AHA21

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Early Intervention can Lead to Prevention Of Postoperative Atrial Fibrillation after Cardiac Surgery

Devesh Rai, MD

Posterior left pericardiotomy can help reduce new-onset atrial fibrillation is suggested by a late-breaking science presented by prominent researchers and cardiothoracic surgeon Dr. Gaudino at American Heart Association 2021 virtual conference on November 14, 2021.

Atrial fibrillation(AF) is the most common complication after cardiac surgery, and the incidence ranges from 15-50%.1 The incidence of postoperative AF has remained similar over the years. The researchers from the Posterior Left Pericardiotomy for the Prevention of Postoperative Atrial Fibrillation After Cardiac Surgery (PALACS) trial built upon the prior smaller studies suggesting posterior left pericardiotomy may decrease new-onset postoperative AF.2 It is an adaptive, single-center, single-blind randomized controlled trial at New York-Presbyterian Hospital.

The trial included patients undergoing coronary artery bypass grafting (CABG), aortic valve and/or aortic surgery with no history of prior AF or other arrhythmias. These patients were started on beta blockers post-procedure. The trialists screened 3601 patients and included 420 patients for randomization with posterior left pericardiotomy vs. no additional intervention. The patients were followed only during the inpatient hospitalization for primary and secondary outcomes. Interestingly, the incidence of new-onset AF was remarkably lower in the intervention group (18% vs. 32%, Relative risk (0.55), p:<0.001) compared to the no intervention group. The authors also report that the need for postoperative antiarrhythmic medications and systematic anticoagulation was considerably lower in the intervention group. However, the length of hospitalization was similar in both groups. Similarly, there was no difference in mortality.2

The decrease in the incidence of postoperative AF can be attributed to lower postoperative pericardial effusion with the posterior left pericardiotomy. This small incision created a pathway for the drainage of the pericardial fluid to the pleural area, thereby inhibiting the inflammatory pathway and atrial remodeling, which could cause AF. Prior to this, many other therapeutic interventions with antiarrhythmic medications have been studied for the potential preventive strategy of AF. Nevertheless, this is a novel surgical technique with potential for future implications.

It is noteworthy, PALACS is a single-center trial with no hard clinical outcomes and comes with limitations. Evaluating the sample size, the mean age of the population was 61 years, and 24% of the participants were women. The mean CHA2DS2VASc score for the sample was 2. An important aspect of the trial is only the inpatient follow-up of the participants; there is a small subset of patients who may develop AF even after four weeks of discharge. The design of the trial is intuitive and aims for a proof of concept regarding the surgical technique.

Dr. Subodh Verma, a prominent researcher and cardiothoracic surgeon from the University of Toronto,  says, “Congratulations to the authors and investigators, this well-conducted surgical trial provides convincing proof of concept that a simple, inexpensive, generalizable, surgical adjunctive procedure of pericardial drainage can safely reduce postoperative AF after cardiac surgery” at the AHA21 while discussing the study.

References:

  1. Verma A, Bhatt DL, Verma S. Long-Term Outcomes of Post-Operative&#xa0;Atrial Fibrillation. Journal of the American College of Cardiology. 2018;71(7):749-751.
  2. Gaudino M, Sanna T, Ballman KV, et al. Posterior left pericardiotomy for the prevention of atrial fibrillation after cardiac surgery: an adaptive, single-centre, single-blind, randomised, controlled trial. The Lancet.

 

“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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Lessons from Legends in Cardiovascular Nursing

Michelle Smith

A significant portion of the AHA 2021 Scientific Sessions was focused on mentorship for early career individuals in research and medicine. Insights from the Interview with Nursing Legends in Cardiovascular Science were particularly illuminating. During this session, Dr. Christopher Lee, Professor and Associate Dean for Research at the Boston College William F. Connell School of Nursing; Dr. Kathleen Dracup, Dean Emeritus and Professor Emeritus, University of California, San Francisco, School of Nursing; and Dr. Martha Hill, Dean America at Johns Hopkins University School of Nursing offered advice from their experiences mentoring individuals of varying career levels. Here are some key takeaways for individuals who want to advance their career:

Take the show on the road

Determine professional goals and how to reach them. For those interested in research, a defined program of research and possibly multiple contingency topics of study that are of interest to several funders is needed. It is also necessary to know the road, or what success looks like given the scientific focus and what one wants to accomplish during an academic career. Finally, it is important to acknowledge that there is no one pathway to success and that success is in many ways self-defined.

Do a legacy exercise

The legacy exercise, which is sometimes referred to as a eulogy or obituary exercise involves imagining your retirement party or eulogy and thinking about who you want to speak and what you want them to say about you. This reflection essentially determines what type of legacy you want to leave behind, what you want to be known for and by whom. 
The exercise often reveals details which are not on your CV. It might not mirror scientific goals, and possibly will not align with perceived ideas of success. Ultimately, the exercise can help one focus on the rewarding aspects of work and other parts of life, even faced with challenges.

Consider personal challenges

Mentors often observe personal challenges among both colleagues. Dr. Lee pointed out that life outside of work and issues of personal importance need to be taken into consideration. In fact, he mentioned that he sometimes advises against taking on additional work or submitting extra grants because of competing demands and priorities on other aspects of life. Dr. Lee is also adamant that the best way to have a lasting and impactful career as a scientist is to have great fulfillment in personal life.

Diversify your research team

Diversity brings great insight into fields in business and research, and in decision making.
 Cardiovascular nurses often do not practice alone, and it would be beneficial for research teams to reflect this. Although diversity was spoken specifically of the multi-professional nature of cardiovascular nursing research, it is not limited to it. 
In a general sense, investigators should seek out collaborators who share passion for research, who are concerned about the outcomes of interest, and who are more knowledgeable about the research methods. These elements can help bolster various aspects of projects.

Network

As exemplified by the speakers, connecting at conferences and in research has led to long collaborations and friendships. Whether a mentor, early career or mid careers professional, the benefits of networking can be incredibly gratifying.

Overall, the speakers addressed ways to alleviate challenges for colleagues of all career phases. Their advice diminished the pressure of preconceived ideas of success by supporting the development of personal definitions of achievement. Determining goals and paths, thinking about legacy, including diverse perspectives in projects, and expanding professional networks give individuals more power and opportunity to grow. The speakers have a wealth of knowledge, experience and advice which make them not only legends, but also champions for the success of others.

 

 
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Channeling Health Care Delivery and Implementation Science in Cardiology for Improved Outcomes

Olubadewa Fatunde, MD MPH

The opening session for AHA21 was nothing sort of inspirational. In the opening session, a quote by Dr. Keith Ferdinand, Professor of Medicine and Chair of Preventative Cardiology at Tulane University, really stuck with me. The topic was how is the field of medicine adjusting in the midst of the challenges faced and inequities uncovered by the COVID pandemic? The simple answer: while positive strides have been made, there is much room for improvement. He then went on to expound about the importance of implementation science, as the best science in the world will do you no good if patients are unable to implement physical activity/dietary guidelines, understand when to take the appropriate medications, or receive preventive vaccines in time.

From the American experience with COVID, part of the difficulty in reaching the average American seems to be the emotional gap between patients and either healthcare institutions or providers. The weight evidence from the trials on COVID vaccines are clear on the efficacy and safety, particularly of the mRNA vaccines. However, delivering the messaging in a way the public will accept remains frustrating in many parts of the country. As a result, only 59% of the US population is fully vaccinated, while 68% have received at least one dose, ranking 51st in the world (1). The way we consume information is drastically different from earlier decades. In 2020, a Pew Research poll revealed more than eight-in-ten U.S. adults (86%) received news from a digital device compared to TV (68%), with those under 50 heavily skewed towards digital news consumption.(2) In this same poll, approximately 50% of adults consumed news from social media.(2, 3)  In contrast, in 2015, 75% of American adults had a PCP, dropping to 64% among 30-year-olds.(4)  During the last true global pandemic, that PCP was more likely to make a house call rather than see a patient 1 to 4 times a year.

The common thread for successful interventions seems to be meeting people where they are. Several panelists on the FIT session on navigating misinformation on social media, noted that as many receive news on socia media, they were motivated to explain new studies and correct misinformation on those platforms where people are likely to spend time and digest information. Admittedly, this effect is hard to measure, and many studies thus far are qualitative in nature. More concretely, two exciting trials presented at #AHA21 seem to shed some light on how we can mobilize these neural structures to improve the rates of uptake of proven behavioral & therapeutic modalities, to yield the morbidity and mortality benefits. Simply, how do we get patients to successfully take their indicated medications?

Dr. Jiang He of Tulane University presented the results of the China Rural Hypertension Control Project, an intervention in rural China utilizing nonphysician community health workers (CHW) supervised by local primary care physicians. These CHW—village doctors—were provided with basic medical training (e.g. standardized BP measurement) and tasked to deliver protocolized antihypertensive medications and counsel patients on medication adherence and lifestyle modification (5, 6). Patients were followed monthly and received discounted or free medications and home BP monitors. After 18 months, this cluster-randomized trial, yielded a 37.1% increase in achievement of goal BP control (< 130/80 mm Hg) of subjects living in intervention villages (57%) compared with those living in control villages (19.9%) (P < 0.001). The average drop in BP in the intervention group was greater by 15/7 mm Hg. (6) The use of community health workers is not a new phenomenon in developing countries. They are often trusted community members who receive training to help address community problems. The first use of CHW with no prior formal training to address problems with rural health was in China in the 1930s.(7) This model later spread to Latin America and Southeast Asia in the 1960s with varying levels of success. Certain countries—including Brazil, Bangladesh, and Kenya—have learned from these early struggles to build sustainable successful CHW models (7-9). Our colleagues in infectious disease have successfully integrated CHW to help tackle lack of adherence to Tuberculosis medications causing resistance, by CHW directly observing patients taking their medicines (DOTS).(10) In the US, CHW was recognized as a standard job classification by the US Department of Labor (US Bureau of Labor Statistics, 2010) for the first time in the 2010 census and continue to be underutilized. If the work of Dr. He and colleagues, can be translated to a form suitable to the US health system, this can hold great promise for prevention of the myriad problems stemming from uncontrolled hypertensions.

Dr. Alexander Blood, of Brigham and Women’s Hospital, provides a glimpse of what this may look like. Based on prior work led by Dr. Benjamin Scirica at the same institution(11), the program uses “navigators” to communicate with patients (via phone, text, and email), pharmacists to prescribe and adjust medication as necessary, as well as an algorithm to help educate patients, integrate data, and coordinate care. (12, 13)  As a result, systolic blood pressure was reduced by 10 mm Hg and LDL cholesterol by 45 mg/dL in approximately 10,000 participants enrolled. In an interview with TCTMD, Dr. Blood compared this program to Warfarin management, where the physician writes the initial prescription and the Pharmacy and Warfarin clinic maintain patient’s INR on a weekly basis. It is unlikely that quarterly or biannual visits will yield effective control in patients with poor health literacy. For patients that needed higher intensity care, they were referred to their physician (12, 13). An important aspect of this trial is the results were consistent in populations typically underserved by the medical system–Blacks, Hispanics, and non-English speaking populations. Dr. Blood noted, “…if you structure the way you’re reaching out to patients, engaging them, and communicating with them—if you’re intentional and equitable in the way you make that type of outreach—it’s possible to engage, enroll, and help patients reach maintenance at similar rates across these subpopulations that are traditionally underserved in medicine.” (12)

In summary, while amazing new discoveries & technologies continue to reshape what is possible in cardiology, it is equally important to apply the same ingenuity to scaling up what we already know works and meet people where they are, in order to guide them to best health that science can offer.

 

References:

  1. Hannah Ritchie EM, Lucas Rodés-Guirao, Cameron Appel, Charlie Giattino, Esteban Ortiz-Ospina, Joe Hasell, Bobbie Macdonald, Diana Beltekian and Max Roser (2020) – “Coronavirus Pandemic (COVID-19)”. Published online at OurWorldInData.org. Retrieved from: ‘https://ourworldindata.org/coronavirus’ [Online Resource]. [Available from: https://ourworldindata.org/covid-vaccinations?country=USA.
  2. Shearer E. More than eight-in-ten Americans get news from digital devices2021. Available from: https://www.pewresearch.org/fact-tank/2021/01/12/more-than-eight-in-ten-americans-get-news-from-digital-devices/.
  3. Shearer E, Mitchell A. News Use Across Social Media Platforms in 20202021. Available from: https://www.pewresearch.org/journalism/2021/01/12/news-use-across-social-media-platforms-in-2020/.
  4. Levine DM, Linder JA, Landon BE. Characteristics of Americans With Primary Care and Changes Over Time, 2002-2015. JAMA Intern Med. 2020;180(3):463-6.
  5. Sun Y, Li Z, Guo X, Zhou Y, Ouyang N, Xing L, et al. Rationale and Design of a Cluster Randomized Trial of a Village Doctor-Led Intervention on Hypertension Control in China. Am J Hypertens. 2021;34(8):831-9.
  6. Neale T. Village-Level Intervention Nets Big BP Control Gains in Rural China. TCTMD. 2021. https://www.tctmd.com/news/village-level-intervention-nets-big-bp-control-gains-rural-china [Accessed November 14, 2021]
  7. Perry H. A Brief History of Community Health Worker Programs. https://www.mchip.net/: USAID; 2013. p. 14.
  8. Lehmann U, Sanders D. Community health workers: What do we know about them? The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. School of Public Health, University of the Western Cape, Evidence and Information for Policy DoHRfH; 2007.
  9. Rosenthal EL, Wiggins N, Ingram M, Mayfield-Johnson S, De Zapien JG. Community health workers then and now: an overview of national studies aimed at defining the field. J Ambul Care Manage. 2011;34(3):247-59.
  10. Farmer P, Kim JY. Community based approaches to the control of multidrug resistant tuberculosis: introducing “DOTS-plus”. BMJ. 1998;317(7159):671-4.
  11. Scirica BM, Cannon CP, Fisher NDL, Gaziano TA, Zelle D, Chaney K, et al. Digital Care Transformation: Interim Report From the First 5000 Patients Enrolled in a Remote Algorithm-Based Cardiovascular Risk Management Program to Improve Lipid and Hypertension Control. Circulation. 2021;143(5):507-9.
  12. O’Riordan M. Pharmacist-Led Intervention Slashes LDL and BP in 10,000 Patients. TCTMD. 2021. https://www.tctmd.com/news/pharmacist-led-intervention-slashes-ldl-and-bp-10000-patients?utm_source=TCTMD&utm_medium=email&utm_campaign=Newsletter111321 [Accessed November 14, 2021]
  13. Blood AJ CC, Gordon WJ, et al. Digital care transformation: report from the first 10,000 patients enrolled in a remote algorithm-based cardiovascular risk management program to improve lipid and hypertension control. Presented at: AHA 2021. November 13, 2021.
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Adding to Statins: Achieving Optimum Reduction of “Bad” Cholesterol

Khairunnisa Semesta, MA

Atherosclerotic cardiovascular disease (ASCVD) is the number one cause of death in the Western world.[1] Since 2016, cardiovascular diseases have caused 1 in 3 deaths in the United States, and this trend is expected to continue in the future. There is a well-established relationship between ASCVD and elevated levels of low-density lipoprotein C (LDL-C), often called “bad” cholesterol because of its potential to accumulate in the blood vessels and contribute to the formation of fat plaques.[2] People with familial hypercholesterolemia (an autosomal dominant genetic disease caused by mutations in the LDLR, LDLRAP, APOB, and PCSK9 genes)[3] are also at risk for ASCVD due to their genetic predisposition to high cholesterol levels.

Currently, the standard of care is statin, a group of drugs that inhibits the HMGR enzyme, a key player in the cholesterol synthesis pathway. Over 55% patients undergo statin management to lower their LDL-C levels and consequently reduce morbidity and mortality.[4] However, 7 out of 10 patients on statins do not achieve their LDL-C goal. In addition, patients on statins still have residual risk of experiencing cardiovascular events and premature mortality.[5] This is due to multiple factors: nonadherence to statin management, which typically is consumed daily; drug intolerance due to the development of statin-associated muscle symptoms[6]; heterogeneity in response[7]; and others. As such, patients who are unable to control their cholesterol levels on maximum statin dose typically require an additional therapy.

Exploring additional therapies for patients who are unable to control their cholesterol levels on statins alone is the goal of the Add on Efficacy: Oral, Nonstatin Therapies for Lowering LDL-C Program in Scientific Sessions 2021, presented by Harold Bays, MD (Medical Director and President of the Louisville Metabolic and Atherosclerosis Research Center) and sponsored by Esperion Therapeutics. Until 2020, there was only one FDA-approved oral nonstatin therapy for ASCVD management: a drug called ezetimibe, which inhibits intestinal cholesterol absorption.[8] In 2020, bempedoic acid (Nexletol™) and bempedoic acid plus ezetimibe (Nexlizet™) were approved as adjuncts to diet and maximally tolerated statin therapy for patients with ASCVD or familial hypercholesterolemia who require additional lowering of LDL-C. Bempedoic acid inhibits ACL, a key enzyme in the cholesterol synthesis pathway. By week 12 of treatment, bempedoic acid and the combination of bempedoic acid and ezetimibe led to 17-18% and 38% and mean reduction of LDL-C, respectively, compared to patients given placebo and maximally tolerated statin dose.

Although statins have typically been the first line therapy for the management of ASCVD, current trends point to the need of developing additional and orthogonal therapies to achieve optimal LDL-C levels. To this end, multiple therapies are used clinically, including oral medications like bempedoic acid, ezetimibe, and bile acid sequestrants as well as other forms of therapeutics like PCSK9-inhibiting antibodies.[9] Beyond this session on non-statin therapies, Scientific Sessions 2021 provides other updates on current clinical management and emerging breakthroughs in cardiovascular health – make sure you tune in to other sessions on November 14-15, 2021!

Reference

[1] Nichols M, et al. (2014) Eur Heart J 35:2950–9

[2] Mihaylova, B. et al. (2012) Lancet 380:581–90

[3] Bouhairie, V. E. and Goldberg, A. C. (2015) Cardiol Clin 33.2: 169-79

[4] Bittner, V. et al, (2015) Journal of the American College of Cardiology, 66.17: 1873-1875

[5] Go, A. S., et al. (2014) Circulation 129: e28-e292

[6] Ward, N. C., et al. (2019) Circ Res 124:328–350

[7] Akyea, R. K. et al. (2019) Heart 105:975–981

[8] Miura, S. and Saku, K. (2008) Intern Med 47.13: 1165-1170

[9] Gupta, M. et al. (2020) Expert Opin investing Drugs 29(6):611-622.

“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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#AHA21: Matching Into Cardiology Fellowship: The Inside Scoop from Program Directors

Bhavya Varma, MD

We were lucky enough to hear from some exceptional PDs and APDs during #AHA21. The process of applying to cardiology fellowship can be daunting. These discussions provide amazing tips and insight on the process so we can best prepare.

What catches your eye on CVs?

Although this will vary by program and individual, a few themes were consistent amongst the panelists. Most programs and directors will be looking for continuation of a story and a common thread between your research, personal statement, and letters. You want to convey who you are and why you have an interest in cardiology. “It’s a two-way street” meaning fellowships also function as a part of a larger clinical and research program. They look for applicants who will fit into their culture and further the values of their program.

Additionally, PDs and APDs will look at the residency training programs, whether you are local and want to stay local, and your research. For your research projects, multiple panelists mentioned quality was more important than quality. The emphasis was showing you could follow a project to completion. “More than case reports or review articles, I look for a substantive experience in research.”

How much weight do you put on the personal statement? Should anything be avoided?

This should be used as a place to tell your story. “What attributes does this person have that will put their trajectory where we want our fellows to go? Does this person have resilience, are they able to turn disadvantages into advantages?”

The main themes that came across in the panelists answers to this question were humility, resilience, and a willingness to learn. Additionally, multiple people highlighted that this is a good place to address anything unusual that could cause confusion in your application – do you have an unusual timeline? Are there gaps in your career? Did you take breaks to do other things? They also mentioned that this would be a great place to highlight how your background prior to medicine/hobbies lend to your interest in cardiology. With this in mind, it’s important to remember this is different than a medical school application and you should be cautious with how provocative or creative you are in your writing. It was also mentioned that you can emphasize your love of a subspecialty but should also remain open-minded to the field as a whole. “The point of fellowship is to introduce you to the field so you can navigate the next steps in your career” and multiple panelists mentioned numerous fellows change their focus throughout fellowship and exploring is encouraged.

Tips for the virtual interview?

“It can be challenging to convey your narrative when you’re not in person. Find a way to project your narrative to someone who may have nothing in common with you.” Make sure you practice this with a loved one or your colleagues. Recognize your ticks, be careful when you’re reading from your screen when answering questions because interviewers notice. Applicants should also be aware that they will be asked behavioral questions (Ex. Tell me about a mistake you made when caring for a patient. Tell me about a challenging patient interaction). Practice these beforehand and think ahead about the kinds of answers you might give.

Be aware of how you look on your camera. Record a mock interview on zoom and watch it. Even small details like lighting and not have distracting objects placed in your screen can have a big impact in the age of virtual interviews. Attend the program orientation session the evening before. Do not turn off your camera, dress professionally, and don’t be late to zoom sessions. Research the program and ask the faculty about it! Show them you are invested and know about the program. It is still not clear whether interviews will be virtual or in-person for the next interview cycle.

Post-Interview Communication?

The main advice here was similar to what we heard during residency interviews: do not lie. Do not tell multiple programs they are your number one choice. Keep in mind, many people change their mind throughout the interview season and ultimately you do not want to make decisions early in the process. With this in mind, telling a program you are enthusiastic and interested can be very helpful. This is especially true during virtual interviews, where it can be difficult for programs to gauge interest and investment. If you genuinely feel you found your top choice, most programs encourage hearing from you. If you are trying to match to a different geographical location, this can also be a good opportunity to reiterate the reasons you want to move. Notably, you need to be mindful about over-communication.

Hearing from those on the other end of the interview process was an excellent opportunity to focus on what is important. Ultimately, its about your love for cardiology and passion for furthering the field! Find you network and enjoy this time as you explore and determine what you want to do in your career.

This program is part of the FIT Program at #AHA21.  The panelists include Drs. Eric Yang, Salim Virani, Carlos Alfonso, Naomi Botkin, Melvin Echols and was moderated by Drs. Aubrey J Grant and Agens Koczo.  All FIT program at AHA Scientific Sessions were produced and moderated by FITs for FITs. 

 

“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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How to Protect Your Aging Heart

Huan Wang, PhD

“Man is as old as his arteries.” –Thomas Sydenham

Cardiovascular diseases are commonly associated with unhealthy lifestyles. Do you know that age is a strong predictor of cardiovascular diseases in both men and women? As you grow older, your risks of suffering a heart attack, to have a stroke, or to develop coronary heart disease and heart failure are getting much higher. Ageing research has been evolving rapidly in the recent decades. In the early days, ageing research was mostly focused on Alzheimer’s disease and related dementias. To improve quality of life in ageing population, other symptoms of ageing including physiological function decline start to capture scientific community’s attention. In AHA Scientific Sessions 2021, a panel of experts and professionals in the field talked about novel strategies to promote healthy vascular aging.

To prevent cardiovascular diseases in aging populations, there are many take-home messages from today’s live session. Dr. Blumenthal from Johns Hopkins University used a simple “ABCDEF” approach1 to highlight the most recent development in cardiovascular diseases management based on most recent scientific discoveries and epidemiological results. Two of the major factors: Diet and Exercise, which are closely associated with body weight management, are further elaborated by Drs. Willett and Donato, respectively.

Dr. Willett is a professor of Epidemiology and Nutrition from Harvard Medical School. He challenged the recommendation of Dietary Guidelines for Americans (DGA). Dr. Willett encouraged the public to focus on evidence-based dietary recommendation, and to evaluate epidemiological studies by using randomized control trials with risk factor, disease incidence and mortality outcomes and prospective epidemiological studies with equal intensity intervention of 12-month and longer. Aside from canonical discussion of dietary recommendation based on health benefits, Dr. Willett raised a pertinent point in environmental sustainability. “How to feed 2 billion people in 2050?” he asked. Climate change is a global crisis and agriculture plays a pivotal role in fighting it. In “the Omnivore’s Dilemma”, Michael Pollan talked about how livestock production is responsible for much of the carbon footprint of global agriculture. The best practice for specific diets to prolong healthy life needs to take into consideration of reducing carbon footprint.

Vascular ageing is comprised of multiple processes including cellular senescence, inflammation and oxidative stress2. Dr. Donato talked about how ageing affects endothelial cell function and habitual aerobic exercise improves endothelial function in men. He also raised an interesting point: this beneficial effect of exercise on endothelial function is sex dependent. More research on sex differences needs to help us understand how to promote healthy ageing. DNA damage is associated with vascular aging. Dr. Shanahan discussed the signaling pathways involving in DNA damage and cellular senescence-associated phenotypes on vascular calcification. Inhibition of DNA damage agents can mediate vascular calcification progression. Can we use DNA damage as a biomarker to detect vascular ageing?

The “One-size-fits-for-all” approach in disease prevention and treatment requires a new perspective. In 2015, Precision Medicine Initiative was launched to accelerate research in disease treatment and prevention by considering individual differences in people’s genes, environments and lifestyles. With the development of next-generation sequencing, risk factors for coronary artery diseases require a modification. Dr. Wolford discussed her research on incorporating genetic backgrounds for disease prediction using polygenic risk scores3. It’s only the beginning of an exciting era using precision medicine as a tool for disease prevention and intervention in cardiovascular diseases.

To protect an aging heart, many approaches need to be implemented. Healthy lifestyles, nice environment and consideration of individual differences are all part of a clue.

REFERENCE

  1. Feldman DI, Wu KC, Hays AG, Marvel FA, Martin SS, Blumenthal RS, Sharma G. The Johns Hopkins Ciccarone Center’s expanded ‘ABC’s approach to highlight 2020 updates in cardiovascular disease prevention. American Journal of Preventive Cardiology. 2021;6:100181.
  2. Donato AJ, Machin DR, Lesniewski LA. Mechanisms of Dysfunction in the Aging Vasculature and Role in Age-Related Disease. Circulation Research. 2018;123(7):825–848.
  3. Wolford BN, Surakka I, Graham SE, Nielsen JB, Zhou W, Gabrielsen ME, Skogholt AH, Brumpton BM, Douville N, Hornsby WE, Fritsche LG, Boehnke M, Lee S, Kang HM, Hveem K, et al. Utility of family history in disease prediction in the era of polygenic scores. medRxiv. 2021:2021.06.25.21259158.

“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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Cancer Warriors losing battle to heart disease?

Gaganpreet Kaur

Your cancer treatment may be over, but does it continue to cause side effects to your body? Chemotherapy and radiation have revolutionized the survival rates among cancer patients, but so is the development of cardiovascular diseases (CVD) in cancer survivors. The scientific session 2021 program committee organized an educational session on cardio-oncology, which included talks by experts on heart health after cancer treatment, feedback link between heart and cancer, racial disparities, and new clinical imaging technology. The session was moderated by Dr. Susan Gilchrist from Houston, TX, Dr. Daniel Addison from Columbus, OH, and Dr. Mary Branch from Oak Ridge, NC. However, my favorite part was a short talk by Ms. Kikkan Randall, the first American cross-country skier to win Olympic gold along with her teammate. The session walked through the science journey and a patient journey and provided us perspective on a healthy heart from both expert’s and patient’s point of view.

Cardiovascular diseases are the leading non-cancerous cause of death among cancer survivors. Cardiac dysfunction, atherosclerosis, arrhythmia, and valvular diseases are major complications observed among cancer survivors. The first speaker in the cardio-oncology session was Dr. Saro Armenian from the City of Hope Comprehensive Cancer Center. He started by discussing the nature of the problem using the “Multiple-Hit” hypothesis, where he discussed how the margin of safety declines following cancer diagnosis and treatment. He further addressed the effect of tumor and cancer therapies on cardiac output, pulmonary function, muscle integrity, and oxygen-carrying capacity, all events ultimately causing cardiovascular aging among patients. He further walks us through how clonal hematopoiesis (a condition where we accumulate somatic mutation in the blood) can be the underlying cause of cardiovascular aging and drive CVD development among cancer patients. You can further read about clonal hematopoiesis and premature aging in one of his publications:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192097/

After a fantastic talk on premature cardiovascular aging in cancer patients, Dr. Clyde Yancy provided an exciting perspective on racial disparities. Adverse differences in numerous cancer burdens exist among specific population groups in the United States. For example, African American men are 111% more like to develop prostate cancer, whereas American Indian/Alaska Natives are twice as likely to develop liver and bile duct cancer. Similarly, racial, and ethnic health care disparities are present in cardio-oncology due to structural racism, higher prevalence of CVD risk factors, and reduced access to specialty care. A multidisciplinary approach involving stakeholders, health care policymakers, clinicians, scientists, and patients is required to resolve these disparities. Lastly, Dr. Clyde Yancy highlighted the importance of diverse population-based study and, in addition to genetic factors, phenotyping the social determinants of CV health. Read one of his recent publications about how poverty can increase the risk of heart problems:

https://pubmed.ncbi.nlm.nih.gov/34240286/

The third talk was from Dr. Rudolf A. de Boer from University Medical Center Groningen about reverse cardio-oncology. When I think about cardio-oncology, I always think about how cancer patients end up developing heart problems. However, he explained how the reverse could be true. He shared preclinical findings on how heart failure promotes tumor growth. Both CVD and cancer share several risk factors. Further, angiogenesis and inflammation under CVD conditions can increase the risk of tumor development. To learn more about cardio-oncology, refer to his recent review: https://www.ahajournals.org/doi/pdf/10.1161/JAHA.119.013754

There were additional highlights on crosstalk on clinical imaging by Dr. Ana Barac from MedStar Heart. She listed the importance of cardiac imaging, echocardiography, and cardiac MRI.

Lastly, Olypoam Kikkan Randall, a cancer survivor, shared how she stayed committed to the 10-minute rule to keep her active despite adversity. Exercise training has been shown to confer beneficial effects in cancer patients at CVD risk. Here is an interesting article documenting a scientific statement from AHA for cancer survivors to manage cardiovascular outcomes. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000679

“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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Forever Young at Heart: Aging and Cardiovascular Risk

Melody Chemaly, PhD

One of the hot topics from this year’s AHA21 Scientific Sessions main event was how to promote healthy vascular aging. Age is the strongest predictor for cardiovascular (CV) risk and risk factors such as genetic predisposition and hyperlipidemia increase CV risk. The general recommendations to reduce CV risk were elegantly presented by Dr Roger S. Blumenthal, MD from Johns Hopkins Ciccarone Center during the “Novel Strategies to Promote Healthy Vascular Aging” AHA21 session. These recommendations mainly focused on promoting a healthy lifestyle via an ABCDE toolbox.

It is important to first Assess someone’s CV risk which can be done using the coronary artery calcium score for example. A novel approach to improve current methods of CV risk assessment above and beyond the current methods is via the implementation of a polygenic risk scores (PGS) which was discussed by Dr Brooke N. Wolford, PhD from the University of Michigan. PGS rely on GWAS data to estimate an individual’s predisposition to a disease and have shown to reclassify about 10% of individuals that were initially misclassified from a ‘low risk’ or ‘intermediate risk’ category into the ‘high risk’ category. The limitation of using PGS however is that it requires genetic testing which might not be currently accessible to all patients. However, the advances in genetic screening technologies might render this possible in the near future.

Blood pressure control is crucial to prevent cardiovascular disease since hypertension increases the risk of stroke, heart attack and heart failure. Controlling blood pressure can be achieved by following a healthy Diet. In light of the growing awareness about climate change, people have been wondering how they can have a diet that is both healthy and sustainable. This contemporary topic was presented by Walter C. Willett, M.D., Ph.D., FAHA from Harvard T.H. Chan School of Public Health and introduced the concept of planetary health diet. This ‘flexitarian’ diet favors plant-based food while allowing one dairy serving a day and other animal products (such as fish, poultry, eggs and meat) to a maximum of two servings a week.  Red meat consumption, which is known to have deleterious effects on planet sustainability, increases LDL-Cholesterol levels in comparison to high quality plant protein diet (legumes, soy, nuts). This means that replacing red meat proteins with plant based proteins can be healthy for us and for the planet.

Exercise in known to reduce all-cause mortality and cardiovascular disease in all ages and even a small amount of aerobic exercise is enough to reduce CV risk. Dr Anthony J. Donato, PhD, MS from the University of Utah presented the benefits of exercise on endothelial dilatation which is a parameter that usually decreases with age and is associated with CV risk. Endothelial cells lose their ability to secrete nitric oxide with time which reduces their vasodilatory properties. Exercise is known to promote a healthier endothelium by increasing endothelial dilatation and reducing endothelial oxidative stress.

A topic that has gained a lot of attention recently in the field of cardiovascular disease and ageing is senescence. Senescence, or biological aging, is induced by DNA damage and leads to metabolically active cells that do not replicate. Vascular senescence increases inflammation and oxidative stress within the vasculature which leads to endothelial dysfunction and smooth muscle cell trans-differentiation. This exciting topic was covered by Dr Catherine Shanahan, PhD from King’s College London where she showed that senescence can accelerate smooth muscle cells ectopic calcification leading to early aging vessels. Senescence is emerging as a key player in chronic diseases and an attractive mechanism that can be targeted to increase longevity.

 

References:

 

  1. Choi SW, Mak TS-H, O’Reilly PF. Tutorial: a guide to performing polygenic risk score analyses. Nat Protoc. 2020 Sep;15(9):2759–72.
  2. Willett W, Rockström J, Loken B, Springmann M, Lang T, Vermeulen S, et al. Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems. The Lancet. 2019 Feb 2;393(10170):447–92.
  3. Guasch-Ferré M, Satija A, Blondin SA, Janiszewski M, Emlen E, O’Connor LE, et al. Meta-Analysis of Randomized Controlled Trials of Red Meat Consumption in Comparison With Various Comparison Diets on Cardiovascular Risk Factors. Circulation. 2019 Apr 9;139(15):1828–45.
  4. Donato AJ, Morgan RG, Walker AE, Lesniewski LA. Cellular and molecular biology of aging endothelial cells. J Mol Cell Cardiol. 2015 Dec;89(Pt B):122–35.
  5. Pierce GL, Donato AJ, LaRocca TJ, Eskurza I, Silver AE, Seals DR. Habitually exercising older men do not demonstrate age-associated vascular endothelial oxidative stress. Aging Cell. 2011 Dec;10(6):1032–7.
  6. Sanchis P, Ho CY, Liu Y, Beltran LE, Ahmad S, Jacob AP, et al. Arterial “inflammaging” drives vascular calcification in children on dialysis. Kidney Int. 2019 Apr 1;95(4):958–72.

“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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Being an Early Career Investigator at AHA21

Moss Zhao, PhD

Over 50 emerging scientists and clinicians were among the finalists of the Early Career Investigator Award in AHA Scientific Sessions 2021. These prestigious awards were designed to recognize the marvelous endeavors by early career investigators who submitted their abstracts to AHA Scientific Sessions 2021. The selection process included not only the quality of the abstracts but also their scientific acumen and contributions to their disciplines.

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 funded by AHA grants and fellowships. There are also more than international ten finalists from institutions in Europe and Asia. During the AHA Scientific Sessions, the finalists will present their oral abstracts. These presentations cover a wide range of topics ranging from basic sciences research to clinical applications. There are also several dedicated networking sessions for junior scientists and clinicians to expand their professional network for career development.

Another highlight of this year’s AHA Scientific Sessions is the joint event of AHA and Japanese Circulation Society (JCS) held on Nov 12, 2021. JCS has been one of the leading organizations of cardiovascular research for nearly 90 years. JCS is not only responsible for research and medical care for cardiovascular disease in Japan and Asia but also for aims to improve the health care system and train future researchers and physicians for cardiovascular diseases. During the annual meeting of JCS, the society always provide emerging scientists, clinicians, nurses, and other healthcare professionals with endless opportunities for networking and career development.

Last but not least, a team of AHA Career Bloggers will be live Tweeting during the scientific sessions. Make sure to follow the hashtag #AHA21 for the latest.

“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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BREAKING: Trials From the Realm of Cardiac Electrophysiology to Look Forward to in AHA Scientific Sessions 2021

Devika Aggarwal, MBBS

The most anticipated cardiovascular conference of the year, AHA Scientific Sessions 2021 is upon us! In the days and hours leading upto the event, speakers have been revising their presentations, moderators going over their notes, and organizers working hard to prevent any glitches for this fully virtual experience. For many attendees, including myself, the most exciting part of the conference is the release of new trial data that may have a bearing on clinical practice and set the direction for future research. This year’s program is heavily ‘charged’ with incredible science in the field of cardiac electrophysiology. Below is a short guide to the studies from the field of electrophysiology being presented in the late breaking science (LBS) sessions.

CRAVE Trial- The Coffee and Real-time Atrial and Ventricular Ectopy (CRAVE) Trial

Presented by Gregory Marcus, MD

LBS.03 Prevention to Intervention in Atrial Arrhythmias, Sunday Nov 14th 8-9 AM EST

Many people report experiencing palpitations with higher caffeine intake and cutting down on coffee is a common advice heard in EP clinics. However, this anecdotal link is not backed by evidence with large population studies showing no association between caffeine intake and arrhythmias.1 Hence, the investigators of the CRAVE trial set out to investigate the effect of caffeine intake on cardiac ectopy.2 Based in University of California, San Francisco, this N-of-1 trial enrolled healthy volunteers and assigned them to 2-day blocks of coffee on-and-off days for 2 weeks. Continuous heart monitors were used to assess the primary outcome i.e., premature atrial and ventricular contractions. The results of this study will be interesting and may finally provide an answer to the important question- to bean or not to bean?

GIRAF Trial- Dabigatran Versus Warfarin on Cognitive Outcomes in Nonvalvular Atrial Fibrillation: Results of the GIRAF Trial

Presented by Bruno Caramelli, MD

LBS.03 Prevention to Intervention in Atrial Arrhythmias, Sunday Nov 14th 8-9 AM EST

Prevention of stroke is one of the pillars of management of atrial fibrillation (AF). However, even in the absence of stroke, patients with underlying AF have an increased risk of cognitive decline and dementia.3 Direct oral anticoagulants (DOACs) such as dabigatran have less food and drug interactions and better safety profiles compared to warfarin and are now considered the preferred agents for long-term stroke prevention in non-valvular AF. However, whether this consistent and stable anticoagulant effect offered by DOACs compared to warfarin translates into prevention or progression of dementia in the elderly patient with AF remains unknown. Investigators of the GIRAF trial conducted a prospective randomized controlled trial (N=200) comparing the effects of dabitran with warfarin on cognitive and functional outcomes at 2 years in an elderly population with AF.4 Clinicians from different fields will be craning their necks for the results of this important trial.

PALACS- Posterior Left Pericardiotomy Reduces Postoperative Atrial Fibrillation After Cardiac Surgery

Presented by Mario F Gaudino, MD

LBS.03 Prevention to Intervention in Atrial Arrhythmias, Sunday Nov 14th 8-9 AM EST

Post-operative AF plagues one-third of patients after cardiac surgery and is associated with longer hospital stays, increased risk of stroke, and higher mortality.5 Drainage of the pericardial cavity into the left pleural place by performing a posterior pericardiotomy has shown benefit in preventing post-operative AF in small studies. In the PALACS study, Dr. Gaudino and colleagues aimed to further assess the impact of posterior pericardiotomy during cardiac surgery on occurrence of post-operative AF.6 If this study also demonstrates a benefit with posterior pericardiotomy, the case for performing this relatively simple surgical procedure will be strengthened.

aMAZE Trial- Outcomes of Adjunctive Left Atrial Appendage Ligation Utilizing the LARIAT Compared to Pulmonary Vein Antral Isolation Alone: The aMAZE Trial

Presented by David Wilber, MD

LBS.03 Prevention to Intervention in Atrial Arrhythmias, Sunday Nov 14th 8-9 AM EST

Persistent symptomatic AF resistant to catheter ablation is an old nemesis of many cardiac electrophysiologists. Pulmonary vein antral isolation (PVI) has a lower success rate in maintaining sinus rhythm for persistent AF as compared with paroxysmal AF. In addition to harboring thrombi, the left atrial appendage (LAA) has been implicated in the maintenance of AF. The surgical Cox-Maze procedure, involving exclusion of the LAA and elimination of foci from in and around the LAA, has shown good results. The aMAZE trial is a randomized open-label trial that evaluated the safety and effectiveness of the transcatheter LARIAT System as an adjunct to PVI in patients with symptomatic persistent and long-standing persistent AF.7 The primary endpoint studied was freedom from episodes of AF > 30 seconds at 12 months. The results of this trial will provide further insight into the utility of LARIAT device LAA occlusion in conjunction with PVI.

 

I-STOP-Afib Trial- Testing Individualized Triggers of Atrial Fibrillation: A Randomized Controlled Trial

Presented by Gregory Marcus, MD

LBS.04 Information Overload? Striving to Improve Care Delivery Through Digital Health and Automated Data, Sunday Nov 14th 2.45-3.45 PM EST

A group of researchers at University of California, San Francisco have been working to study the triggers of AF in partnership with patients through the Health eHeart Study and StopAfib.org. In preparation for the I-STOP-Afib trial, they conducted a survey of 1,295 patients and found that almost three-quarters of patients self-identified triggers for episodes of AF, most commonly alcohol, caffeine, exercise, and sleep deprivation.8 The I-STOP-Afib study randomized patients to either trials of exposure and elimination of self-identified AF triggers for 6 weeks or symptom surveillance only.9 They used a smartphone application to direct the 2 groups, record daily AF episodes, and assess daily the quality of life at the end of 10 weeks. Regardless of the results, this study will set an example of using technology to empower patients to take charge of their own health.

Detection of Atrial Fibrillation in a Large Population Using Wearable Devices: The Fitbit Heart Study

Presented by Steven Lubitz, MD

LBS.04 Information Overload? Striving to Improve Care Delivery Through Digital Health and Automated Data, Sunday Nov 14th 2.45-3.45 PM EST

Over the past few years, wearable tech has been making waves in the field of EP. Smartwatch based continuous rhythm monitoring has shown promise in the detection of undiagnosed AF. The Fitbit Heart Study is a remote single-arm trial of 450,000 Fitbit device users in the US.10 It is designed to study the validity of a novel software algorithm for detecting AF. The study used compatible Fitbit devices using pulse photoplethysmography to detect irregular heart rhythms and followed abnormal readings with a week-long ECG patch. The strength of the Fitbit Heart Study over prior studies like the Apple Heart Study will be a large, predominantly female population using both iOS and Android smartphone platforms.

Log into AHA Scientific Sessions to livestream the release of these and other exciting trials. Keep buzzing #EPEEPS!

References:

  1. Voskoboinik A, Kalman JM, Kistler PM. Caffeine and Arrhythmias: Time to Grind the Data. JACC Clin Electrophysiol. 2018;4(4):425-432. doi:10.1016/j.jacep.2018.01.012
  2. https://clinicaltrials.gov/ct2/show/record/NCT03671759?view=record
  3. Santangeli P, Di Biase L, Bai R, et al. Atrial fibrillation and the risk of incident dementia: a meta-analysis. Heart Rhythm. 2012;9(11):1761-1768. doi:10.1016/j.hrthm.2012.07.026
  4. https://clinicaltrials.gov/ct2/show/NCT01994265
  5. Greenberg JW, Lancaster TS, Schuessler RB, Melby SJ. Postoperative atrial fibrillation following cardiac surgery: a persistent complication. Eur J Cardio-Thorac Surg Off J Eur Assoc Cardio-Thorac Surg. 2017;52(4):665-672. doi:10.1093/ejcts/ezx039
  6. Abouarab AA, Leonard JR, Ohmes LB, et al. Posterior Left pericardiotomy for the prevention of postoperative Atrial fibrillation after Cardiac Surgery (PALACS): study protocol for a randomized controlled trial. Trials. 2017;18(1):593. doi:10.1186/s13063-017-2334-4
  7. Lee RJ, Lakkireddy D, Mittal S, et al. Percutaneous alternative to the Maze procedure for the treatment of persistent or long-standing persistent atrial fibrillation (aMAZE trial): Rationale and design. Am Heart J. 2015;170(6):1184-1194. doi:10.1016/j.ahj.2015.09.019
  8. Groh CA, Faulkner M, Getabecha S, et al. Patient-reported triggers of paroxysmal atrial fibrillation. Heart Rhythm. 2019;16(7):996-1002. doi:10.1016/j.hrthm.2019.01.027
  9. https://clinicaltrials.gov/ct2/show/study/NCT03323099
  10. Lubitz SA, Faranesh AZ, Atlas SJ, et al. Rationale and design of a large population study to validate software for the assessment of atrial fibrillation from data acquired by a consumer tracker or smartwatch: The Fitbit heart study. Am Heart J. 2021;238:16-26. doi:10.1016/j.ahj.2021.04.003

“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.”