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Catheter Ablation as First Line Therapy for Atrial Fibrillation: Are we there yet?

For the last two decades, the management of patients with atrial fibrillation (AF) had stayed in an “equipoise” between rate and rhythm control as shown by AFFIRM and RACE trials 1,2. However, rate control strategy remained the predominant mantra in AF management for the majority of patients in clinical practice.

The most recent American College of Cardiology/American Heart Association/Heart Rhythm Society AF guidelines were written in 2014 followed by a guideline update in 2019 3,4. At that time, most randomized controlled trials comparing CA with medical therapy included patients after they had failed at least 1 anti-arrhythmic drug (AAD), and very few trials utilized AF ablation as first-line therapy. These guidelines recommend CA for paroxysmal AF in symptomatic patients if they are intolerant to at least 1 AAD as a Class I-A recommendation. Guidelines also suggest that CA is reasonable as an initial rhythm control strategy for some patients with recurrent symptomatic AF even before the therapeutic trial of AAD (Class II-B).

Over the last 3 years, the pendulum has swung dramatically in the favor of rhythm control with much credit to CA. The “big bang” started with CASTLE-AF showing the benefit of catheter ablation in reducing all-cause mortality or heart failure hospitalizations in AF patients with heart failure 5. While the CABANA trial did not deliver the paradigm shifting results everyone in the electrophysiology community had hoped for, it still demonstrated the safety of CA and its superior role in preventing recurrent AF 6.

The last 6 months have been incredible in AF management with mounting evidence in favor of early rhythm control. EAST-AFNET 4 trial showed that early rhythm control with Flecainide (35.9%), Amiodarone (19.6%), and Dronaderone (16.7%) results in an improvement in the composite outcome of death, stroke or major adverse effects as compared with rate control (HR 0.79; 96% CI 0.66-0.66; p=0.005) 7. Important to note that only 8% of patients in this trial underwent CA.

Following this momentum 3 landmark trials in the last 4 months have demonstrated the benefits of CA with cryoballoon as the initial therapy in AF. The STOP AF First Trial randomized 203 paroxysmal AF patients to cryoablation or drug therapy and showed that CA was superior to AAD in preventing recurrent AF (P<0.001) 8. Similarly, the EARLY AF investigators randomized 303 patients to cryoablation or AAD and showed a significantly lower rate of recurrent AF with cryoablation using continuous cardiac rhythm monitoring post-ablation 9.  The CRYO FIRST trial continued the same theme and showed that CA was superior to AAD as initial therapy for the management of symptomatic paroxysmal AF 10.  Importantly, all 3 trials also demonstrated the safety profile of cryoablation. Now there are several reasons why CA is superior to AAD.

  1. AAD has limited efficacy and they have rare but life-threatening side effects. A significant proportion of patients discontinue AAD due to these side effects. The most feared side effects include prolonged QTc related arrhythmias like Torsade de Pointes or multiorgan side effects from Amiodarone.
  2. The safety profile of CA is excellent and it continues to improve.
  3. The advances in ablation techniques have resulted in improved efficacy of CA in maintaining long-term sinus rhythm.

3 older randomized trials have also compared CA to drug therapy and when the pooled evidence is considered for CA as first-line therapy in AF, similar results are observed 11. Overall, CA results in a 38% reduction in recurrent atrial arrhythmia (P<0.001), and the number needed to treat (NNT) to prevent 1 arrhythmia was 5 with effects consistent across radiofrequency or cryoablation 11. The hospitalization rates in CA were also significantly lower (68% reduction, P<0.001). These results were achieved without any significant increase in major adverse events.  The possible rationale for these results is that early effective rhythm control may modify the electrical and structural substrate that sustains AF and thus prevents atrial myopathy as it is well known that recurrent paroxysmal AF episodes can potentially progress to persistent AF (AF begets AF).

Based on this data, I believe there is sufficient evidence to consider CA as first line therapy in symptomatic patients with paroxysmal AF after a careful discussion of risks and benefits. Of course, such decision making should be patient centered. It is possible that future guideline updates may upgrade CA as a Class 1-A recommendation in this patient population.

References

  1. Van Gelder IC, Hagens VE, Bosker HA, Kingma JH, Kamp O, Kingma T, et al. A Comparison of Rate Control and Rhythm Control in Patients with Recurrent Persistent Atrial Fibrillation. New England Journal of Medicine 2002;347:1834–1840. doi:10.1056/NEJMoa021375.
  2. A Comparison of Rate Control and Rhythm Control in Patients with Atrial Fibrillation. New England Journal of Medicine 2002;347:1825–1833. doi:10.1056/NEJMoa021328.
  3. January Craig T., Wann L. Samuel, Calkins Hugh, Chen Lin Y., Cigarroa Joaquin E., Cleveland Joseph C., et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation 2019;140:e125–e151. doi:10.1161/CIR.0000000000000665.
  4. January Craig T., Wann L. Samuel, Alpert Joseph S., Calkins Hugh, Cigarroa Joaquin E., Cleveland Joseph C., et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. Journal of the American College of Cardiology 2014;64:e1–e76. doi:10.1016/j.jacc.2014.03.022.
  5. Marrouche NF, Brachmann J, Andresen D, Siebels J, Boersma L, Jordaens L, et al. Catheter Ablation for Atrial Fibrillation with Heart Failure. New England Journal of Medicine 2018;378:417–427. doi:10.1056/NEJMoa1707855.
  6. Packer DL, Mark DB, Robb RA, Monahan KH, Bahnson TD, Poole JE, et al. Effect of Catheter Ablation vs Antiarrhythmic Drug Therapy on Mortality, Stroke, Bleeding, and Cardiac Arrest Among Patients With Atrial Fibrillation: The CABANA Randomized Clinical Trial. JAMA 2019;321:1261. doi:10.1001/jama.2019.0693.
  7. Kirchhof P, Camm AJ, Goette A, Brandes A, Eckardt L, Elvan A, et al. Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. New England Journal of Medicine 2020;383:1305–1316. doi:10.1056/NEJMoa2019422.
  8. Wazni OM, Dandamudi G, Sood N, Hoyt R, Tyler J, Durrani S, et al. Cryoballoon Ablation as Initial Therapy for Atrial Fibrillation. New England Journal of Medicine 2021;384:316–324. doi:10.1056/NEJMoa2029554.
  9. Andrade JG, Wells GA, Deyell MW, Bennett M, Essebag V, Champagne J, et al. Cryoablation or Drug Therapy for Initial Treatment of Atrial Fibrillation. New England Journal of Medicine 2021;384:305–315. doi:10.1056/NEJMoa2029980.
  10. Kuniss M, Pavlovic N, Velagic V, Hermida JS, Healey S, Arena G, et al. Cryoballoon ablation vs. antiarrhythmic drugs: first-line therapy for patients with paroxysmal atrial fibrillation. EP Europace 2021. doi:10.1093/europace/euab029.
  11. Turagam MK, Musikantow D, Whang W, Koruth JS, Miller MA, Langan M-N, et al. Assessment of Catheter Ablation or Antiarrhythmic Drugs for First-line Therapy of Atrial Fibrillation: A Meta-analysis of Randomized Clinical Trials. JAMA Cardiology 2021. doi:10.1001/jamacardio.2021.0852.

“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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Can your leg and arm tell a failing heart?

For the heart’s health condition, everything is interconnected. Other parts of the body might be reflective or instigators of a failing heart. Among all of the important issues related to cardiovascular disease, skeletal muscle is on top of that list. Conventionally, the main function of skeletal muscle is tightly related to physical capabilities. It’s only the partial facts. Skeletal muscle plays a pivotal role in supporting our physical well-being in many ways that are more than organizational. The relationship between skeletal muscle mass and cardiometabolic health starts to attract the researcher’s attention.

As we know, skeletal muscle mass decreases during the aging process, while cardiometabolic health often declines. A recently published epidemiology study investigated the relationship between skeletal muscle mass and cardiovascular disease in a group of adults (3042 people) without pre-existing cardiovascular risk in a 10-year follow-up study, ATTICA1. After adjusting for various confounders, this study showed a significant inverse association between skeletal muscle mass and cardiovascular incidence (HR 0.06, 95% CI 0.005 to 0.78). Moreover, it showed that people in the highest skeletal muscle mass group had 81% lower risk for a cardiovascular event. The results are quite intriguing. Does decreased skeletal muscle mass contribute to poor heart health or does a failing heart cause muscle mass decrease? It’s hard to figure out the cause and effect without understanding the relationship between skeletal muscle and the heart.

Chronic heart diseases and heart failure impair muscle function2. In particular, many heart diseases affect exercise performance. For certain cardiac conditions such as atherosclerotic heart disease, exercise stress test is widely used to measure heart functional capacity, and also used as a diagnostic tool to evaluate the efficacy of treatment and predict prognosis. Cardiac function affects exercise performance in many ways and reduced cardiac output response to exercise leading to skeletal muscle hypoperfusion and lactic acidosis3. The pathophysiological mechanisms impairing skeletal muscle function in heart failure are discussed in a review, shown in Fig12. In heart failure, many stimuli contribute to skeletal muscle contractility apparatus dysfunction such as systemic inflammation, TGF family members, adrenergic signaling, decreased anabolic stimuli and increased calcium shuttling/overload (Fig. 1). Skeletal muscle atrophy can be caused by biological processes such as protein degradation, impaired growth factor signaling and skeletal muscle inflammation.

Heart failure with increased systemic inflammation can trigger skeletal muscle inflammation. it’s also true the other way around: skeletal muscle injury can cause local activation of innate immune system4. Danger-associated molecular patterns (DAMPs) can be released from dying myocytes. DAMPs encompass diverse mediators including alarmins (HMGB1, S100A8/9/12, S100B, IL1a, HSPs), bioactive lipids, extracellular matrix fragments and nucleotides (ATP, CpG, dsRNA)5. The impact of local skeletal muscle immune responses has been proved both harmful and beneficial. Traditionally, a stimulated immune response (M1-like macrophages) is a sign of disease. However, distinct macrophage subsets (M2-like macrophages) help tissue regeneration in chronic skeletal muscle pathologies6. The relationship between skeletal muscle damage and inflammation is complicated. And how they play a role in heart diseases require more research in the future.

To go back to the original question in this blog, the answer is a yes. Yes, skeletal muscle (leg and arm muscle) can tell the basic condition of the heart. And is it good for your heart if there is more muscle mass? Maybe. The absolute muscle mass does not tell us the function of the muscle, other aspects of muscle, for example, different types of fiber may hold the key.

References

  1. Tyrovolas S, Panagiotakos D, Georgousopoulou E, Chrysohoou C, Tousoulis D, Haro JM, Pitsavos C. Skeletal muscle mass in relation to 10 year cardiovascular disease incidence among middle aged and older adults: the ATTICA study. Journal of Epidemiology and Community Health. 2020;74(1):26 LP – 31.
  2. Kennel PJ, Mancini DM, Schulze PC. Skeletal Muscle Changes in Chronic Cardiac Disease and Failure. Comprehensive Physiology. 2015;5(4):1947–1969.
  3. Lunde PK, Sjaastad I, Schiøtz Thorud H-M, Sejersted OM. Skeletal muscle disorders in heart failure. Acta Physiologica Scandinavica. 2001;171(3):277–294.
  4. Lavine KJ, Sierra OL. Skeletal muscle inflammation and atrophy in heart failure. Heart failure reviews. 2017;22(2):179–189.
  5. Chan JK, Roth J, Oppenheim JJ, Tracey KJ, Vogl T, Feldmann M, Horwood N, Nanchahal J. Alarmins: awaiting a clinical response. The Journal of Clinical Investigation. 2012;122(8):2711–2719.
  6. Villalta SA, Deng B, Rinaldi C, Wehling-Henricks M, Tidball JG. IFN-γ Promotes Muscle Damage in the <em>mdx</em> Mouse Model of Duchenne Muscular Dystrophy by Suppressing M2 Macrophage Activation and Inhibiting Muscle Cell Proliferation. The Journal of Immunology. 2011;187(10):5419 LP – 5428.

“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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Series 1 – Interview with a Pioneer in Humanitarian and Voluntary Work: Dr. Yassine Abdeljebbar

I have always been impressed and inspired by the impact of medicine and voluntary work on people’s life.  I have recently known about great initiatives and projects organized by young physicians across the globe to help those who are in need. I had the pleasure to interview one of these inspiring physicians, Dr. Yassine Abdeljebbar. I decided to dedicate series of blogs to talk about voluntary and humanitarian work, how to get involved in these projects and how was Dr. Yassine Abdeljebbar’s experience in this field.

It is our pleasure to interview you Dr. Yassine Abdeljebbar!! To start our interview, tell us about yourself and your brief journey.

 I am a young doctor, started my career in a public hospital and joined from the beginning of my career the health center located in the Algerian extreme south, In Guezzam more precisely. I came to the United States of America to do research as a postdoctoral fellow at Mount Sinai hospital Icahn school of medicine in 2019.

Originally from west Algeria, since I started studying medicine, I have always tried to put my services to the most disadvantaged, which provided me a rich experience in the charitable field. I am a member of many organizations and medical associations, even environmental ones such as Collective HAMEB, Je Vous Aime, AAMICO, OIM , we Algerians .. etc

 Today, I am committed to promoting a positive spirit in the new generations. I aim to inspire the young people who would, in turn, like to become activists by sharing my experience and my passion for mutual aid and solidarity through various humanitarian actions, conferences, workshops, appearances on television, radio, and on social networks.

How did you come up with the idea of ​​devoting yourself to humanitarian work?

The idea of ​​humanitarian work had been around since I was young.  As a human, I felt a desire but, above all an immense need to help others.  I have never imagined walking my way past someone who needs me without reaching out to him.  I dreamed of doing medicine to help those who are suffering because I can understand their struggles. My principle is humanity above all. As a doctor, you should put yourself in the patient’s shoes, sympathize with his pain, and then do everything possible to ease the pain.

Thanks to my parents, I am capable of chairing my passion for charity work today. They encouraged me to study medicine and help people who are in need.

Any advice for doctors or future doctors who want to get into humanitarian work?

Humanitarian work doesn’t just give you moral satisfaction, it’s also a great way to learn medicine in the field, so never hesitate to get involved with others. It’s an excellent experience that will help you and your community.

Stay tuned for more discussions in future blogs!! In future blogs, we will discuss more of these humanitarian activities, share some photos of prior experiences, and share resources for those interested in joining.

I would like to say a special thank you to Dr. Yassine Abdeljebbar, who dedicated the time to interview with us and share his experiences with all of us.

 

“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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Whole Exome Sequencing of Congenital Heart Disease Patients in Sub-Saharan Africa

My research is on the genetics of congenital heart disease (CHD), and although it is one of the most common birth defects, the genetic causes of most cases are unknown. So I’m always interested to read new papers on the topic to see how different groups are addressing the problem and to find new candidate disease genes to look into.

A group at the NIH led by Dr. Paul Kruszka recently published a paper in Circulation: Genomic and Precision Medicine titled “Exome Sequencing and Congenital Heart Disease in Sub-Saharan Africa”. The authors begin by pointing out that while there are many studies using whole-exome sequencing to identify genes associated with CHD, these cohorts are primarily made up of patients of European descent. However, CHD and the pathogenic variants that cause it do not discriminate based on ethnicity. This group sought to help fill the gap in research on non-syndromic CHD cases in sub-Saharan Africa.

Using data from 98 trios of patients and their parents, they identified de novo variants (found in a patient but not their parents) or singleton variants (found only in one patient) in 9 genes known to cause CHD. They also identified several very rare protein-truncating variants in 5 known CHD genes and 3 novel candidate genes that are predicted to be intolerant to loss-of-function. They functionally tested high-interest candidate genes in knockout Drosophila models, as they have similar cardiac developmental networks to humans. These experiments identified 4 genes that resulted in elevated fly mortality which were not previously associated with CHD (UBB, EIF4G3, SREBF1, and METTLE23).

For me, the main takeaway from this paper is tied to its limitations of small sample size and lack of a control population for testing variant burden. We need to focus on creating diverse and representative patient and control cohorts in sequencing studies to identify novel disease-causing genes and pathways and prevent misclassification of variants. In accomplishing that, our research can be as meaningful as possible to as many patients as possible.

References

Ekure EN, et al. Exome Sequencing and Congenital Heart Disease in Sub-Saharan Africa. Circulation: Genomic and Precision

 

“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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Vlog: What is one piece of advice you wish you previously knew or you think other early career investigators should know?

I am delighted to share my latest vlog where I ask researchers at various different stages of career development (from undergraduates to faculty members) to share one piece of advice they would give other trainees.

Thanks so much to everyone who agreed to participate in the video!

Check out the advice from the following researchers at the University of Minnesota’s Lillehei Heart Institute:

  • Megan Eklund, Researcher, Lab of Dr. Kurt Prins
  • Thijs Larson, Undergraduate Researcher, Lab of Drs. Daniel and Mary Garry
  • Javier Sierra-Pagan, Medical Scientist Training Program (MSTP) student, Lab of Dr. Daniel Garry
  • Lynn Hartweck, Research Associate, Lab of Dr. Kurt Prins
  • Satyabrata Das, Assistant Professor
  • Kurt Prins, Assistant Professor

Special thanks to my husband, Tony Prisco, who helped put the video together!

Hope you enjoy this vlog and thanks for checking it out!

 

“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 Rising Value of Plain Science Talk: Part 2

In part 1 of this blog series, I laid out two main plot points that I wanted to focus on when it comes to the ideas behind Plain Science Talk, 1) Traditionally scientific information has been communicated in extremely technical and specialized formats, geared towards peers and subject matter experts, and 2) Traditional spaces where science information is shared tend to be “closed circuits” of pay-walled and sometimes hard to discover specialty journals, coupled with once or twice a year professional gatherings like conferences and workshops. While these structures were never intended as barriers, their historical origins and continuation to our present-day do contribute to the overall limitation of science information dissemination, and the ability to maximize the benefits of science in the broadest forms possible.

In an effort to spotlight novel approaches that can be leveraged to expand outreach, and provide a path to more science being available to the global population, I pointed out Knowledge Transfer and Translation (KTT) and Online-based Media, as key strategies and tools that can help achieve our desired aims. The ultimate goal here is to show, with a few examples, how science can be adapted and modernized in a way that effectively contributes, not just to other scientists, but to a much wider proportion of the public.

(Submitted by author,  CC-0 images at pixabay.com)

If the past year (and still counting) of the pandemic has exposed us to one thing, well that would be the under-prepared healthcare states that our various global societies are existing in, with regards to delivering and optimizing public health. The other thing that the Covid-19 pandemic has shown us is the need for amplified and optimized science communication approaches so that the general public can be better served by the information scientists have to offer. Better communication will also help to clarify the reasons and factors involved in how science operates, and how the information gathering and disseminating process is always in a state of evolution and advancement.

The spotlight I want to place on KTT is geared towards emphasizing the difference between information sharing between specialists versus information sharing with non-specialists and multidisciplinary audiences. The traditional framework of scientific journals and specialty conferences is based on a “membership” structure: paid subscriptions to high impact/highly specialized publishing platforms, as well as tiered annual membership fees, to access conferences and participate in ancillary workshops and seminars constructed by other members of the professional organization. There is in fact value in this framework. I believe for the most part it serves the greater good for specialists and highly-invested individuals to have domains where their interactions are concentrated and their in-group information sharing is optimized.

This is undoubtedly the main reason why these types of specialized subject matter communication approaches exist. These methods encourage and facilitate science advancement by having highly knowledgeable experts engage with one another to challenge and expand the potential of information gathering. So my spotlight and encouragement for broader Knowledge Transfer & Translation are not meant to be a replacement to the first-order framework of in-group communication, but instead, it is my attempt to highlight the importance of what I’ll call “second-order communication” framework. This is the communication between subject matter experts and the more generalized audience, composed of multidisciplinary groups and specialists in other fields, as well as casually interested and invested members of society, without specific professional ties to the scientific data being communicated.

The majority of KTT approaches in the scientific fields are left to individuals that act as separate but integral links in the information chain. The original researchers are reliant on others to absorb the information they produce and move it in a direction that can be used by others in organizations such as government policymakers, industrial development, news media sharing, etc. This is mostly because the traditional academic/educational models experienced by scientists are very rarely designed with broader communication as a required skill to develop and expand over time. Science communication is classically seen as published articles in specialized journals, and infrequent conference talks & presentations to rooms full of experts in the fields related to the topics discussed.

Transfer of knowledge to a much wider group of people is often thought of as a task left for other individuals (not the original scientists) to deliver. The idea of Knowledge Translation is even more distant as an aim from many scientists. Translation (taking the gained information and finding a way to make it more immediately impactful in society, either by the production of something new or implementing new policy) is the most underserved aspect of science information gathering. Thousands of new research articles are produced every year, the vast majority of it goes unnoticed and without impacting people or the planet we share with millions of other species.

(Submitted by author, CC-0 images at pixabay.com)

My second spotlight is aimed directly at where you and I are in right now, namely “the internet”! Many have long seen the potential that online-based communication has to offer when it comes to expanding the reach of specialists. I won’t go through a timeline of the evolving state of the web, but suffice to say, in the most recent versions of online media, the expansion of reach that individuals have, especially through the use of Social Media (#SoMe), has reached a level that greatly facilitates information sharing and that idea of “second-order communication” between specialists and a wider group of individuals unrelated to the field specialists within an in-group.

The expanding communication platforms available for scientists and other subject matter experts must be seen for their highly valuable potential. The ability to directly share information with the public in forms that are not “pay-walled” or exclusive to specialists is undeniably a positive evolution of the whole communication framework. Having said that, it is important to note that new forms of communication also bring about the important need to learn and gain incremental experience in the methods and approaches that optimize the final goal of beneficial information sharing with wider audiences.

Everyone needs “practice” to get better at information sharing (it certainly takes “practice” to get better at information gathering). It doesn’t help that classically, science communication has been left out of the traditional structures of science education and implementation. But now is as good a time as any to commit to gaining new skills (one of the side effects of the pandemic on society as a whole, is realizing the need for novel skill acquisition!). The online world is rapidly evolving as well, and with it, new communication frameworks are quickly becoming more normalized (web-based video conferencing, more robust social media use, new platforms, and functionalities on existing apps, etc.). The more experts are able to directly communicate with each other and with broader groups of people, the faster we can reach the aims of KTT and provide our communities with useful data that can benefit us, and the world we live in.

 

“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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Management of Acute Myocardial Infarction Complicated by Cardiogenic Shock

Cardiogenic shock (CS) is caused by severe impairment of myocardial performance causing a lack of end-organ perfusion. CS carries a very high mortality and in the past few decades, the only intervention that provided clear survival benefits was early revascularization. In the late 1990s, the widespread availably of percutaneous coronary interventions led to an improvement in the CS mortality rate. However, afterward, the mortality rate plateaued despite all the new developments in mechanical support devices. Recently the American Heart Association (AHA) published a scientific statement to guide managing patients presenting with myocardial infarction complicated by cardiogenic shock. (1) In this blog, I will review the document’s highlights.

Key points:

– The lack of a standardized cardiogenic shock definition led to uncertainty in comparison of outcomes across the nation.

– Endorsement of the Society for Cardiovascular Angiography and Intervention (SCAI) new classification schema for cardiogenic shock. (Figure 1) (2) Based on the SCAI classification, the AHA statement proposed their management guidelines. (Figure 2)

Figure 1: SCAI’s classification of cardiogenic shock. ( adapted from Baran DA et al.)(2)

 

Figure 2: Consideration of early mechanical circulatory support (MCS) in the context of shock classification. (Adapted from Henry TD et al.)(1)

– Use the minimum necessary dose of vasopressors to maintain a mean arterial blood pressure of 65 and above.

– Norepinephrine is your first go-to pressor.

– In unstable bradycardia, Epinephrine or dopamine is recommended.

– In dynamic LVOT Obstruction, use pure vasopressors such as phenylephrine or vasopressin.

– In refractory hypoxemia or severe acidosis, the efficacy of catecholamines is compromised, hence vasopressin is recommended.

– Worsening hypoxemia or severe acidosis increase the risk of ventricular fibrillation and death, hence early endotracheal intubation and mechanical ventilation is recommended.

– Echocardiogram should be performed as soon as possible with focusing on left and right ventricular function, valvular lesions, pericardial effusion/tamponade, and mechanical complications.

– Patients who are relatively stable (stage A and B) should be brought to the cardiac catheterization lab as soon as possible. However, patients in stages C, D, and E should be stabilized first with minimal delay.

– PCI of the culprit’s vessel is recommended regardless of the delay. In cases of multivessel disease, PCI should be performed on the culprit lesion only. Prior to giving contrast, LVEDP should be documented if possible.

– Given that CS is a risk factor for stent thrombosis. Third-generation oral PY12 is recommended over clopidogrel. However, bleeding risk should be evaluated especially in the setting of large-caliber access for MCS.

– RHC is not required to diagnose CS especially if it will delay reperfusion. However, invasive measurements could guide management. There are no randomized clinical trials to validate its routine use.

– Over the past decade, several MCS devices were developed. Although theoretically, MCS should help patients with CS, so far, the data behind it is very limited.

– MCS should be considered in patients who are persistently hypoperfused and hypotensive on vasopressors with low cardiac index.

– For patients with Left ventricular failure, Intra-aortic balloon pump (IABP), Impella, Tandem heart or VA ECMO should be considered. In right ventricular failure, consider Impella RP or Protek Duo. In patients with Biventricular failure, consider Bilateral Impella pumps or VA-ECMO with a venting device (IABP or Impella). (Figure 3)

Figure 3: Mechanical support devices suggested according to the clinical picture. (Adapted from Henry TD et al.)(1)

CS continues to be a very complex entity with very high mortality. The difficulty in conducting trials in this vulnerable population is one of the main challenges. In order to fill this gap, the AHA statement outlined the essential areas for future research.(1) Multiple studies are being conducted and hopefully, these studies will provide us with valuable information to improve the outcomes of this morbid condition.

References:    

  1. Henry TD, Tomey MI, Tamis-Holland JE, et al. Invasive Management of Acute Myocardial Infarction Complicated by Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation. 2021;143(15):e815-e29.
  2. Baran DA, Grines CL, Bailey S, et al. SCAI clinical expert consensus statement on the classification of cardiogenic shock. Catheter Cardiovasc Interv. 2019;94(1):29-37.

“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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Top 10 Tips for Incoming Cardiology Fellows

Cardiology fellowship comes at you fast. Within the first day, you realize how much nuance exists within the field that you hadn’t been exposed to in internal medicine, and there are lots of patients whose care depends on those details. At the same time, you quickly come to appreciate how much of an impact you can make on a patient’s health and just how rewarding the field is. it’s a beautiful journey! In thinking back on the last two years, I wanted to share my top 10 tips and insights on fellowship aimed at incoming fellows.

  1. Learn from everyone. Nurses, techs, the cath lab team, sonographers, any staff with any clinical experience. There is often a sense you get when things aren’t right, and it takes a while to learn. These folks have developed it.
  2. It will take you at least 6 months to start to feel somewhat comfortable, a year before you think you got a hang of things, and that’s normal.
  3. Ask for help often. Key resources: senior fellows. They know everything, or they know who does.
  4. When you are on call, you are never alone. Get in the habit of communicating with your attending, even in the middle of the night. It’s the best thing for patient safety and your learning, and the attendings want it too.
  5. “Don’t guess when you can know.” The credit for the quote goes to Dr. Neil Stone, but the point is to get all the information you need (safely) and double-check the basics. The stakes are high in cardiology, so do the little things that prevent errors.
  6. Stay well outside of work. Family, friends, exercise, sleep, hobbies, whatever makes you you. These things are never more important than now. Burnout is real, prevalent, and painful.
  7. Meaningful learning happens through rote repetition in cardiology. Whether it’s in the cath lab or on echo, you will make insights through monotonous reps of seemingly routine studies/cases that you can’t make through any other means. Show up and dive in.
  8. It may take you a while to have the bandwidth to delve into academic pursuits outside of “just being a fellow” – that’s okay. Fellowship is hard.
  9. Recognize sick from not sick, and if someone is sick, move fast.
  10. When you consent a patient for a procedure, know the facts, and tell them. There is no such thing as a no-risk procedure. I will never forget this, after being involved in a case of a PA rupture during a straightforward right heart cath leading to a cardiac arrest. Make sure they know what they are signing up and consent is truly informed.

I would recommend going into cardiology to those who are interested 10 times out of 10. Congrats to those just starting out! I hope this list gives some pointers that help as you embark on your own journey in the field.

 

“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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Should interventional cardiologists perform thrombectomy?

“Sutor, ne ultra crepidam” a Latin expression for shoemakers not beyond the shoe, a common saying to warn people to avoid passing a judgment beyond their expertise.

With mechanical thrombectomy changing the management of stroke and becoming the standard of care for patients with large vessel occlusion (LVO), a new challenge has emerged, adequate access for care.

A recent cross-sectional study by Aldstadt et al.1 aimed to determine the percentage of the US population with 60 min (ground or air) to a designated or non-designated endovascular capable stroke center, or percentage of non-designated endovascular centers that were 30 min from an endovascular capable center.  They reported that overall a 49.6% of the US population is within 60 min of an endovascular capable stroke center, while 37% of the US population lacked access to endovascular capable centers within 60 min. For the non-endovascular stroke centers, 84% have access within 60 min, and 45.4% are within 30 min drive from an endovascular capable stroke center.

Since time is the brain, increasing the access to care is of paramount importance and increasing the number of well-trained physicians equipped to perform and treat stroke holistically.  Since there are approximately 10 times more interventional cardiologists, radiologists, and vascular surgeons than neuro interventionalist in the USA (10.000 vs. 800-1000)2, some non-endovascular capable hospitals have explored the option of incorporating some of this workforce to contribute to patient care.

Some retrospective studies3 with low sample sizes have described that their interventional cardiologist team was able to perform a thrombectomy safely, with the guidance of a stroke neurologist. Nonetheless, they are not clear on the prior training these cardiologists have had regarding neurovasculature, the nuances of the procedure, critical care, and stroke neurology.

Endovascular Neurosurgery and Interventional Neuroradiology is a field shared by physicians with different backgrounds in training, such as neurosurgeons, neurologists, and interventional radiologists. Regardless of their background or training, they are all required to complete an additional 1-2 years of training exclusively for neurointervention. Endovascular physicians trained rigorously per ACGME4 requirements were most of the physicians involved in the clinical trials (ESCAPE and DAWN) and maintained a high caseload volume of thrombectomy. The cumulative case volume is crucial since it has been associated independently for obtaining good recanalization and outcomes.5

Even if the technical aspects have various similarities between the endovascular fields, shoemakers not beyond the shoe, cannot be translated from one field to another without proper training. To adduce that interventionalist cardiologist can inherently treat intracranial diseases would be, in my opinion, not in benefit of the care of the patient, even if they are the only option nearby where no endovascular treating center can be reached, the patient outcome of patients is directly correlated with the expertise of the treating physician.

Nonetheless, interventional cardiologists should only be allowed to perform thrombectomies if they complete a full endovascular fellowship with the requirements established by the ACGME and as the other specialties go through (interventional radiology, neurosurgery, and neurology). This formal training could contribute to those rural areas where there is no possibility to access an endovascular center. More efforts should be made to increase access to endovascular capable stroke centers, to continue training neurosurgeons, radiologists, and neurologists to meet patients’ demands requiring this life-saving treatment.  But I don’t consider converting specialists in treating myocardial infarctions to stroke being a priority in the US.

REFERENCE

  1. Aldstadt J, Waqas M, Yasumiishi M, et al. Mapping access to endovascular stroke care in the USA and implications for transport models. Journal of NeuroInterventional Surgery. 2021:neurintsurg-2020-016942.
  2. Hopkins LN, Holmes DR. Public Health Urgency Created by the Success of Mechanical Thrombectomy Studies in Stroke. Circulation. 2017;135(13):1188-1190.
  3. Hornung M, Bertog SC, Grunwald I, et al. Acute Stroke Interventions Performed by Cardiologists: Initial Experience in a Single Center. JACC Cardiovasc Interv. 2019;12(17):1703-1710.
  4. Hussain S, Fiorella D, Mocco J, et al. In defense of our patients. J Neurointerv Surg. 2017;9(6):525-526.
  5. Kim BM, Baek J-H, Heo JH, Kim DJ, Nam HS, Kim YD. Effect of Cumulative Case Volume on Procedural and Clinical Outcomes in Endovascular Thrombectomy. Stroke. 2019;50(5):1178-1183.

“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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Blood pressure and the consumption of sodium and potassium, which is more important?

Nutrition is one of many lifestyle factors that contribute to cardiovascular disease. Specifically, both sodium and potassium are known to influence the regulation of blood pressure (raising and/or lowering). The dysregulation of blood pressure is related to either too much sodium or little potassium (1-2). Jackson et. al., 2018, surveyed 765 participants to obtain estimates of sodium and potassium intake through 24 hour urine collections. Only about 4.2% dietary sodium intake met the dietary guidelines of less than 2300mg/d, and dietary potassium was reported as 1997 mg/d. The recommended intake for potassium is 4700mg/d. Furthermore, the study highlighted that a 1000-mg-lower level of sodium intake was associated with a –4.4 mmHg level of systolic BP and a 1000-mg higher level of potassium intake a –3.4 mmHg level of systolic BP.

Source: https://ods.od.nih.gov/factsheets/Potassium-HealthProfessional/

Similjanec et al., 2020, showed how dietary potassium could reduce the detrimental effects of sodium on vascular function. The investigators used a 24-hr urine collection and were able to group individuals into a salt-resistant group. Salt resistance was defined as a change of 5 mmHg or less in 24-h mean arterial pressure. In the figure to the left, the authors show how

a potassium-rich diet can mitigate the effects of high dietary sodium on flow-mediated dilation, a technique that shows the strong association of cardiovascular disease risk (3). See figure 3.Thus, adequate consumption of dietary potassium could be protective to many people in the U.S.

Source:  https://pubmed.ncbi.nlm.nih.gov/31562419/

Looking at the nutrients together and the impact on health is vital, especially in the case of blood pressure regulation. Similjanec et. al., 2000, results in highlight the need to consider potassium in future investigations for the management of blood pressure and cardiovascular disease risk.

Kogure et al., 200, used an OMRON Healthcare urinary Na/K ratio monitor to look at the urine ratio of Na/K. This handheld self-monitoring device was supported through multiple measurements of the urinary Na/K ratio which were strongly related to home hypertension regardless of the treatment status for hypertension (4). Figure 4 highlights the prevalence of home hypertension over 10 days.

A solid starting spot for keeping your blood pressure in check is to look for some dietary sources you enjoy. Here are some good dietary sources of potassium to add to the diet from the national institute of health’s webpage.

Apricots for the win!

Source: https://ods.od.nih.gov/factsheets/Potassium-HealthProfessional/

 

References:

1) Jackson, S. L., Cogswell, M. E., Zhao, L., Terry, A. L., Wang, C. Y., Wright, J., Coleman King, S. M., Bowman, B., Chen, T. C., Merritt, R., & Loria, C. M. (2018). Association Between Urinary Sodium and Potassium Excretion and Blood Pressure Among Adults in the United States: National Health and Nutrition Examination Survey, 2014. Circulation137(3), 237–246.

2) Smiljanec K, Mbakwe A, Ramos Gonzalez M, Farquhar WB, Lennon SL. Dietary Potassium Attenuates the Effects of Dietary Sodium on Vascular Function in Salt-Resistant Adults. Nutrients. 2020; 12(5):1206.

3) Ras RT, Streppel MT, Draijer R, Zock PL. Flow-mediated dilation and cardiovascular risk prediction: a systematic review with meta-analysis. Int J Cardiol. 2013 Sep 20;168(1):344-51. doi: 10.1016/j.ijcard.2012.09.047. Epub 2012 Oct 4. PMID: 23041097.

4) Kogure, M., Hirata, T., Nakaya, N. et al. Multiple measurements of the urinary sodium-to-potassium ratio strongly related home hypertension: TMM Cohort Study. Hypertens Res 43, 62–71 (2020). https://doi.org/10.1038/s41440-019-0335-2

“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.”