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#AHA20 and#COVID-19: Late-breaking science insights from the AHA COVID-19 registry

The American Heart Association (AHA) COVID-19 registry, leveraging the existing AHA Get With The Guideline (GWTG) platform, was developed to better understand hospital outcomes and adverse cardiovascular complications for patients with COVID-19.

The registry was formulated to accelerate the pace of COVID-19 research and quality improvement, where granular data were collected and analyzed at an unprecedented pace, shortening time to discovery and dissemination of results. As of November 9, 109 sites across the United States had enrolled over 22,500 patients in the registry. Data derived from the registry provided for some interesting results, presented at the late-breaking science session 7 at AHA Scientific Sessions.

Cardiovascular risk factors: The vast majority of hospitalized COVID-19 patients had cardiovascular risk factors, with only fewer than 15% having no traditional risk factors. Hypertension predominated (~60%), followed by diabetes (35%) and notably, obesity (45%).

In-hospital cardiac complications: The registry predominantly found that in-hospital cardiac complications occurred less frequently than initially feared, with the cardiovascular (CV) composite of complications (including CV death, myocardial infarction [MI], stroke, heart failure and shock) occurring in approximately 8.8%. Individual CV complications occurred as follows: MI ~3%;  stroke, heart failure, and shock ~2%. Myocarditis was uncommon, occurring in 0.3%. Deep vein thrombosis (DVT) and pulmonary embolism (PE) occurred in 3.8%, substantially lower than those reported in prior single center reports.

The death occurred in ~19.5% in total, with respiratory causes predominating (72%) and only 10% being attributed to a cardiac cause. 18% had other causes, commonly sepsis. The need for mechanical ventilation was ~20%.

Racial and Ethnic Differences in Presentation and Outcomes for Patients Hospitalized with COVID-19 [1]

Race and ethnicity data of 7,868 hospitalized patients across 88 registry sites from Jan 1 to July 22, 2020 revealed an over-representation of Black and Hispanic patients, who accounted for >50% of hospitalizations. They were significantly younger than patients of other ethnicities at the time of hospitalization. Hispanics were more likely to be uninsured.

The longest duration from symptom onset to hospital arrival and a diagnosis of COVID was observed in Asian patients, who also had the highest cardiorespiratory disease severity at presentation.

There was a significant burden of CV risk factors among black patients with obesity (49.3%), diabetes (45.2%), and hypertension (69.9%) being the highest reported prevalence across ethnic groups.

Mortality: The overall mortality in this dataset was 18.4% with a total of 1,447 deaths, among which, 53% occurred among Hispanic and Black patients. However, after adjusting for sociodemographic, clinical, and presentation features, mortality and major adverse cardiovascular or cerebrovascular events did not differ by race/ethnicity.

Nevertheless, given the greater burden of mortality and morbidity of Black and Hispanic patients, the authors recommended that interventions to reduce disparities in COVID-19 be focused upstream from hospitalizations.

Association of Body Mass Index (BMI) with Death, Mechanical Ventilation, and Cardiovascular Outcomes in COVID-19 [2]

In an important analysis looking at the association of BMI with COVID-19 outcomes, this study found that obesity, and particularly class III obesity, is over-represented in the registry among patients of COVID19, with the largest differences observed among adults < 50 years. Higher obesity class associated with younger age. Higher BMI class was also associated with a higher prevalence of the black race.

Among 7606 patients, the composite primary endpoint of in-hospital death or mechanical ventilation occurred in 2109 (27.7%) patients. After multivariable adjustment, classes I to III obesity were associated with progressively higher risks of in-hospital death or mechanical ventilation. Significant BMI by age interactions was seen for all primary endpoints. There was no association between obesity class and major adverse cardiac events (MACE). As for venous thromboembolism, Class II obesity was associated with a composite higher risk of venous thromboembolism.

Severe obesity (BMI ≥40 kg/m2) was associated with an increased risk of in-hospital death only in those ≤50 years (hazard ratio, 1.36 [1.01–1.84]). In light of these findings, the authors underscored the importance of clear public health messaging and a rigorous adherence to COVID-19 prevention strategies in all obese individuals regardless of age, but especially those <50 years who may underestimate their risk for COVID-19.

The entire session can be viewed on-demand until the 4th of January 2020: AHA Goes Viral: COVID-19, Influenza Vaccines, and Cardiovascular Disease. Both the above studies were also simultaneously published in Circulation.

References:

  1. Rodriguez F, Solomon N, de Lemos JA, Das SR, Morrow DA, Bradley Smet al. Racial and Ethnic Differences in Presentation and Outcomes for Patients Hospitalized with COVID-19: Findings from the American Heart Association’s COVID-19 Cardiovascular Disease Registry. Circulation. 2020 Nov 17. doi: 10.1161/CIRCULATIONAHA.120.052278. Epub ahead of print.
  2. Hendren NS, de Lemos JA, Ayers C, Das SR, Rao A, Carter S. Association of Body Mass Index and Age With Morbidity and Mortality in Patients Hospitalized With COVID-19: Results From the American Heart Association COVID-19 Cardiovascular Disease Registry. Circulation. 2020 Nov 17. doi: 10.1161/CIRCULATIONAHA.120.051936. 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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DAPA-CKD: Is SGLT2i the ANSWER? Will the guidelines change?

Over the past years, series of clinical trials prove the beneficial effect of glucose cotransporter 2 (SGLT2) inhibitors in reducing the risk of cardiovascular events in people with type 2 diabetes mellitus. The results from these trials were consistent, significant, and demonstrated a considerable reduction in heart failure hospitalization among patients who used SGLT2 inhibitors, whereas the benefit on atherothrombotic events such as myocardial infarction and stroke was moderate.

Similar findings from The Canagliflozin and Renal Events in Diabetes With Established Nephropathy Clinical Evaluation trial (CREDENCE) were obtained for patients with type 2 diabetes mellitus and chronic kidney disease who are exceptionally at higher risk for cardiovascular disease. In CREDENCE trial, Canagliflozin reduced the risk of chronic kidney disease, cardiovascular death or hospitalization, myocardial infarction, and stroke. Although diabetes is not the only cause of chronic kidney disease, and people with chronic kidney disease are still at increased risk for cardiovascular disease, regardless if they had a preexisting history of cardiovascular disease or not. Therefore, its essential to implement guidelines that recommend the use of certain therapeutics as routine treatment for primary and secondary prevention of cardiovascular disease in patients with chronic kidney disease, regardless of their diabetes status.

During #AHA20, I enjoyed attending the online session by Dr. John McMurray, where he shared scientific breakthrough results from the Dapagliflozin And Prevention of Adverse Outcomes in Chronic Kidney Disease (DAPA-CKD) Mega-Trial. The session reported the results of the effect of dapagliflozin on prespecified kidney and cardiovascular outcomes in patients with chronic kidney disease with and without diabetes. The DAPA-CKD trial was a randomized, double-blind, placebo-controlled, multicenter trial, where adults with or without type 2 diabetes, with estimated glomerular filtration rate (eGFR) between 25 and 75 ml/min/1.73 m2, and a urinary albumin-to-creatinine ratio (UACR) between 200 and 5000 mg/g were eligible for DAPA-CKD trial. In this trial, patients were randomized to dapagliflozin 10 mg once daily or placebo with follow up at 2 weeks, 2,4, and 8 months and at 4 months intervals thereafter. The primary composite outcome was the time to the first occurrence of any of the following: > 50% decline in eGFR, onset of end-stage renal disease, or death from kidney or cardiovascular disease. Moreover, secondary outcomes were: 1) kidney composite outcome identical to the primary endpoint with the exception of death from cardiovascular death 2)( a cardiovascular composite outcome consisting of hospitalization for heart failure or death from cardiovascular  causes; and 3) death from any cause.

 

Effects of dapagliflozin on prespecified clinical outcomes according to the baseline history of cardiovascular disease.

 The DAPA-CKD trial found that among patients with cardiovascular disease who received dapagliflozin, the primary composite outcome occurred in 11.2% participants, while the primary outcome occurred in 17.2% in participants who were in the placebo group, (HR 0.61; 95% CI, 0.47-0.79) and the corresponding numbers in people without cardiovascular disease were 7.9% and 12.9% respectively, (HR 0.61; 0.48-0.78).

The DAPA-CKD trial also found that for both the primary and secondary prevention patients, the event rates favored dapagliflozin for all components of the primary and secondary outcomes, although reduction in cardiovascular risk was not statistically significant.

DAPA-CKD Figure

Additionally, among patients with cardiovascular disease, cardiovascular death or hospitalization for heart failure occurred in 9.3% of participants in the dapagliflozin group and 12.8% of participants in the placebo group, (HR 0.7; 0.52-0.94) and the corresponding numbers for patients without cardiovascular disease were 1.8% and 2.7% respectively, (HR 0.67; 0.40-1.13). The observed reduction in cardiovascular risk for these two groups was driven by reduction in heart failure hospitalization which occurred in 4.1% of participants in the dapagliflozin group and 7.3% participants in the placebo group with cardiovascular disease and the corresponding numbers for patients without cardiovascular disease were 0.3% and 1.0% (HR, 0.31; 0.10-0.94) respectively. These results show that dapagliflozin reduced the risk of adverse kidney outcomes irrespective of baseline cardiovascular disease status. Moreover, the mortality benefit from dapagliflozin as demonstrated from the DAPA-CKD study supports the findings of the DAPA-HF trial. In summary, dapagliflozin reduced the risk of kidney failure, death from cardiac disease or hospitalization for heart failure, furthermore, it prolonged survival, in people with chronic kidney disease, irrespective of the presence of a concomitant cardiovascular disease.

 

What is next?

The data from DAPA-CKD trial for dapagliflozin effect on patients with cardiovascular disease and chronic kidney disease is clear, but we have so much work to do. Is Dapagliflozin the answer? How would this change the guideline directed medical therapy (GDMT) for the care of patients with an increased heart failure, cardiovascular or chronic kidney disease risk, regardless of their glycemic status?

 

References:

  1. Effect of Dapagliflozin on Clinical Outcomes in Patients with Chronic Kidney Disease, With and Without Cardiovascular Disease. John J.V. McMurray , David C. Wheeler , Bergur V. Stefánsson , Niels Jongs , Douwe Postmus , Ricardo Correa-Rotter , Glenn M. Chertow , Tom Greene , Claes Held , Fan Fan Hou , Johannes F.E. Mann , Peter Rossing , C. David Sjöström , Robert D. Toto , Anna Maria Langkilde , and Hiddo J.L. Heerspink for the DAPA-CKD Trial Committees and Investigators
  2. Presented by Dr. John J. V. McMurray at the American Heart Association Virtual Scientific Sessions, November 13, 2020.
  3. Heerspink HJ, Stefánsson BV, Correa-Rotter R, et al., on behalf of the DAPA-CKD Trial Committees and Investigators. Dapagliflozin in Patients With Chronic Kidney Disease.N Engl J Med 2020;383:1436-46.
  4. Presented by Dr. Hiddo J.L. Heerspink at the European Society of Cardiology Virtual Congress, August 30, 2020.
  5. Rationale and protocol:Heerspink HJ, Stefansson BV, Chertow GM, et al., on behalf of the DAPA-CKD Investigators. Rationale and protocol of the Dapagliflozin And Prevention of Adverse outcomes in Chronic Kidney Disease (DAPA-CKD) randomized controlled trial. Nephrol Dial Transplant 2020;35:274-82.

“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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A Career in Preventive Cardiology: It’s A Lot More Than Statins

I spent the finale of #AHA20 Tuesday evening at the “What You Need to Know for a Career in Preventive Cardiology” fireside chat hosted by the lovely Dr. Anum Saeed with experts Drs. Ann Marie Navar, Andrew DeFillips, Seth Martin, Michael Shapiro, and Martha Gulati. The panel discussed the following topics:

Exploring the field of prevention when your program may or may not have a prevention program 

Certainly, one month of exposure is not enough to truly get a taste of the multiple flavors within this field which includes exercise, cardiac rehab, hypertension, advanced lipidology, multimodality imaging and risk scoring, diabetes, and obesity. That being said, it’s important to find a way to get involved even if your program doesn’t have a prevention program. Request to spend elective time in other specialties including Endocrinology where SGLT2 inhibitors are routinely prescribed, clinics where weight-loss medications are frequently used, and other areas in medicine that may intersect within prevention. If you do spend time in cardiac rehab, don’t just spend time with the physicians but also hang out with the exercise physiologists on the floor who engage with cardiac patients- there’s a lot to be learned from them.

Finding an academic position in prevention

Unfortunately, the current reality is that reimbursement for preventive services does not pay the bills for a cardiology division. This means that it’s extremely important for you to find a niche or expertise within cardiology that gets you paid. This can include an imaging modality, interventions (yes, there are interventionalists who practice as preventive cardiologists!), quality improvement care, research, healthcare delivery, technology, and clinical care.  The hope is that in the not-too-distant future, we will transition to more of a value-based care model.

Another very insightful pearl from the panel: when you ask for your position, know what you need early on and ask for what you want. DEFINE WHAT YOU NEED UPFRONT and where you need that time to develop a program, work on research, or start an initiative that will be productive for your department.

A day in the life of an academic preventive cardiologist

This varies widely depending on the unique interests and expertise of the individual. This can range from spending 2 week blocks caring for patients in the cardiac intensive care unit to then being off for 2 weeks followed by an outpatient clinic and research time. If you are primarily research, this may mean having a clinic one day a week with 70% of the time focusing on writing/research and attending national meetings, and collaborating with preventive groups across the world.

The future of prevention

“We’re more than giving statins.” The exciting areas of prevention and late-breaking science that were highlighted during #AHA20 speak for themselves. SLGT2 inhibitors, the promise of Inclisiran, and the polypill are just the tip of the iceberg within the field of prevention. With artificial intelligence and machine learning, polygenetics, implementation science, health equity, and digital technology, the field of prevention will be pivotal in improving outcomes such as myocardial infarction, for example, by tailoring therapy based on individual risk rather than covering everything with all available treatments. Lastly, if there is a silver lining of this #COVID-19 pandemic, it is that the cardiovascular risk factors and health disparities that have come to the surface are now being prioritized as the path for future research trials and public health movements.

I’ll leave you with a Chinese proverb one of our panelists shared: “A superior doctor prevents sickness; A mediocre doctor attends to impending sickness; An inferior doctor treats sickness.”

Stay well, be well, and be safe. And wear a mask.

 

“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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Last Day of #AHA20: COVID-19 Galore!

The last day of the amazing #AHA20 featured a series of COVID-19-related research presentations.

First, data from the AHA COVID-19 Registry, a large database collecting data about COVID-19 patients and outcomes around the country, were shared. The registry includes data from 109 hospitals and over 22,500 records of patients who were hospitalized with COVID-19. Notably, large numbers of COVID-19 patients in this registry had cardiovascular risk factors such as hypertension and diabetes. Prior cardiovascular disease was also common. The disease was additionally noted to have a high morbidity and mortality rate, with more than 20% of hospitalized COVID-19 patients requiring mechanical ventilation.

One interesting study examined racial and ethnic differences in the AHA COVID-19 Registry of patients hospitalized with COVID-19, focusing primarily on the association of these factors with in-hospital death as the primary outcome and secondary outcomes such as major adverse cardiovascular events (MACE: death, myocardial infarction, stroke, new onset heart failure or cardiogenic shock) or COVID-19 cardio-respiratory disease severity scale. Notably, Black and Hispanic patients accounted for >50% of hospitalizations in this Registry, suggesting significant over-representation of Black and Hispanic patients compared with the census demographics in their areas. Cardiovascular risk factors such as obesity and hypertension were also more common in Black and Hispanic patients. Mechanical ventilation and need for renal replacement therapy were more likely in Black patients. Overall in-hospital mortality was high at 18.4%, and particularly high for those older than 70 years old.

In fully adjusted models taking into account age, medical history and sociodemographic features, there was no statistically significant difference in mortality and MACE among different racial or ethnic groups, though Asian patients had a higher COVID-10 disease severity on presentation. These findings suggest that though race and ethnicity are not independently associated with worse in-hospital outcomes in COVID-19 patients, Black and Hispanic patients bear a greater burden of morbidity associated with COVID due to their disproportionate representation among patients hospitalized with CVOID-19. This study was simultaneously published online in Circulation.

One additional study examined the association between body mass index (BMI) with a composite of in-hospital death and/or mechanical ventilation (primary outcome), as well as with MACE (a composite of in-hospital all-cause death, stroke, heart failure, myocardial infarction), deep vein thrombosis and renal replacement therapy (secondary outcomes). Patients with a higher BMI were more likely to be admitted to the hospital with COVID-19. In analyses adjusting for age, sex, ethnicity, comorbidities, cardiovascular disease and chronic kidney disease, higher class obesity was associated with higher likelihood of in-hospital mortality or mechanical ventilation. MACE was not associated with obesity class. Deep venous thrombosis or pulmonary embolism were not associated with obesity class. Class I, II and III obesity, however, were noted to have a higher likelihood of need for mechanical ventilation, regardless of age. Moreover, when stratified by age, BMI >40 kg/m2 was associated with a higher risk of in-hospital death only in lower age groups (<50 years old). These findings suggest that better public health messaging may be required for younger obese individuals who may underestimate their own risk related to COVID-19. This study was also simultaneously published in Circulation.

 

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

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The Final Day (5/5) of AHA Scientific Sessions “Step on the Gas, so you can Hit the Breaks”

In the scientific session titled “Beyond Biomarkers: Inflammation and CVD across the Translational Spectrum”, inflammation was the topic of interest. It is important to note that inflammation has been established as a focus for the development of complications for cardiovascular diseases for some time now. The changes in inflammatory markers have been shown to be predictive of future cardiovascular events. But, do we know what exactly inflammation is? Are the markers we use precise enough to provide meaningful guidance for specific targeted therapies?

Dr. Russell Tracy from the University of Vermont was given the challenging opportunity to open the session in explaining how inflammation in cardiovascular disease works. He starts off by highlighting not just the amount of cells to consider, but all the different types and subtypes. There’s a multitude of pathways linked to inflammation and atherosclerosis. He proposed to focus on the pathophysiology that plays a role over the lifespan. Interestingly, the concept of trained immunity was highlighted as an influencer to the chronic inflammation that is signaled through adipose tissue. Dr. Tracy goes on to share that the inflammatory process could be related to input from multiple small pathways and that adaptative immunity impacts the inflammation research is attempting to characterize (Figure 1).

Figure 1.

Dr. Peter Libby from the Brigham and Women’s Hospital took a shot at addressing why some anti-inflammatory therapies work and then why some do not. He highlighted three studies to keep in mind for attendees: 1)  the Canakinumab Anti-inflammatory Thrombosis Outcomes Study or “CANTOS”, 2) the Cardiovascular Inflammation Reduction Trial “CIRT”, and 3) the Colchicine Cardiovascular Outcomes Trial or “COLCOT.  CANTOS focused on interleukin-1ß (IL-1ß) and its role in the reduction of rates of recurrent myocardial infarction, stroke, and cardiovascular death among stable patients with coronary artery disease who remain at high vascular risk (1). Canakinumab at a dose of 150 mg every 3 months led to a lower rate of recurrent cardiovascular events (1).

CIRT addressed low-dose methotrexate use among patients with stable coronary artery disease (CAD). The investigation showed low-dose methotrexate does not reduce inflammatory markers or cardiovascular events (2). Dr. Libby quickly pointed out the difference in baseline inflammation between the two populations. Where the CANTOS study already showed some residual inflammation as compared to CIRT.

He went on stating,

You have to step on the gas to press the breaks.”

The baseline level of inflammation is a characteristic to be more aware of when designing and evaluating drug studies like CIRT.

COLCOT involved the use of Colchicine to decrease the migrations of neutrophils, a white blood cell type that is essential for the resolution of inflammation. Neutrophils are a marker used for cardiovascular risk (4). Colchicine at a dose of 0.5 mg daily showed a significantly lower risk of ischemic cardiovascular events. Dr. Libby summed the presented work up with the slide below addressing residual inflammatory risk (Figure 2).

Figure 2.

He left the attendees with Winston Churchill’s famous quote from London’s Mansion House, just after the British routed Rommel’s forces at Alamein, driving German troops out of Egypt,

This is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.”

Referring to the development of targeted anti-cytokine therapies for the treatment of atherothrombosis.

Overall it seems there is an oversimplification of inflammation at times, thus inaccurately conveying the heterogeneity of the processes involved. It is a challenge to accurately assess the mechanisms underlying CVD risk in each patient. More work around specific anti-inflammatory pathway is vital to characterize inflammation and develop targeted therapies that provide a cardiovascular benefit.

 

References:

  1. Ridker PM, Thuren T, Zalewski A, Libby P. Interleukin-1β inhibition and the prevention of recurrent cardiovascular events: rationale and design of the Canakinumab Anti-inflammatory Thrombosis Outcomes Study (CANTOS). Am Heart J. 2011 Oct;162(4):597-605. doi: 10.1016/j.ahj.2011.06.012. Epub 2011 Sep 14. PMID: 21982649.
  2. Ridker PM, Everett BM, Pradhan A, MacFadyen JG, Solomon DH, Zaharris E, Mam V, Hasan A, Rosenberg Y, Iturriaga E, Gupta M, Tsigoulis M, Verma S, Clearfield M, Libby P, Goldhaber SZ, Seagle R, Ofori C, Saklayen M, Butman S, Singh N, Le May M, Bertrand O, Johnston J, Paynter NP, Glynn RJ; CIRT Investigators. Low-Dose Methotrexate for the Prevention of Atherosclerotic Events. N Engl J Med. 2019 Feb 21;380(8):752-762. doi: 10.1056/NEJMoa1809798. Epub 2018 Nov 10. PMID: 30415610; PMCID: PMC6587584.
  3. Tardif JC, Kouz S, Waters DD, Bertrand OF, Diaz R, Maggioni AP, Pinto FJ, Ibrahim R, Gamra H, Kiwan GS, Berry C, López-Sendón J, Ostadal P, Koenig W, Angoulvant D, Grégoire JC, Lavoie MA, Dubé MP, Rhainds D, Provencher M, Blondeau L, Orfanos A, L’Allier PL, Guertin MC, Roubille F. Efficacy and Safety of Low-Dose Colchicine after Myocardial Infarction. N Engl J Med. 2019 Dec 26;381(26):2497-2505. doi: 10.1056/NEJMoa1912388. Epub 2019 Nov 16. PMID: 31733140.
  4. Kain V, Halade GV. Role of neutrophils in ischemic heart failure. Pharmacol Ther. 2020 Jan;205:107424. doi: 10.1016/j.pharmthera.2019.107424. Epub 2019 Oct 16. PMID: 31629005; PMCID: PMC6981275.

 

“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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Lurking: The Art of Passive Learning in Meetings

The types of annual society meetings are as diverse as there are professional societies worldwide. Some medical, scientific, and academic societies are made up of extremely specialized sub-subfields. While other professional societies cast a wide net, bringing in members from different specialties that share some but not a lot of similarities. And of course, there are some associations that have evolved over the years to provide the best of both worlds, acting like a big umbrella for a very diverse membership, and providing space for the subspecialties to find their own niches within the structure of the whole organization. The American Heart Association is exactly this type of professional partner organization. Medical doctors from numerous specialties belong to the AHA, but so do nurses, and many other healthcare professionals, biomedical scientists, and non-medical researchers and professionals involved in fields that still contribute and promote better cardiovascular health for the public.

As an early-career biomedical researcher, I am involved in a number of these types of professional societies and organizations, each of which provides me with different and valuable experiences and opportunities to expand and develop my career path forward. Within the AHA, I slot into the council on Basic Cardiovascular Sciences (BCVS), one of sixteen different councils that make up the whole association. One of the best attributes of the AHA general structure is the fact that there are specialty annual meetings organized by the different councils (check out my blog about #BCVS20 from a few months back!), as well as a general annual meeting for the whole AHA community (just like the present ongoing #AHA20). This provides someone like myself the chance to network and builds professional connections on multiple levels. It also provides everyone a chance to expand and learn from other fields, bringing in a true sense of multi-disciplinary potential.

This year, unlike any other year before, Scientific Sessions have converted into a fully virtual setting, an appropriate response to the current Covid-19 pandemic. This has promoted all of us to become much savvier (or at least in a constant state of ‘figuring it all out’) with webcam video conferencing, seminar presenting or attending, and online learning. I’m glad that Sessions this year provided an unparalleled On-Demand package, allowing everyone registered to have access extending into early 2021, giving us plenty of time to rewatch or catch up on missed sessions. This is a very welcome outcome for having a virtual meeting, one that is worth taking full advantage of.

 

Source: Collage from CC-0 images at www.pixabay.com

Another fun new wrinkle I’ve been fully exploiting these past few days has been the use of a very online strategy called Lurking, a term that describes (in this specific context) joining a presentation session, and passively observing the action happening without actively participating in it. What a perfect way to describe and contextualize something that almost all conference attendees have done in-person before. In a #Virtual meeting, one can employ the lurking ‘maneuver’ even more brazenly! Lurking is a perfect strategy to jump into a session midway, or switch quickly from session to session, picking up some new information, and seamlessly moving on to the next item on the schedule, without ever disturbing any other attendees or presenters. I have definitely done a lot of lurking at #AHA20, especially in sessions that are not geared towards my area of expertise in experimental lab biology. Lurking has given me the ability to try out sessions, and learn something completely unrelated to my everyday science. Lurking also gave me the ability to quickly and discreetly bailout of sessions that I couldn’t find my way into, allowing me to pivot into other sessions that better fit my train of thought. Having the chance to attend a highly multi-disciplinary professional meeting, coupled with the ability to sample and view, in a discreet and un-disturbing fashion, many types of presentations is truly a valuable and welcome learning experience.

When possible, I highly encourage the adoption and wide use of online lurking strategies, especially in virtual setting conferences that may be on your calendars in the near future!

 

“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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Setting Expectations for AI Models in Medicine

Artificial intelligence is a hot topic in every field, and these algorithms are being widely used in scientific research. Particularly in my field of genetics and genomics, machine learning methods are invaluable for gleaning insights from large amounts of highly dimensional data. But there are many things to consider before applying AI and ML in a clinical setting, when real people are on the other end of the predictive model. It is important to set expectations for what AI can and cannot accomplish and what is needed for a broad application of AI in medicine in the future. In the session “Hype or Hope? Artificial Intelligence and Machine Learning in Imaging”, presenters gave a great overview of the applications of AI, its limitations, and the advancements that are needed for a wide application of AI in medicine.

Dr. Geoffrey Rubin described many different scenarios in which AI can be deployed. Specifically, he talked about how AI can be used in predictive analytics to make test selection and imaging more efficient, in image reconstruction to reduce noise, in image segmentation to identify regions of interest and provide quantitative analysis, and in interpretation to derive unique characteristics that cannot be measured directly, identify abnormalities, and create reports. In addition, Dr. Tessa Cook explained in greater depth how AI can be used as clinical decision support to incorporate diverse data types and aid in proper test selection. Dr. Damini Dey also discussed how AI can improve diagnosis and prediction, characterize disease, and personalize therapy. Overall, it is important to determine where AI can provide the greatest value while introducing the least amount of risk.

However, there are many limitations to AI and ML models. First, as Dr. David Ouyang noted, because these models are trained by humans, they can only perform tasks that a human could theoretically do. AI just performs these tasks faster, more consistently, and at a larger scale. He noted that these models are not effective unless trained on broad underlying datasets, and that unless explicitly programmed, they do not accurately weight rare significant events. AI models can easily become uninterpretable black boxes, keeping experts from recognizing where they are failing. Dr. David Playford emphasized that due to these and other limitations, AI models are not yet clinically accurate in all areas.

There are many steps that must be taken before AI models can achieve wide use in clinical settings. Dr. Ouyang suggests standardized baselines and open access to measure advancements among tools. Dr. Cook implements a “trust and value” checklist to assess how each tool was trained and tested, as well as what it can and cannot do, before using it for clinical decision support. Dr. Playford advocates for randomized trials to establish proof-of-concept and compare outcomes to the current standard of care. Most importantly, steps must be taken to reduce bias in AI models, which can negatively impact the care of underrepresented populations. Multidisciplinary collaborative teams can ensure that the data aligns with the clinical question being tackled, diverse yet consistent training datasets are being used, and methods such as transfer learning are implemented to produce more accurate predictions on previously unseen datasets. While AI can be an important tool in clinical decision making, it is ultimately the responsibility of each physician to ensure that AI tools are serving their patients as effectively as possible.

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

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The Impact of COVID on Medical Education

Since the beginning of the COVID-19 pandemic, our lives have been significantly affected on every level. Different countries reacted in various ways and almost everybody was under lockdown at a certain point. With time, everyone has adapted to the new “normal”. Masks are on all the time, no handshakes or hugs, and if anyone gets slightly closer physically, we tend to get extremely uncomfortable. On the professional side, all health care workers were impacted too. At the very beginning, all elective procedures were delayed, there were long working hours, more stress, and a lack of personal protective equipment. Patients who were legitimately sick did not seek medical advice and hospitals were at full capacity. Additionally, didactics were canceled, medical students were asked to stay at home, in-person national and international conferences were canceled, and many more. As a result, training and education were disrupted but the medical community stepped up to the challenge and explored different avenues to ensure steady and proper education for all healthcare workers.

In the past several months, all professional societies (AHA, ACC, ESC, TCT, ASE, and many more) did a phenomenal job in reducing the impact of the pandemic on medical education. All conferences were switched to a virtual platform, different ideas were applied to keep everyone engaged, registration fees were reduced significantly or completely waived. I must point out that now it is possible to attend all national and international conferences from the comfort of your living room, listen and interact with experts in the field, and attend the sessions that you have missed at your convenience. Additionally, for grand rounds and didactics, remote education facilitated learning from experts from all over the world. Although all these efforts helped mitigate the effect of the pandemic on education, however, everyone is still hoping for in-person conferences. Unfortunately, the ESC has decided to deliver its full portfolio of congresses and events virtually up to the ESC Congress in September 2021. Moreover, the ACC annual meeting was pushed back to May 2021 and it is expected to be in-person and virtual. Although recently, promising news about the vaccine has been published however it is unclear for how long will the pandemic last. In my opinion, the COVID pandemic expedited the development of remote education and eventually, it will become a cornerstone in medical education. In the time being, we have to work on overcoming this pandemic without impacting our education and most importantly staying safe.

 

“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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Highlights from AHA20

AHA20 is wrapping up today with the final sessions. It’s been another excellent meeting with tons of new data that was presented. One consistent theme remains, debates continue to drive the conversation in the management of patients with cardiovascular diseases.

  1. The ISCHEMIA trial did not disappoint again. It led to great discussions regarding the contemporary management of patients with stable ischemic heart disease.”- First, the debate regarding PCI vs optimal medical therapy rages on. Dr. Sripal Bangalore and Dr. William Boden make their case for their approach to managing these patients.

The post ISCHEMIA world left us with burning questions about the optimal approach to imaging.

– CT vs SPECT for the evaluation of patients with SIHD

Guidelines will be surely updated after this landmark trial, but what remains certain is that a patient-centered approach to imaging is the key to optimal decision making.

 

  1. Optimizing GDMT in HF patients with more pills. How much is too much?

This year’s sessions added to our armamentarium in the management of patients with Heart failure and reduced ejection fraction (HFrEF). The GALACTIC-HF trial enrolled 8256 patients with LVEF <35% and pro-BNP >400 pg/ml to receive Omecamtiv Mercabil vs. placebo. With a primary composite outcome of cardiovascular death or CHF event, those enrolled to receive the selective cardiac myosin activator in addition to GDMT demonstrated a reduction in the primary composite outcome, driven by a reduction in CHF events.

The results of this trial brought on questions regarding where newer agents in our HFrEF patients would rank in importance. Do we run the risk of polypharmacy and non-adherence with each newer agent? How much bang for our buck can we expect to receive?

Key takeaways from the discussions regarding GDMT include:

  1. Early initiation and up-titration of medical therapy improve outcomes in HF patients.
  2. Recognize signs of worsening HF and decompensation
  3. Referral to advanced heart failure cardiologists when you need help.

Debates trigger conversations, conservations lead to action. Action in this setting leads to improved patient outcomes. AHA 2020 Scientific Sessions was no different and provided great examples of this rhetoric.

One thing not up for debate at this year’s Scientific Sessions was clear. It was the call to action against structural and institutionalized racism, the fight for diversity, equity, and inclusion for all. From the opening address to the final sessions, AHA 2020 made it a point to bring these conversations to the forefront to impact change. At the end of these 5 days, I feel re-invigorated and optimistic that our actions moving will speak louder than our words. Here’s to hoping we can meet again in person at next year’s Scientific Sessions.

“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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Developing Your Career as an Academic Physician

For all early-career physicians out there, I am sure you were not only looking for the latest in science at AHA 2020 but also some guidance on career development, and the session “Developing your Career as an Academic Physician” was just perfect.  Here I will review some of the fantastic talks from this session.

It started with “Pearls for Becoming an Academic Leader” by Dr. Jennifer S. Lawton, chief cardiac surgery at Johns Hopkins University, and offered the perfect blend of inspiration, encouragement, and advice on being an academic leader. I am sharing some pearls from this talk:

  • DECIDE: Decide if leadership is right for you and why you want to be a leader?
  • PREPARE: Prepare to be a leader (leadership books/courses), gain experience (program director, lab director, multidisciplinary teams, write protocols for your institution), learn time management for different roles (clinical, academic, leadership, mentorship), and build your credibility.
  • COMMUNICATE: Keep your CV updated and make it available at a moment’s notice and be ready to articulate your 5 and 10-year goals.
  • ATTACH: Attach yourself to mentors and learn from their success/failures and seek their advice regularly. Find sponsors who can open doors for you.
  • 70/20/10 Rule: Being an academic leader is 70% on the job training, 20% is learned from mentors/sponsors and 10% is formal leadership training.

The follow-up amazing talk was “What Really is Work-Life Balance” by Dr. Sasha Shillcutt, Tenured Professor of Anesthesiology at the University of Nebraska Medical Center. Loss of control over work is an important reason for burnout and this talk really re-framed my concept of Work-Life balance as it emphasized the concept that we are in the “driver’s seat” of our career. Two main concepts that were presented are:

  • Time Management Traps & Myths: Learn to say “No” to tasks that no longer interest you and success is directly linked to saying no.
  • Set Boundaries: Successful health care workers set boundaries that are intentional, efficient, and healthy. It takes practice and planning to set boundaries but they make your life easy.

“Maintaining Clinical Skills While Working in the Lab” is a challenge faced by physician-scientists and Dr. Emily MacKay from the University of Pennsylvania discussed some remarkable strategies for this.

  • Cognitive Reframing: The idea is to reframe your perspective about a challenge into an opportunity while the objective facts of the situation remain the same. For researchers that spend most of their time in the lab, make the most of your clinical time and develop “deliberate practice” where the focus is on quality, attention to detail, mindful and purposeful performance of procedures.
  • Context Switching: If you hit roadblocks with one problem where the solutions are not obvious you can physically distance yourself from the problem, and then come back to it later and this will help you find a solution.
  • Handling Commitment: Using the Eisenhower matrix to identify tasks that are urgent and important and need to be handled quickly vs tasks are urgent but not important and can be delegated or tasks that are important but not urgent and can be scheduled.

I will encourage all early careers to watch this session and take notes as it is full of pearls for career development.

 

“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.”