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The New Phase of the Prevention Pyramid–the Primordial Prevention

You are what your mother eats: launch a new generation into a lifetime of ideal cardiovascular health

––#AHA21 Recap from presidential lecture by Dr. Don Lloyd-Jones, AHA President

My PhD research was focused on maternal nutrition and epigenetics. When I started graduate school, the field of epigenetics just started to make some splash in the scientific community. As a new graduate student, I have a plethora of questions. What is epigenetics? Why should I care to study it? How does that have anything to do with nutrition? You are what your mother ate. The food your mother had during pregnancy and lactation can forever change your health through epigenetic regulation (without changes in your genetic makeup). This became my passion, to understand how maternal nutrition affects offspring and how to promote healthy life from the beginning of everything.

At 2021 scientific sessions of American Heart Association (AHA), Dr. Don Lloyd-Jones gave an inspirational speech about the next phase of the Prevention Pyramid–the Primordial Prevention (Fig.1). The previous Prevention Pyramid contains three segments which were chronically progressed: Tertiary Prevention,

Secondary Prevention, and Primary Prevention. With the development of medical devices and acute therapy, the Tertiary Prevention helped in-hospital mortality rate drop from more than 30% to less than 5%. The Secondary Prevention applies discharge therapies and significantly reduces the recurrent incidences of cardiovascular diseases (CVD) events. The current strategy to fight CVD is through reducing incidences via targeting risk factors, called the Primary Prevention. Starting from the Framingham Heart Study, many important risk factors of CVD such as age, blood cholesterol level, blood pressure, smoking status have been identified. The previous Prevention pyramid made a big success in terms of CVD prevention until 2011. Then the progress curve starts to show stagnation, partly because of obesity epidemics sequelae and widening social-economics disparities.

With the help of pioneer research from Dr. Jeremiah Stamler from Northwestern University, modern CVD studies start to shift focus to study healthy people for low risk factor identification. AHA developed criteria, “Life’s simple 7TM” , defining ideal cardiovascular health (CVH): stop smoking, eat better, get active, lose weight, manage blood pressure, control cholesterol, and reduce blood sugar1. High CVH is associate with better CVD events prevention, the CVH trajectories from childhood are set as early as the 3rd grade2. Current research showed that women with ideal maternal gestational CVH is 8+ times more likely to have offspring with ideal CVH 10 years later3. The importance of Primordial Prevention is unignorable. From the latest discoveries of epigenetics studies, results suggest that not only mother’s CVH can affect babies’ CVH, father’s CVH could potentially possess certain influences as well4.

“No man is an island”, as John Donne wrote. Social determinants of health can affect 80% to 90% of a person’s risk factors (Fig. 2). To promote a better CVH for the whole community, AHA relentlessly aims to drive a more equitable health impact to the society. “Let’s do this for all the children in our life”, as Dr. Lloyd-Jones concluded, AHA is dedicating funding for more research studies to guide us towards an exciting phase of CVD prevention, the Primordial Prevention in the foreseeable future.

REFERENCES

  1. Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L, Greenlund K, Daniels S, Nichol G, Tomaselli GF, Arnett DK, Fonarow GC, Ho PM, Lauer MS, Masoudi FA, et al. Defining and Setting National Goals for Cardiovascular Health Promotion and Disease Reduction. Circulation. 2010;121(4):586–613.
  2. Allen NB, Krefman AE, Labarthe D, Greenland P, Juonala M, Kähönen M, Lehtimäki T, Day RS, Bazzano LA, Van Horn L V, Liu L, Alonso CF, Webber LS, Pahkala K, Laitinen TT, et al. Cardiovascular Health Trajectories From Childhood Through Middle Age and Their Association With Subclinical Atherosclerosis. JAMA Cardiology. 2020;5(5):557–566.
  3. Perak AM, Lancki N, Kuang A, Labarthe DR, Allen NB, Shah SH, Lowe LP, Grobman WA, Lawrence JM, Lloyd-Jones DM, Lowe Jr WL, Scholtens DM, Group HF-USCR. Associations of Maternal Cardiovascular Health in Pregnancy With Offspring Cardiovascular Health in Early Adolescence. JAMA. 2021;325(7):658–668.
  4. Hughes V. Epigenetics: The sins of the father. Nature. 2014;507(7490):22–24.

“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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Keeping a Pulse on Cardiovascular Health: AHA 2021 Scientific Sessions

Before I joined the AHA 2021 Scientific Sessions, I was not sure what to expect from this virtual conference. The COVID-19 pandemic caused a pivot towards virtual events and remote discussion. With every virtual event is the concern of a poor audio or internet connection, or less than smooth transitions between speakers which distract from the content. However, the conference lacked these technical faux paus, and was a great experience. There was so much opportunity to learn about emerging research, and hear from leaders in cardiovascular health. The sessions focused on the future, improving health outcomes and preparing early career professionals. There was significant acknowledgement of the impact of the COVID-19 pandemic on health outcomes and disparities, and implications for the future through the lens of cardiovascular health. What stood out was not only the depth of insight among the speakers and transformative research, but the dynamic conversations and presentations.

As a spectator of these sessions, I was struck by the emphasis on career building and the angles in which this can be addressed and improved upon. Utilization of social media and networking were emphasized as methods to both reach the public and support collaboration. Cardiovascular experts and researchers divulged their best methods for moving forward with research and clinical practice.

I was also inspired by the work of award recipients, such as the Distinguished Achievement Awards and the Early Career Abstract Awards. As an individual in my early career, the experience of the recipients encouraged me to explore unique areas of my own research and delve into projects focused on improving clinical care.

Overall, the AHA 2021 Scientific Sessions were informative, intriguing and motivating. I look forward to future AHA conferences and hope that my career will take me on a similar path to the impressive speakers highlighted during the events.

 

“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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Reaction of AHA Scientific Sessions 2021

This was my second time participating in AHA Scientific Sessions. Unlike previous years, I served as an AHA Early Career Blogger to livestream the conference on social media. Together with nearly 20 other bloggers, we created hundreds of tweets to keep the world engaged with AHA events and talks. For me, it was also a great opportunity to network and seek new collaborations. During the conference, I met over 50 clinicians and scientists who shared similar research interests and scientific passions with me. We have already set up plans to further discuss our thoughts to put our ideas into practice.

Supported by my AHA Postdoctoral Fellowship, I presented my abstract on novel stroke imaging to identify high-risk patients before a stroke happens. It is amazing to see the increasing number of early career investigators tackling the challenge of cardiovascular and cerebrovascular diseases. A larger number of them have been also funded by AHA grants and fellowships. A lot of shared the positive influence of receiving research support from AHA and how the award propelled their career development. We encouraged all trainees to apply for the numerous grants and fellowships that AHA offers.

Another highlight of this year’s conference was the international components where speakers from Europe and Asia demonstrated their amazing work virtually. For example, a joint event was held in collaboration with the Japanese Circulation Society (JCS) on the first day of the conference. Colleagues from Japan demonstrated their wonderful research and clinical practice to improve patient care for cardiovascular and cerebrovascular diseases. Like all the other sessions, there was so little time for all the conversations. Everybody is looking forward to an in-person event in 2022.

“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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Highly Effective Scientists: Leading an effective research lab

AHA Scientific Sessions 2021 was an exciting event with many educational opportunities to gain career development strategies to increase scientists’ productivity and effectiveness at work and in life. As an early career scientist, I often wonder how some of my colleagues, both early career and more seasoned investigators, can be so successful in their ability to publish papers or receive grants while maintaining a perfect balance with their personal lives. In a fantastic session titled “Strategies for Career Success by Highly Effective Scientists”, panelists, including Dr. Elizabeth McNally, Dr. Pilar Alcaide, Dr. Jil C. Tardiff, and Dr. Pradeep Natarajan, shared and discussed strategies that highly effective scientists use to increase efficiencies at work and at home to maximize productivity. This session offered a broad overview of strategies for early career scientists. However, in this first installment, I will present my perspective on leading an effective research lab, which applies to early career investigators (ECIs) in transition periods in their careers. I have detailed several guiding tips towards leading a successful research lab in the following.

 

Leading an effective team

For many transitioning from a graduate or postdoc role to their first academic appointment, the idea of launching your own lab can bring both feelings of excitement and uncertainty. We know there are many possibilities for success. Still, the path to a well-functioning and healthy lab can be overwhelming. Here are some tips on planning ahead and moving forward with your lab even when resources run low:

 

Make the most of your resources: Regardless of the resources that may have been available in your lab in graduate school or as a postdoc, opportunities afforded to you in your new environment may be very different, and your expectations may need adjustment. Importantly, before jumping in your work with a team, familiarize yourself with the elements in your new environment that mirror your previous setting and the factors that may challenge the work you intend to do. For instance, your start-up package may not allow you to recruit graduate students or postdocs, but you may find an excited group of undergraduates who may be ready to work with you. Importantly, you should move forward with the resources at your immediate use. Additionally, you may be able to position yourself with new colleagues and their labs to borrow equipment or tools that can help offset your limitations and avoid significant delays in building your lab and moving analyses forward. Finally, remember that both you and your students are on a clock; moving forward with available resources will ensure the success of all parties in your lab.

 

Recruiting: Choosing the best team will depend on the project’s needs and available resources. With each candidate, carefully read their resume/CV to access their availability timeline, degrees attained, and grades in relevant subjects. At every step of the recruitment process, foster diversity and inclusion to gain the best candidate who can offer a wide range of skills and experiences that can inform the team’s work. References are helpful but limited as the environments that may have garnered success or failure for the candidate in one group may differ in the next. Also, assess the candidate’s strengths and weaknesses, keeping in mind the projects that may be a good fit for the candidate. You may also want to include your team in the interview process with a new candidate and gain oral feedback on how they see the individual fitting with the project needs and the lab culture. Finally, even if a candidate accepts the position, try not to consider the person recruited until they arrive for their first shift. It’s not uncommon for candidates to show enthusiasm at the interview stage but fail to come to start the work. You will also want to be mindful that the first three months of work is a trial period where the new recruit will acclimate to the lab and demonstrate the quality of their work, which may or may not need to be adjusted to the expectations of the lab. This period is an excellent opportunity to learn more about the candidate’s skills and personality, perspectives, how quickly they overcome learning curves and establish fit within the group.

 

Avoid decision paralysis and get moving: Realistically, a mountain of decisions need to be made when starting a lab. New faculty are thrust into many firsts: first projects, first lab members, first major purchases, etc. Feeling completely unprepared at this level of independent responsibility is the norm. Regardless, the sheer number of decisions can be paralyzing, especially when combined with perfectionist personalities, common among scientists. In a letter to young scientists at Science.org, Somerville et al. recommend that ECIs just need to start doing something to overcome decision paralysis. It is the only way for the lab trainees and its leader to get moving. Additionally, in those moments of doing, you can build realistic expectations about the actual needs of your research and the team and what is feasible to be conducted in a given period. The lab will feel most successful when expectations are checked, and outcomes are realistic.

 

Setting your lab culture: The most successful labs are a product of the brilliant minds that share membership. Importantly, successful labs share a common understanding of how they can be an environment that will generate positive training experiences for all and productivity. Through shared vision and expectations, lab members are made to feel like they belong, that their work is valued, have a sense of autonomy, and know how to succeed. You may have had the opportunity to work with several labs before becoming independent, or you may only know one lab family. Whatever the experience, it is likely there were scenarios where things worked extremely well – you gained hands-on training, communication was well established, feedback on performance was constructive, you felt that your efforts lead to presentations or publications that would support your career advancement — and other experiences that could have used improvement. Drawing on your past experience can help define how you want to manage your lab and the expectations that your trainees expect from each other and you for overall success. At Nature.com, Hagerty et al. wrote about setting clear lab expectations. These could be a lab manual with values and daily expectations or periodic lab meetings discussing lab culture. Topics like socialization, conflict resolution, and inclusions can be presented with a plan for how expectations can be manifested daily. Setting the tone of lab culture should be deliberate and can build on your own experiences. As the leader, you should make your aspirations clear and be a regular example of your team’s expectations. Additionally, with regular assessments, you will notice what works and what doesn’t. You can revise your lab manual and adjust your culture with the inclusion of your team. Dr. McNally also provided some other excellent tips for growing a healthy lab:

Take care of yourself: Last but certainly not least, it’s important to state that while a lab can definitely run on its own (especially if established well), the lab leader must also set means for self-care and feedback. ECIs should utilize their own advisors/mentors to discuss the progress and nature of their labs and do so regularly. You should also engage with colleagues or other individuals outside the lab to discuss problems that may arise and have an external perspective on resolving issues. When something does go wrong, give yourself a break from the situation and allow the matter to breathe and dissipate before coming to firm solutions. Sometimes, firing people will have to happen, and it’s ok to recognize that it is a difficult decision to make. Remember that even as a leader, you are human and have emotions in many of your investments, especially your research lab. Finally, learning to say “No” to opportunities that may overextend or add little benefit to your team and yourself may be the best solution to maintain a healthy and well-functioning research lab.

 

I hope you found these guides useful for planning and building your future research lab. Perhaps these tips helped improve your current lab. Next time, I will touch on another valuable topic to ECIs and their success.

References:

https://www.science.org/content/article/three-keys-launching-your-own-lab

https://www.nature.com/articles/d41586-018-07383-0

“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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AHA Scientific Session 2021: Updates in Stroke: Careers & Future Directions in Vascular Neurology

Panelists: Drs. Anjail Sharrief, Ashutosh Jadhav, Louise McCullough, Alicia Zha. Moderator: Dr. Lauren Fournier

The session kickstarted by highlighting the duration of neurology training and the timeline to consider a career path and why is it important to do a fellowship? In current times, there is rapid growth in the field of medicine, with this, there is an increase demand to have specialists and hence choosing a fellowship is important. This session discussed extensively about a career in Vascular Neurology, comprising of panelists with different yet similar background in the field of vascular neurology. There was a shocking revelation in the dearth of vascular neurologists as compared to our counterparts, cardiologists. The graduate ratio of stroke neurologist to that of cardiologist is ~1:10, however, the disease burden is not proportionate. A part of this could be attributed to the amount of exposure we get in acute stroke management during our training and hence can be inclined towards either an inpatient or outpatient setting without a formal fellowship, but wait… there is more to it; The panelists gave us an insight into post stroke care and management, which is also equally important and we don’t follow in the post discharge period. And that’s when fellowship becomes important as it gives your patient a continuity of care at a community level.

There is more to it than just the title of a vascular neurologist; There are various aspects of stroke care that we can dive into such as health equity in stroke patients, stroke in young, stroke in women to name a few. The newly evolving field of telemedicine/ tele stroke has become an important aspect of our day-to-day practices and is rapidly changing how patient care can be delivered in an effective and efficient manner. When does this become important, as Dr. Jadhav gave an instance, flying a patient from 45 minutes away and treating them acutely doesn’t end there, as a stroke neurologist, you have an added advantage of following this patient when discharged to the community especially if there is lack of a stroke neurologist with the gift of tele-medicine and training to ensure secondary care. Drs. Sahrrief and Zhao spoke about the importance of training and practicing telemedicine to stay continually in touch with the patients and communities for their betterment and managing secondary stroke prevention by providing close follow-ups, assessing with social work needs etc. As this form of medicine is becoming more popular and is now being incorporated into ACGME curriculum, it is important to look if the fellowship program can ensure proper training as this can teach us early on to triage patients and manage their care.

Neurointerventional radiology has been steadily gaining momentum in recent times as more trainees from a neurology background are interested in pursuing a career in this field. A summary of the field of neurointerventional radiology including the different training pathways and what is the formula for a successful match was made by Dr. Jadhav. Having addressed this, the panelists stressed the importance of picking a specialty that you are passionate about as this will eventually make the journey worth it.

A topic that most of us want to know and be a part of, RESEARCH. Research in one form or the other is part of our training, the question is, how do we make the most out of this and keep it consistent? Having a research foundation early on in training is important, but what brings this foundation together? The right mentor and environment are of utmost important when you are a novice. As trainees, we can start by familiarizing with clinical research methods, clinical trials, interpreting articles and carry these lessons to further build on in fellowship programs. There are multiple online resources which can help us achieve this, one such example is through AHA which offer courses on epidemiology.

Dr. McCullough discussed, Mobile Stroke Unit, and how it is changing the phase of acute stroke management in the pre-hospital setting and studies are currently looking into cost effectiveness. Stay tuned as more updates will be presented at International Stroke Conference!!!

The panelists then discussed, the “happening lytic”, TNK, and its future in acute stroke therapy.

The closing discussion was a question which we have all had at some point in our career, what are the ways to ensure a smooth transition after training; Some important take away points included, if looking for an academic opportunity, how is your support system and resources. In general, it is to understand your worth, negotiating time and money, protected time for your academic interests. The first 3-5 years in any setting is very crucial in establishing yourself and knowing how you want to shape your career. Nobody is a 100% certain, you need to have an open mind and work with the flow. It’s good to keep in mind that there is no perfect job and the trick is to learn to evolve and carve the niche for ourselves.

“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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Social Media Advice for Early and Mid-Career Professionals from #AHA21

The schedule of events as a first-time attendee to AHA Scientific Sessions can be overwhelming! As an early career blogger, I decided to attend sessions to get advice from professionals on managing social media presence in “Social Media in Cardiology- Managing Misinformation as Fellows in Training”. It was reassuring to take part in a lively discussion with many participants asking questions ranging from, “How do I start developing my social media presence” to “How do I deal with mansplaining?” We were lucky enough to have experienced panelist give their insights.

There are many benefits to taking part in social media as an early career professional. It can be used as a platform to find role models and mentorship or start project and publication collaborations. These connections can be established by simply joining broad dialogues, tagging experts in a conversation, or sending a direct message to interesting people. Establishing a social media persona can also include creating a place to ask questions, sharing expert consensus, and guiding dialogue in a specific discipline. As field experts and early career scientists, we are uniquely positioned to gather cutting edge information and share our knowledge with broader audiences. In order to be successful in these endeavors, choose your social media platform carefully. Understanding the age-group audience predominating that specific platform can inform the type of content you decide to post and will influence how you frame your ideas.

While participating in an environment that is not curated can allow you the freedom of sharing pictures of your dogs along with scientific news, panel experts also reminded us that everything on social media lives forever. The downsides of social media include hostility, mansplaining, and being discredited and turned into a meme. Not everything you post can be edited, and typos can be an annoyance for yourself and others when conversations are picking up speed. However, when your post turns out to be factually wrong or misguided, a public apology might ensue. Being transparent about how you gathered information and why you are sharing it with others can help establish and maintain trust in quickly developing online discussions.

Things can also get tricky when dealing with misinformation or with patients asking for medical advice. Many patients seek to educate themselves by seeking information online, and practitioners have a responsibility to educate and be effective leaders in this online space. In fact, social media training is becoming a desirable and valuable skills set for many early and mid-career professionals. Professionals can use social media to spread scientific evidence for the greater good but will also need to develop an approach for responding to misinformation. When engaging in difficult conversations, be explicit about the limits of what you are offering and avoid driving more traffic to misinformation pages. Be cautious when engaging with misinformation posts; give others the benefit of the doubt but stay concise in your responses and only provide the correct information. If you are unable to engage in a meaningful discourse you can move on, or if you are so inclined you can call out, block, ignore, or mute hostile people. There is a balance between the benefits you gain from social media and the time you spend online. Overall, to make social media a positive part of your career, make sure to set boundaries, build trust, and be accurate about what you post. Social media can be an effective way to build your professional persona, make meaningful connections, and communicate science if you develop the right approach.

This program is part of the FIT Program at #AHA21.  The panelists Danielle Belardo MD, Amir Goyal MD MAS, Martha Gulati MD MS FAHA, Virginia Bartlett, and was moderated by Christina Rodrigues Ruiz, MS and Sasha Prisco MD, PhD.

“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 pursuit of Ideal cardiovascular health: It’s never too LATE! But the earlier, the better!

“Cardiovascular health after 10 years: What have we learned and what is the future” was my topic of choice from this year’s AHA21 main scientific sessions. It has been over 10 years since American heart Association (AHA) published a formal definition of cardiovascular health (CVH). In the last 10 years, more than 2,000 publications have tried to address the concept of CVH. AHA 2020 impact goal was to improve the CVH of ALL Americans by 20%, while reducing deaths from cardiovascular (CV) disease and stroke by 20%. Seven key health metrics were used to define CVH including: smoking status, physical activity, healthy diet, blood glucose level, blood cholesterol level, and blood pressure. Each metric was stratified into three statuses: poor, intermediate, and ideal. The initial approach was to improve individuals’ health from poor status into intermediate status and subsequently to ideal status and later promote and preserve ideal CVH through individual’s life(1).

In the last 10 years, many community-based cohort studies including Atherosclerosis Risk in Communities (ARIC), Multi-Ethnic Study of Atherosclerosis (MESA), Women’s Health Initiative (WHI), Coronary Artery Risk Development in Young Adults Study (CARDIA), and Cardiovascular Health Study (CHS) have investigated the association of CVH metric with CV outcomes. A meta-analysis of 13 studies showed that as the number of Ideal CVH metrics decrease the relative risk of all-cause mortality and CV mortality increase in a linear fashion(2). Moreover, studies have expanded the impact of CVH metrics on other chronic disease like cancer, chronic kidney disease, dementia, chronic obstructive pulmonary disease, and hip fracture(3).

Disappointingly, national data have shown that high CVH is uncommon. Only 7% of U.S. adult population meets the criteria for high CVH, 34% for moderate CHV and 59% for Low CVH group(4). It is estimated that 70% of CV events are attributable to low/moderate CVH and up to 2 million CV events can be prevented if all U.S. adults attained high CVH(5). This implies that potential impact of maintaining high CVH is substantial. The question is how early we should intervene to maintain high CVH.

Prevalence of ideal CVH decline significantly with age. In a study of pooled data from 5 community-based cohort, CVH trajectories were defined starting from age 8 to age 55. 5 unique trajectories have been identified. The prevalence was 30.7% for high rapid decline, 10.3% for intermediate rapid decline, 24.3% for high slow decline, 17.4% for intermediate stable and 17.3% for high stable trajectory(6). These trajectories showed that by age 8, already 20% of 8-year-old children do not have ideal CVH. Loss of ideal CVH metrics occurs at different rate across life span, but late adolescence seems to be a critical time where rapid CVH decline occurs. Moreover, analysis of baseline demographic characteristics by CVH trajectory showed that high stable trajectory is most common among white females and high rapid decline trajectory is most common among African American males. Finally, individuals with high stable trajectory were more likely to have ideal diet and physical activity compared to other CVH metrics at baseline (smoking, blood pressure, glucose, lipid level) suggesting that the best approach to maintain ideal CVH is through promoting healthy behavior.

References:

  1. Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic Impact Goal through 2020 and beyond. Circulation. 2010;121(4):586-613.
  2. Guo L, Zhang S. Association between ideal cardiovascular health metrics and risk of cardiovascular events or mortality: A meta-analysis of prospective studies. Clin Cardiol. 2017;40(12):1339-46.
  3. Ogunmoroti O, Allen NB, Cushman M, Michos ED, Rundek T, Rana JS, et al. Association Between Life’s Simple 7 and Noncardiovascular Disease: The Multi-Ethnic Study of Atherosclerosis. J Am Heart Assoc. 2016;5(10).
  4. Virani SS, Alonso A, Aparicio HJ, Benjamin EJ, Bittencourt MS, Callaway CW, et al. Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association. Circulation. 2021;143(8):e254-e743.
  5. Bundy JD, Zhu Z, Ning H, Zhong VW, Paluch AE, Wilkins JT, et al. Estimated Impact of Achieving Optimal Cardiovascular Health Among US Adults on Cardiovascular Disease Events. J Am Heart Assoc. 2021;10(7):e019681.
  6. Allen NB, Krefman AE, Labarthe D, Greenland P, Juonala M, Kahonen M, et al. Cardiovascular Health Trajectories From Childhood Through Middle Age and Their Association With Subclinical Atherosclerosis. JAMA Cardiol. 2020;5(5):557-66.

“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 Long Way from Home from Achieving Health Equity in Stroke: The Stroke Council Award Lecture in 2021

The American Heart Association (AHA) Stroke Council, one of the 16 councils within the AHA, is one of the largest councils within the organization. Amongst the awards it bestows at the major stroke-related conferences worldwide is the Stroke Council Award, a prestigious prize awarded to a single investigator at the AHA Scientific Sessions annually.1 Selection is made from amongst ‘those who actively work to integrate stroke and heart disease in clinical care, education or research’.1

This year, the award went to Dr. Bruce Ovbiagele, MD, MSc, MAS, MBA, MLS, FAAN, FAHA, who is a Professor of Neurology and an Associate Dean at the University of California, San Francisco.2 Dr. Ovbiagele has worked on stroke care for the underserved both in the US and in Sub-Saharan Africa and has >500 publications, >100,000 citations, and an h-index of >80.3  He has previously served as a member of the NIH-NINDS Advisory Council, Chair of the International Stroke Conference, Officer of the World Federation of Neurology, and is currently a part of of the FDA Peripheral & Central Nervous System Drugs Advisory Committee.2

Dr. Ovbiagele’s award lecture at the AHA (Session Number ST.AOS.380), titled ‘Different Strokes for Different Folks: Achieving a Higher Health Equity Say-Do Ratio’ focussed on the disparities in stroke burden and outcomes for different populations (Figure 1). Citing data from the AHA 2020 Update on Heart Disease and Stroke Statistics, Dr. Ovbiagele highlighted how African-Americans continue to have the highest stroke incidence and mortality rate of all communities, with African American men aged 45-54, for instance, having three times the mortality rate than their white counterparts.4 Dr. Ovbiagele stressed upon the widely reported and consistently poorer outcomes for women after stroke, coupled with the increased disability and lower quality of life.5 These disparities may have been further exacerbated by women having a lower likelihood of receiving thrombolysis.5,6,7

Figure 1

More than a decade ago, the AHA/ASA had put out a policy statement describing in clear terms how minority populations continue to receive suboptimal treatment for both primary and secondary stroke prevention strategies in comparison to whites.Health equity in stroke, however, seems to be a long way from home, with little progress reflected in the AHA 2021 Stroke Statistics Update, when put beside the AHA 2011 Update. Poorer outcomes for stroke continue to be pervasive globally, but even in high-income countries, the disparities between populations remain substantial. These disparities are evident at all levels, from stroke prevalence, first stroke incidence, stroke recurrence, to mortality.7,10

Summarizing the prevailing hypotheses (effect modification or differential impact, measurement errors, incomplete assessment, novel emerging factors) on why African Americans have an unexplained higher risk of stroke despite adjustment, Dr. Ovbiagele noted that a better comprehension of these risk factors could produce valuable opportunities for stroke prevention. Dr. Ovbiagele added a greater nuance for the audience that for different racial and/or ethnic minorities, indicators of socioeconomic status are not equivalent. In addition, they have higher exposure to multiple psychosocial stressors, which in turn have been demonstrated to increase stroke risk. For instance, Egido et al’s data from INTERSTROKE demonstrated a 30% and 35% increase in stroke risk by psychosocial stress and depression, respectively.11 Dr. Ovbiagele then raised the yet unclear question of the existence of racial differences in the susceptibility and/or resilience to these psychosocial factors.

Dr. Ovbiagele laid down the various perspectives around the arguments of race being not a biological construct, but a social construct. These perspectives are well-reflected in the 2020 pledge by the board of directors of the American Medical Association (AMA) on ending racial essentialism.12 Willarda Edwards, MD, the Chair of the AMA Task Force on Health Equity, captured this elegantly as: “Recognize that when the race is described as a risk factor, it is more likely to be a proxy for influences including structural racism than a proxy for genetics”.12

References:

  1. American Heart Association. Stroke Council Award and Lecture. Available at: https://professional.heart.org/en/partners/awards-and-lectures/lectures/stroke-council-award-and-lecture Accessed Nov 14, 2021
  2. American Academy of Neurology. Boards of Directors. Available at: https://www.aan.com/about-the-aan/board-of-directors-bruce-ovbiagele/ Accessed Nov 14, 2021
  3. Google Scholar Profile. Bruce Ovbiagele. Available at: https://scholar.google.com/citations?user=dqwMdcYAAAAJ&hl=en Accessed Nov 14, 2021
  4. Virani SS, Alonso A, Benjamin EJ, et al. Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association. Circulation. 2020;141(9):e139-e596. doi:10.1161/CIR.0000000000000757
  5. Bushnell C, McCullough LD, Awad IA, et al. Guidelines for the prevention of stroke in women: a statement for healthcare professionals from the American Heart Association/American Stroke Association [published correction appears in Stroke. 2014 Oct;45(10);e214] [published correction appears in Stroke.2014 May;45(5):e95]. Stroke. 2014;45(5):1545-1588. doi:10.1161/01.str.0000442009.06663.48
  6. Virani SS, Alonso A, Benjamin EJ, et al. Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association. Circulation. 2020;141(9):e139-e596. doi:10.1161/CIR.0000000000000757
  7. Cruz-Flores S, Rabinstein A, Biller J, et al. Racial-ethnic disparities in stroke care: the American experience: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42(7):2091-2116. doi:10.1161/STR.0b013e3182213e24
  8. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics–2011 update: a report from the American Heart Association [published correction appears in Circulation. 2011 Feb 15;123(6):e240] [published correction appears in Circulation. 2011 Oct 18;124(16):e426]. Circulation. 2011;123(4):e18-e209. doi:10.1161/CIR.0b013e3182009701
  9. Virani SS, Alonso A, Aparicio HJ, et al. Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association. Circulation. 2021;143(8):e254-e743. doi:10.1161/CIR.0000000000000950
  10. Howard VJ, Kleindorfer DO, Judd SE, et al. Disparities in stroke incidence contributing to disparities in stroke mortality. Ann Neurol. 2011;69(4):619-627. doi:10.1002/ana.22385
  11. AMA: Racism is a threat to public health. American Medical Association. Published Nov 16, 2020. Available at: https://www.ama-assn.org/delivering-care/health-equity/ama-racism-threat-public-health Accessed Nov 14, 2021
  12. Egido JA, Castillo O, Roig B, et al. Is psycho-physical stress a risk factor for stroke? A case-control study. J Neurol Neurosurg Psychiatry. 2012;83(11):1104-1110. doi:10.1136/jnnp-2012-302420

“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 #AHA21: Coffee and SGLT2 inhibitors!

So much great work is being shared at the AHA. I’d like to put a spotlight on two studies that stood out from Day 2 of #AHA21!

The CRAVE  Trial

The Coffee and Real-Time Assessment of Atrial and Ventricular Ectopy (CRAVE) trial attempted to address an urban myth that has been around for decades: coffee could contribute to arrhythmias. But is this actually true? The objective of this study was to assess in a more structured and scientific way to study the effects of coffee on individuals in the ambulatory setting. In this randomized crossover trial, 100 participants were each given a Fitbit Flex 2 (an accelerometer that can records step counts and number of hours of sleep), a Zio Patch (a continuously recording electrocardiogram [ECG] device), and a continuous glucose monitor to measure glucose levels. Study investigators also obtained blood samples to extract DNA to determine whether participants exhibited fast or slow caffeine metabolism genetic variants.

Participants were randomly assigned using a mobile app to either consume or avoid coffee on a day-to-day basis. Coffee consumption was validated via geo-location trackers, money incentives and daily surveys. Study investigators then compared days when people were assigned to drink coffee with those in which they were assigned to avoid it. Increased coffee consumption did not lead to an increase in atrial arrhythmias (in fact, it was associated with less supraventricular tachycardias [SVT]). However, increased coffee consumption was associated with more premature ventricular contractions (PVCs). Genetic analyses of DNA samples from participants showed that faster metabolizers were more likely to have more PVCs.

In the analysis of the Fitbit data, coffee intake was associated with 1000 additional steps on those days in which coffee was consumed, but with less sleep that same evening. Slow metabolizers of caffeine were more affected and were more likely to have reduced sleep. There were no differences in serum glucose levels with regard to coffee intake.

Study investigators concluded that coffee consumption did not lead to increased atrial arrhythmias but did increase PVCs and that coffee consumption. It also led to more physical activity, may lead to less sleep, with differential effects depending on how well people can metabolize caffeine. This is further evidence that the physiologic effects of caffeine intake are complex and varied in different populations, and should be further studied.

https://www.youtube.com/watch?v=AAc0JnX90NA&ab_channel=AHAScienceNews

The EMPULSE Trial

The Empagliflozin in Patients Hospitalized for Acute Heart Failure  (EMPULSE) trial was a randomized, placebo-controlled trial that assessed the safety and efficacy of the sodium glucose transporter cotransporter-2 (SGLT2) inhibitor empagliflozin in 500 patients who were hospitalized for acute decompensated heart failure (regardless of whether or not they had diabetes, HFpEF or HFrEF). This last distinction is key as many recent studies of empagliflozin have focused specifically on diabetic patients or patients with heart failure with reduced left ventricular ejection fraction (HFrEF). Primary outcomes included death, number of heart failure events (HFE), time to first heart failure event, change in baseline Kansas City Cardiomyopathy Questionnaire (KCCQ-TSS) after 90 days of treatment. Participants were randomized to empagliflozin 10 mg daily (and continued for at least 90 days) or to a placebo during their acute heart failure hospitalization.

After 90 days of treatment starting during their hospitalization for acute decompensated heart failure, participants who received empagliflozin were 36% more likely to see a clinical benefit (a composite of time to death, number of HFEs, time to HFE, and change from baseline KCCQ-TSS). There was a 35% percent reduction in death or first heart failure event. There was also greater weight loss, greater reduction in NT-proBNP and there were no safety concerns associated with taking the medication. Findings were similar in patients without and with diabetes, those with HFpEF and HFrEF as well as those with a new heart failure diagnosis or those with chronic heart failure.

In conclusion, this study showed that empagliflozin was both safe for patients to start taking during a hospitalization for acute decompensated heart failure and led to lower likelihood of death or new heart failure events – among other benefits – if the medication was started during that hospitalization, regardless of one’s diabetes status or ejection fraction. More work needs to be done to better understand the mechanism by which SGLT2 improve these clinical outcomes, though some speculate that their benefits have to do with the diuretic effect of the medication. In a similar vein, EMPEROR-Preserved Trial published in the New England Journal of Medicine earlier this year showed that empagliflozin reduced the risk of cardiovascular death or hospitalization in patients with heart failure with a left ventricular ejection fraction of at least 40%, regardless of whether or not they have diabetes.

Studies such as EMPULSE and EMPEROR-Preserved provide further support for utilization of empagliflozin in all patients with heart failure – not just those with a reduced ejection fraction (for which a number of studies have already shown clinical benefit, and for which SGLT2 inhibitors are already standard of care). Lively discussions in the medical community are ongoing as to whether we should be placing all patients – with reduced and preserved ejection fraction –  who are hospitalized with heart failure on an SGLT2 inhibitor, prior to discharge.

https://www.youtube.com/watch?v=Vtflg2v8m8A&ab_channel=AHAScienceNews

 

“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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Health Equity, the Forgotten Pillar

This year’s AHA21 Scientific Session placed an intense spotlight on understanding and achieving health equity in cardiovascular health (CVH). AHA has a broad vision for being transformative in all of the ways that structural inequities influence health outcomes. Specifically, AHA’s 2024 Impact Goal states that: Every person deserves the opportunity for a full, healthy life. As champions for health equity, by 2024, the American Heart Association will advance cardiovascular health for all, including identifying and removing barriers to health care access and quality.

On Day 1 of AHA21, during the ‘Cardiovascular Health After 10 Years: What Have We Learned and What is the Future?’ session, we engaged with experts about the genesis of CVH, how it has been studied throughout the life span over the past decade, and methods for influencing CVH at critical life stages. Darwin Labarthe, MD, MPH, PhD, provided a historical review of the conceptual origins and definition of CVH, and the meaning of CVH in translation. CVH is defined by key features of AHA’s Life’s Simple 7, including assessments of diet, smoking status, physical activity, weight management, blood pressure, cholesterol, and blood glucose.

Ideal CVH is determined by the absence of clinically diagnosed CVD together with the presence of the 7 metrics. Longitudinal evidence has shown that maintaining ideal CVH is more cardioprotective than improving and achieving CVH from a lower CVH level. But US NHANES data shows that about 13% of adults meet 5 of the 7 criteria, 5% have 6 of 7, and virtually 0% have ideal CVH or meet 7 of 7 metrics. This begs the question of how do we attain and maintain a high level of CVH? Ideally, maintaining CVH by Life Simple 7 standards should be SIMPLE…just ensure that all 7 metrics are met, and you will have ideal CVH! But realistically, it is near impossible for individuals to achieve ideal CVH. It is more likely that both individual and population-level efforts are needed to achieve and maintain CVH.

From a life course perspective, high CVH in adulthood is more likely when high CVH is present in early life. But as the panelist continued to describe the state of CVH in America, we quickly learned that while high CVH is consistently associated with lower risk of cardiovascular disease (CVD), disparities in CVD rates vary by sociodemographic factors like age, sex, race/ethnicity, and educational attainment. A recent study by panelist Amanda Marma Perak, MD, MS, FAHA, FACC, and colleagues (2020) using data from the CARDIA study found that less than a third of young adult participants had high CVH, and this was lower for Blacks than Whites and those with lower than higher educational attainment. These results demonstrate that CVH is far from ideal even among younger cohorts. Over the last few decades, we have witnessed increasing rates of cardiovascular abnormalities and subclinical and overt CVD in adolescents and emerging or young adults. The low prevalence of ideal CVH in young adults suggests that factors contributing to CVD risk may be embedded at earlier life stages. The experiences that happen or do not happen in early life settings (i.e., family, households, schools, communities, etc.) are important opportunities to achieve or maintain high CVH. The drivers of health disparities, like social determinants of health (SDOH), structural racism, and rural health inequalities, are necessary to achieve sustainable health equity and well-being for all. One method is effectively developing culturally-tailored community-engaged partnerships to promote CVH. LaPrincess Brewer, MD, MPH, shared the phenomenal community-based interventions being conducted to intervene on low CVH in Black neighborhoods by addressing SDOH at the community-level. These included the Fostering African-American Improvement in Total Health CVH (FAITH!) CVH wellness program, Community Health Advocacy and Training (CHAT) program, and The Black Impact Program.

The conversation on CVH and health equity continued strong on Day 2 of AHA21 at the ‘Achieving Health Equity: Advancing to Solutions’ session. With a panel of leading experts in health equity research, calls for action rang out at each presentation. David Williams, PhD, argued that racial inequalities in health are fortified from centuries of established institutional/structural racism, individual discrimination, and cultural racism, which result in a significant cost to mental health and millions of African-American lives lost each year. Sonia Angell, MD, MPH built on the discussion with a call to action in investing in understudied and marginalized communities that experience poorer CVH. Importantly, as clinicians, research scholars, and policymakers, we need to consider the significant impact of spending more time addressing intervention areas with the largest impact on health, like the structural causes of health inequities. When we work to eliminate structural causes of health inequities, we can begin to spend less time and energy working on small impact areas like counseling, education, and referrals for emergency foods and housing. Ultimately, we can reduce the time and costs of mitigating health inequities when we focus on eliminating the structural causes of health inequities.

Finally, in a powerful video, Health Equity: Patients’ Perspectives, we were invited to hear the stories and experiences of those from Black and Hispanic/Latino communities who were significantly affected by health inequities and failed by their healthcare systems. The tales were jarring and left the audience and panel with a strong sense of remorse. The impact of inequalities in health has been a regular staple in marginalized communities across America for centuries. Collectively, from these voices, we recognize that patients and participants need to be treated as humans. In seeking to meet AHA’s 2024 Impact Goal, I want to echo the sentiments of Kirsten Bibbins-Domingo, PhD, MD, MAS, that equity was always an important pillar in health quality and safety, but it is the forgotten pillar. We must make health equity front and center. As such, we need to 1) actively make health equity a priority and place it front and center in our professional and personal work; 2) have respect for all of humanity from all social groups; and 3) we need better science to understand how risk and disease are being experienced.

References

  1. Lloyd-Jones, Donald M., et al. “Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic Impact Goal through 2020 and beyond.”Circulation 4 (2010): 586-613.
  2. Enserro, Danielle M., Ramachandran S. Vasan, and Vanessa Xanthakis. “Twenty‐year trends in the American Heart Association cardiovascular health score and impact on subclinical and clinical cardiovascular disease: the Framingham Offspring Study.”Journal of the American Heart Association 11 (2018): e008741.
  3. Benjamin, Emelia J., et al. “Heart disease and stroke statistics—2017 update: a report from the American Heart Association.”circulation 10 (2017): e146-e603.
  4. Perak, Amanda M., et al. “Associations of late adolescent or young adult cardiovascular health with premature cardiovascular disease and mortality.”Journal of the American College of Cardiology 23 (2020): 2695-2707.
  5. He, Jiang, et al. “Trends in Cardiovascular Risk Factors in US Adults by Race and Ethnicity and Socioeconomic Status, 1999-2018.”JAMA 13 (2021): 1286-1298.

“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.”