heart Association presented National Health and Nutritional Examination Survey (NHANES) data suggesting that depression increases risk of heart failure, coronary disease, or cerebrovascular disease even after adjusting for Life’s Simple 7: physical exercise, heart healthy diet, weight, blood pressure, cholesterol, blood sugar, and tobacco use4.

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These provocative findings leave us with many questions: What mechanisms are responsible for poor outcomes among patients with social isolation or depression? Does access to care or medication adherence mediate these effects? Would interventions to reduce social isolation or depression improve cardiovascular outcomes in the long-run? There is a lot left to discover in this bio-psychosocial model, but I for one am looking forward to future work in the field.

 

References:

  1. CW Cene et. al. Social Isolation Independently Predicts Incident Heart Failure Among Older Women: Findings From the Womens Health Initiative Study. Poster Presentation, American Heart Association 2019 Scientific Sessions, Philadelphia, PA, November 16-18, 2019 (https://www.abstractsonline.com/pp8/#!/7891/presentation/29740)
  2. Christensen AV, et al. Heart 2019;0:1–7. doi:10.1136/heartjnl-2019-315460
  3. K Vu et. al. Depressive Symptoms, Cardiac Function, and Risk of Heart Failure With Preserved or Reduced Ejection Fraction in Late Life: The Atherosclerosis Risk in Communities (ARIC) Study. Poster Presentation, American Heart Association 2019 Scientific Sessions, Philadelphia, PA, November 16-18, 2019 (https://www.abstractsonline.com/pp8/#!/7891/presentation/29738)
  4. Y Khan et. al. Depression and Non Fatal Cardiovascular Diseases Among Adults in the United States. Poster Presentation, American Heart Association 2019 Scientific Sessions, Philadelphia, PA, November 16-18, 2019 (https://www.abstractsonline.com/pp8/#!/7891/presentation/29739)

 

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

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10 Easy Ways To Make The Most Of Your Time At Scientific Sessions

Anyone who has attended any of the scientific sessions realizes very quickly that it is a marathon, not a sprint. We may have specific goals to accomplish while at the sessions so how can we make the most of our time? Although there is no one right answer, through my personal experience, I believe the following is a useful way to get started. 

 

  1. Take a look ahead – The sessions are jam packed with several sessions occurring at the same time or in overlapping times. If you look at the program ahead of time, you will be able to better organize your time and prioritize what sessions are going to be most beneficial. 
  2. Get the inside scoop – If you are a first-time attendee speak to your colleagues, faculty, and mentors who have attended scientific sessions about their experiences. By speaking to my mentors, I was able to get tips and tricks that helped me focus my energy on lectures that would be engaging and pushing myself to going to sessions that may be out of my comfort zone. Often, there are professional interest groups that you are able to attend to network or take a deep dive into specific topics. 
  3. Look good…feel good – I cannot count amount of times I have been thankful for wearing business casual to semi-professional clothes. You will be surprised at how often you will run into program directors, researchers, investigators, or others that could serve as a mentor. I always wear a dress shirt, blazer, and slacks when I am attending the sessions. If I am presenting then I will always have a tie. Trust me gents, it goes a long way.  
  4. Keeping it profession – To build on #3, keep plenty of business cards on hand. Each time I interact with anyone at the sessions, I give them my business card and ask for theirs. Fortunately, my fellowship provides me with business cards but if yours does not, you can easily make them at a low cost. I also then store the business cards in an app that helps keep them organized. This will help reach out to your network later and easily allow others to be able to reach you. 
  5. Team building – It’s been a tradition for UMass to have a team dinner at any and all scientific sessions. It’s a great way to discuss our day, see what our colleagues are engaged in, and what we are looking to accomplish for the remainder of the sessions.

    Team Dinner – continuing to bond, support, and encouraging.

  6. Engage in tech – The sessions have several platforms to enhance the experience. Specifically, apps are created to help improve the experience, provide maps (very helpful if you’re not familiar with the venue), and allow you to create a schedule to stay organized. Twitter is becoming a fantastic modality to stay informed of the most recent trails, engaging small group talks, or networking opportunities. 
  7. Network – The sessions are filled with a vast range of attendees. I always make an effort to introduce myself to anyone who is look at the same poster as me, sitting next to me at a session, or even getting coffee. Of course this requires us to get out of comfort zone but it becomes easier and incredibly fruitful. 
  8. Stay hydrated – I always bring a water bottle with me to the sessions. You will be going from session to session and forget to take care of your needs. A protein bar is also a great idea and may hold you over until you get to a proper meal. 
  9. Support your colleagues – If residents, fellows, or attendings are presenting at the sessions, I always try to make it. Not only does it give me a chance to engage in his/her research but also offers a chance to learn. We often are not familiar with the research our colleagues are undertaking but this gives the perfect opportunity to become more involved and potentially collaborate.

    Our fantastic medical student Benjamin Maxwell with our amazing faculty member Dr. Lara Kovell who has helped serve has a mentor roll.

  10. Enjoy!! No matter what happens or how prepared you are, enjoy the energy surrounding the sessions. This is a time for you to get excited about science, clinical trials, and celebrate the success in our field. I always come away with more than when I first arrived and use this momentum to continue to progress in my career. 

 

Attending scientific sessions is a time we get inspired, have renewed energy, and perhaps most importantly continue to grow professionally and personally. Hopefully gleaming from my experience will help enhance your own. 

 

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

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Why Get Involved with the AHA as a Trainee?

Keeping tradition with Dr. Ivor Benjamin’s visit to the AHA FIT & Early Career Lounge last year, current AHA President Dr. Bob Harrington came by the Lounge today to engage and interact with FITs and research trainees alike. He expounded on his own journey towards the AHA Presidency, from getting involved with the AHA as a cardiology fellow to volunteering on many councils within the organization.

His path was one filled with persistence and hard work, yet he emphasized the importance of mentorship in his career trajectory. At Duke University, Dr. Robert Califf served as an early mentor of his, and Dr. Harrington continues to collaborate with Dr. Califf on research projects, he said that he still views him as a career mentor. Yes, even while holding arguably the peak leadership role within American cardiology, the President of the AHA still has mentors who advise him.

At another FIT/Early Career session, Dr. Jared Magnani, Chair of the FIT Programming Committee, emphasized the role of knocking on doors, seeking out opportunities, and seeking out mentors. While we may feel like we have wonderful mentors at our home institutions, it is crucial to broaden your horizon and learn about the breadth of career paths that have been tread elsewhere.

So, why get involved with the AHA as a trainee? Mentorship. Opportunities. And the opportunities to meet mentors.

For a more detailed list of the opportunities that exist for AHA FITs to get involved, see the AHA FIT Newsletter published earlier this year.

But by getting involved with the AHA as a trainee, whether it be through applying for research funding or volunteering for committees within your council, allows you the unique opportunity to network with mentors (faculty & peer) from across the country. These people can become invaluable resources as you progress in your career, and as Dr. Harrington reiterated, it is crucial to find mentors in all aspects – research, clinical, leadership, work-life balance, etc.

Dr. Harrington’s Q&A session in the FIT Lounge today demonstrated the AHA leadership’s willingness and readiness to be available to mentor trainees. As a trainee, getting involved with the AHA demonstrates your willingness and readiness to be mentored by them.

To learn more about mentorship opportunities through the AHA as a FIT/Trainee, please email [email protected].

And to learn about how to Cultivate a Successful Mentor/Mentee Relationship, stop by the AHA FIT & Early Career Lounge tomorrow at 10am to hear tips from our faculty panelists.

The AHA FIT Programming Subcommittee with AHA President, Dr. Bob Harrington.

The AHA FIT Programming Subcommittee with AHA President, Dr. Bob Harrington.

 

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

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Finding your way at a large national conference: tips and tricks

Attending a scientific conference can be daunting, especially for trainees. You’re still getting your sea legs so-to-speak with regard to your science, and on top of that, you may be presenting a poster or talk to an audience of the most distinguished researchers in your field. Many of us feel the same way, and it can be difficult to muster the courage to go up to someone and introduce yourself. But this is the perfect time to do it!

To really make the most out of your conference experience, especially at a large meeting like AHA Scientific Sessions, it is important to prepare ahead of time! Yes, you will need to book your flight and hotel and register for the conference itself, but you also need to consider how you’re getting to the airport or how you’re getting from the airport to your hotel. Do you know if there is a special lot for rideshare pickups or are you getting a shuttle? Does your hotel offer early check-in? These are all important questions, and at least in my experience, are often overlooked. Plan ahead for the little details, so your brain can be as stress-free as possible on the day of your travel.

Next, to the conference itself. Plan which sessions that you want to go to, but don’t overbook yourself. Scientific conferences often have some downtime, but perhaps you want to get a little exercise while you’re away or if you plan to get a late dinner with colleagues, you might want to skip the early-morning session. Find out what works best for you, so that you can focus on the science and network without feeling completely drained.

Planning which sessions you want to attend can be extremely important for poster presentations. Often, there are so many posters that you won’t have time to wander up and down the entire exhibit hall perusing at your leisure. Search the program using keywords and make a list of a handful of posters you’d like to see. Or if you have a colleague presenting a poster, do them a favor a pay a visit. If they have legions of people trying to get a glimpse of their work, then move on, but if they’re waiting and nobody is talking with them, go up and talk. It can be extremely isolating to stand next to a poster waiting anxiously for someone to come by and show interest.

One great way to get to know more people in any scientific society is to get involved. If you’re a trainee, there is usually some standard way that you can volunteer to join a committee. In AHA, you can apply to be an early career blogger! This is a surefire way to meet people. This serves many purposes. It helps the society in various ways. It also helps your CV. Finally, you are forced to meet and interact with people, many of whom may be in leadership roles. Knowing people at the conference you’re attending is a great way to boost the number of people that come to your poster or presentation and generally improves your conference experience.

My last tip is to have fun. If you use your time wisely, you can come away from a conference with a head full of new ideas in addition to some new friends.

 

 

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.