AHA20

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A Resident in a Virtual Sea of Cardiology: My #AHA20 experience

Andi Shahu, MD, MHS

As a current Internal Medicine resident and one of the youngest members of this year’s class of AHA Early Career Bloggers, my #AHA20 experience was equal parts thrilling, educational, and overwhelming. This was my first time attending the AHA Scientific Sessions and my second virtual conference experience after this year’s QCOR 2020 Scientific Sessions.

On a personal level, although it was convenient to virtually attend from my couch or work rather than fly across the country, I found it challenging to balance my time attending the conference with my clinical work: I was rotating on the Medical ICU at the time and was on call at times during the conference. Nevertheless, the more affordable and virtual nature of the conference and the ability to view sessions that I missed on-demand felt more inclusive to me. I also really appreciated the number of sessions dedicated to early-career trainees and attendings.

It was difficult at times to keep up with a large number of sessions or choose from the rich diversity of options, but overall I loved that there was a little something for everyone. I particularly enjoyed sessions about current state of care for heart failure, controversial trials such as OMEMI, STRENGTH and exciting, ingeniously-designed trials like SAMSON, and the big topic of #AHA20, the intersection of COVID-19 and cardiovascular health.

Most strikingly, the fact that the conference was all-virtual allowed for greater democratization of the dissemination of cardiovascular knowledge. In addition to all the wonderful content supplied by the AHA, there existed in parallel an equally comprehensive and all-consuming universe of discussion on Twitter. I found myself partaking in quite a few amazing Tweetorials or Twitter discussions about different topics presented at #AHA20! Any presentation you could think of was further broken down into bite-sized pieces of information by numerous expert cardiologists in the field. You could ask any question, and a leading expert in that area who had also viewed the presentation could answer your question to help you better understand the topic! As a trainee, I thought this made it easier for me to engage with other conference attendees in a medium with which I, as a millennial, am very comfortable. I also thought that the continued reinforcement of takeaways from the conference via my Twitter news feed helped me retain more knowledge than I usually do after I leave a conference. Although there was a deluge of content to wade through, the ability to re-watch sessions or re-read discussions about them made it easier to reinforce my learning.

Attending #AHA20 virtually as a trainee and getting to engage in the incredible online discussions both during and after sessions on Twitter was a very enriching experience for me. The ability to interact online and in real-time with other trainees, fellows, and attendings around the world made me feel as though the whole experience was more equitable, democratic, and accessible to early-career attendees like me. Finally, most of all, it engendered in me an even greater excitement to begin my Cardiology training in July 2021 and to continue conducting research that I can hopefully present at future AHA meetings.

 

“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 Reflection on Prevention: Can a Holistic Approach to Prevention Include a Polypill?

Kyla Lara-Breitinger, MD

Does a polypill obviate the need for behavioral changes? Absolutely not. As a physician training in Cardiology, I spend a sizeable part of my time discussing achievable weekly nutritional goals with patients in addition to stressing the importance of medication adherence. I ask myself after watching the “Bending the Curve for CV Disease- Precision or Polypill,” would I recommend a pill that can treat both hypertension and hypercholesterolemia and decrease the risk for CV disease? Certainly, this would make medication adherence for our patients much simpler, especially with the combination of atenolol, ramipril, hydrochlorothiazide, and simvastatin into one pill.

The International Polycap Study (TIPS-3) presented by Drs. Prem Peis and Salim Yusuf was a double-blinded, randomized trial of more than 5,700 adult men and women at increased CV risk with an intervention of the once-daily polypill, aspirin, combination of both or placebo (see figure). Endpoints of CVD events included CV death, non-fatal stroke, non-fatal MI, heart failure, resuscitated cardiac arrest, or arterial revascularization.

To summarize the results, 5-year outcomes found that the polypill was superior to placebo in decreasing systolic blood pressure, LDL-C, and non-fatal CV events in mostly Southeast Asian participants.  Low-dose aspirin resulted in lower stroke risk and the additive effect of aspirin to the polypill had a higher reduction in nonfatal CV events when compared to the double placebo arm. The side effects of the intervention group included dizziness and hypotension.

 As I return back to clinical responsibilities, I reflect on the AHA Scientific Sessions with particular attention to this polypill. Would you recommend a pill that was cost-effective that decreased pill-burden in your patient? I think I would but not at the cost of leaving behind crucial behavior changes that are integral for health and well-being.

More importantly, the following slide resonated with me the most and I believe conceptualizes a comprehensive framework for prevention and precision medicine:

The takeaways here are that there is a continuum of care across a spectrum of healthy, at risk, and diseased patients we see on a daily basis. Each group in this spectrum requires an individualized, community, and health system approach to intervention and implementation of decreasing cardiovascular risk. The domains needing to be addressed are part of a long list but each important in their own right:

Health Literacy

Health System

Health Policy

Socio-Behavioral Sciences

Human Resource Training

Health Economics

Technological Innovations

Media and Communication

Monitoring and Evaluation

With this framework in mind, I challenge myself and you all to think more deeply about how we might integrate universal standards along with individually-tailored preventative interventions when managing our patients. Our day-to-day clinic experience can at times lull us into the feeling of an unchanging routine, however this presentation was a great reminder of future opportunities to probe further to apply novel universal approaches while also seeking to understand individual patients’ health behavior needs and pushing individualized medicine further in the domain of CV prevention. This will be accomplished through quality care projects, educational work, health equity advocacy, and investigative research.

Take care and be well.

References:

https://www.nejm.org/doi/full/10.1056/NEJMoa2028220

“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 Sweet Spot in Treatment of Heart Failure With Reduced Ejection Fraction: SGLT2 Inhibitors

Sasha Prisco, MD, PhD

I am pleased to have the opportunity to summarize an important recent paper on the use of sodium-glucose co-transporter 2 (SGLT2) inhibitors by Drs. Muthiah Vaduganathan, Gregg Fonarow, and colleagues in JAMA Cardiology,1 that was published simultaneously with AHA20.

Background:

SGLT2 inhibitors are a class of medications that were initially developed for management of diabetes but were serendipitously found to be effective in treating individuals with heart failure. In May 2020, dapagliflozin became the first SGLT2 inhibitor approved by the US Food and Drug Administration (FDA) for use in patients with heart failure with reduced ejection fraction (HFrEF) after the pivotal Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF) trial, which showed that dapagliflozin reduced heart failure events and mortality.2 In the EMPEROR-Reduced (EMPagliflozin outcomE tRial in Patients With chrOnic heaRt Failure With Reduced Ejection Fraction) trial, use of another SGLT2 inhibitor, empagliflozin, was also found to reduce risk of cardiovascular death and heart failure hospitalizations.3

Major Question Addressed in the Paper: What proportion of contemporary patients with HFrEF in the US are potentially eligible for initiation of dapagliflozin based on the FDA label?

Approach: The investigators studied patients with HFrEF (EF≤40%) who were in the AHA Get With The Guidelines-Heart Failure (GWTG-HF) registry. They assessed patients admitted between January 2014 to September 2019 at 529 sites (started with 586,580 patients). Patients were excluded if they had any of the following based on the FDA label for dapagliflozin: estimated glomerular filtration rate [eGFR]<30 mL/min/1.73 m2 at discharge, dialysis (either history of chronic dialysis or required dialysis during hospitalization), and/or type 1 diabetes. After excluding patients who met the aforementioned criteria and those who had missing discharge eGFR or vital signs, the primary study cohort consisted of 154,714 patients at 406 sites.

Major Results:

  • Of the 154,714 patients studied in the GWTG-HF registry, 125,497 (81.1%) were candidates for initiation of dapagliflozin based on the FDA label.
  • When only looking at sites with ≥10 hospitalizations (355 sites that enrolled 154,522 patients), the median proportion of dapagliflozin candidates was still 81.1% (25th-75th percentiles 77.8-84.6%).
  • A higher proportion of patients without type 2 diabetes than with type 2 diabetes were candidates for dapagliflozin (85.5% vs. 75.6%).
  • The most frequent reason for not meeting the FDA label was eGFR<30 mL/min/1.73 m2, which was met more frequently in patients with a history of or new diagnosis of diabetes than those without diabetes (23.9% vs. 14.3%).
  • There was lower use of evidence-based heart failure therapies in the GWTG-HF patients compared to patients in the DAPA-HF trial.

Histogram from Vaduganathan et al. evaluating the proportion of patients meeting the dapagliflozin FDA label criteria from hospitals with at least 10 eligible HFrEF hospitalizations.

Major Study Limitations: Since the GWTG-HF data are de-identified, only unique hospitalization episodes were presented so some patients may be represented more than once in this study. Glycated hemoglobin levels were not measured in a protocolized way, thus type 2 diabetes could be underdiagnosed in this study. Data regarding post-discharge labs and the use of therapies were not available.

Key Take Home Message: This study using a large AHA registry (GWTG-HF) strikingly found that 4 out of 5 adults with HFrEF (regardless of whether the patient has type 2 diabetes) may be eligible for initiation of dapagliflozin, supporting the broad applicability of this therapy in US clinical practice.

For further learning, there are several great OnDemand sessions from AHA20 on SGLT2 inhibitors.

AHA20 OnDemand Sessions on SGLT-2 inhibitors:

  • New Glucose-Lowering Agents with CV Benefits: Working… But How?
  • SGLT2i for Non-Diabetic Indications: Updates from Mega-Trials and Mechanistic Insights
  • Novel Anti-Diabetic Agents: A Tidal Wave of Change in the Cardiovascular Care of Patients with CKD
  • The Heart, the Kidney, and SGLT2 Inhibition: For Clinical Trials to Patient Care

Potential Future Research Directions:

  • Determine the mechanisms leading to the efficacy of SGLT2 inhibitors in HFrEF.
  • Investigate the renal effects of SGLT2 inhibitors and whether SGLT2 inhibitors can be safely used in patients with more severe chronic kidney disease.
    • DAPA-CKD4 (Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease), which included patients with eGFR as low as 25 mL/min/1.73 m2, showed that dapagliflozin reduced risk of sustained eGFR decline of at least 50%, end-stage kidney disease, or death from renal or cardiovascular causes regardless of the presence or absence of type 2 diabetes.
    • EMPEROR-Reduced included HFrEF patients with eGFR as low as 20 mL/min/1.73 m2.
  • Evaluate whether SGLT2 inhibitors are beneficial in patients with heart failure with preserved ejection fraction (HFpEF). Current ongoing/future clinical trials with HFpEF patients include DELIVER (NCT03619213), EMPEROR-Preserved (NCT03057951), EMPA-HEART 2 (NCT04461041), PRESERVED-HF (NCT03030235), and EMBRACE-HF (NCT03030222).
  • Assess the effects of simultaneous use of SGLT2 inhibitors and another class of diabetic medications that have shown beneficial cardiovascular disease (CVD) effects, glucagon-like peptide-1 receptor agonists (GLP-1RA) and determine which of these two classes of medications should be prioritized in drug-naïve patients with type 2 diabetes and atherosclerotic cardiovascular disease (ASCVD).

Potential mechanisms underlying the beneficial effects of SGLT2 inhibitors. Figure from Dr. Subodh Verma’s talk entitled “SGLT2 inhibitors: Why do they work” in the “New Glucose-Lowering Agents with CV Benefits: Working… But How?” session at AHA20.

 

References

  1. Vaduganathan M, Greene SJ, Zhang S, Grau-Sepulveda M, DeVore AD, Butler J, Heidenreich PA, Huang JC, Kittleson MM, Joynt Maddox KE, McDermott JJ, Owens AT, Peterson PN, Solomon SD, Vardeny O, Yancy CW, Fonarow GC. Applicability of us food and drug administration labeling for dapagliflozin to patients with heart failure with reduced ejection fraction in us clinical practice: The get with the guidelines-heart failure (gwtg-hf) registry. JAMA Cardiol. 2020
  2. McMurray JJV, Solomon SD, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA, Ponikowski P, Sabatine MS, Anand IS, Bělohlávek J, Böhm M, Chiang CE, Chopra VK, de Boer RA, Desai AS, Diez M, Drozdz J, Dukát A, Ge J, Howlett JG, Katova T, Kitakaze M, Ljungman CEA, Merkely B, Nicolau JC, O’Meara E, Petrie MC, Vinh PN, Schou M, Tereshchenko S, Verma S, Held C, DeMets DL, Docherty KF, Jhund PS, Bengtsson O, Sjöstrand M, Langkilde AM, Investigators D-HTCa. Dapagliflozin in patients with heart failure and reduced ejection fraction. N Engl J Med. 2019;381:1995-2008
  3. Packer M, Anker SD, Butler J, Filippatos G, Pocock SJ, Carson P, Januzzi J, Verma S, Tsutsui H, Brueckmann M, Jamal W, Kimura K, Schnee J, Zeller C, Cotton D, Bocchi E, Böhm M, Choi DJ, Chopra V, Chuquiure E, Giannetti N, Janssens S, Zhang J, Gonzalez Juanatey JR, Kaul S, Brunner-La Rocca HP, Merkely B, Nicholls SJ, Perrone S, Pina I, Ponikowski P, Sattar N, Senni M, Seronde MF, Spinar J, Squire I, Taddei S, Wanner C, Zannad F, Investigators E-RT. Cardiovascular and renal outcomes with empagliflozin in heart failure. N Engl J Med. 2020;383:1413-1424
  4. Heerspink HJL, Stefánsson BV, Correa-Rotter R, Chertow GM, Greene T, Hou FF, Mann JFE, McMurray JJV, Lindberg M, Rossing P, Sjöström CD, Toto RD, Langkilde AM, Wheeler DC, Investigators D-CTCa. Dapagliflozin in patients with chronic kidney disease. N Engl J Med. 2020;383:1436-1446

 

“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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Reflections and Projections: An Interview Post a Virtual Conference

Mo Al-Khalaf, PhD

As many of us know and have experienced by now, the 2020 global pandemic has forced most conferences to cancel, postpone, or alter their planned in-person settings. For meetings that opted to switch these important gatherings to a brand new all-virtual format, many challenges were faced, but also new opportunities to re-invent the conference experience have sprouted. In my personal perspective, I continued to see rapid evolution and advancement of the virtual format setting of such meetings, from the early days of the pandemic in the spring to the most recent conference I participated in, which just happens to be the biggest meeting in the cardiovascular field, the American Heart Association Scientific Sessions. Earlier, I wrote a couple of blogs describing my experience at #AHA20 (you can read them here: “The Year #Virtual became #Reality”, and “Lurking: The Art of Passive Learning in Meetings”)

Today though, instead of my thoughts, I wanted to interview someone that has even more insight and know-how with AHA meetings, and therefore can really speak to the differences (and opportunities) that make this year a unique conference experience. My guest for this post-conference interview is Dr. Sean Wu, MD. PhD., a physician-scientist at the Stanford Cardiovascular Institute, and the Institute for Stem Cell Biology and Regenerative Medicine at Stanford University School of Medicine. He is also the current Chair of the Basic Cardiovascular Sciences (BCVS) Early Career Committee, and a long time active member of the AHA and BCVS council. Sean and I work together within the BCVS community, and we’re both big fans of using social media to communicate science, and promote networking (you can follow Sean on Twitter here, and the BCVS Early Career Committee here).

This transcript is a lightly edited version of the interview we conducted on webcam, shortly after the end of #AHA20.

Mo: Let’s start with a big-picture view of the meeting. Could you tell us how the overall experience was like in your viewpoint, given that this year’s #AHA20 was a virtual conference?

Sean: The AHA meeting has given us a taste for what’s to come in the future. Clearly many have seen positives from this format: easy tracking and joining of sessions; rewatch or catch-up of missed sessions; ease of asking questions using chat boxes instead of physically asking questions on the mic in a room. However, certainly, there is a reduction in the networking potential, but continued innovation and offering of social networking sessions, such as BCVS Early Career Social at #AHA20, can replace some of those missed opportunities.

Mo: Share with us one of the sessions that most interest you at #AHA20, and tell us a little bit about why it was a highlight for you?

Sean: There were so many great sessions, it is hard to pick just one of course. Certainly, a session that garnered attention and featured a lot of the up-and-coming areas of science was called “Cardio-Oncology, Meet Your New Neighbour: Immunology”. This session was a highlight for many reasons, such as the ability to combine multiple disciplines such as cancer disease and therapy, cardiovascular disease and research, as well as the fundamental mechanisms of immunology that tie these diseases and require novel research approaches and future therapy options.

Mo: Considering the format change in 2020, conference planning and attending has gone through a lot of innovative changes. What role do you see social media playing in complementing the experiences of a virtual setting meeting?

Sean: Definitely social media has changed multiple aspects within our scientific community. On social media, the democratic stage allows voices from all levels of the community to interact and discuss openly just published research being shared online. Discussions spark and propel future research avenues. When it comes to the virtual format of conferences presently, social media chats, specific hashtags, and the resulting impressions and other metrics have increased significantly compared to previous years, continuing the upward slope of gain that social media involvement has in the scientific communities that populate it.

Mo: Some of the advantages of virtual meetings include ease of access, lower financial commitments, and increased diversity of participants. Would you say these advantages are enough for you to recommend this experience to trainees and early career professionals?

Sean: At the present moment, and in a future where virtual conferences are the only options, the recommendation is for sure to join in and participate, because the knowledge gained and evolving networking avenues are still very relevant and important to have, This is especially vital at the trainee and early career level in science, which typically has limited potential for interaction outside the requirements of pushing research forward. Additionally the ability to have more global participation in meetings that can bring scientists that otherwise would have been too geographically far, and/or face financial difficulty to make it to the meeting, for them to be part of the gathering is a definite advantage of virtual meeting formats.

Mo: In your viewpoint, what are some of the high-value components to add when a conference planning committee is set to organize a future science meeting?

Sean: One of the most important aspects of science meetings is promoting networking opportunities, especially for the early-career scientists attending those meetings. These types of networking sessions can be designed as mixers/socials, or more structured mentoring/advice panel discussions. These sessions are extremely valuable components of a scientific meeting. Another type of session that would be very beneficial to have is something designed to illustrate or highlight “New Frontiers” or new advances in the field. This is one of the most anticipated aspects of a meeting, where scientists get exposed to novel tools, new scientific approaches, and integration of the latest technology into one’s area of research.

I’d like to thank Dr. Sean Wu for sharing his memories (reflections) and future thoughts (projections), stemming from the recent conclusion of #AHA20. In science and medicine, as is with so many other fields, we continue to adapt to the changing landscape of our professional careers. Virtual meetings were new to us in 2020, but with continued innovation and trial, we will integrate this novel approach and utilize it to continue advancing our fields.

 

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

Aaysha Cader, MD, MRCP

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?

Noora Alhajri, MD, MPH

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

Kyla Lara-Breitinger, MD

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!

Andi Shahu, MD, MHS

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”

Patrick Tomko

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

Mo Al-Khalaf, PhD

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.”