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CardioPulmonary Resuscitation (CPR) in the Time of COVID-19

As we continue to see the increasing number of coronavirus disease 2019 (COVID-19) cases and amid the second peak of this pandemic in the United States (US), everyone from physicians to the general public should know how to approach and perform basic life support (BLS) with certain precautions and modifications of routine BLS protocols for patients with suspected or confirmed COVID-19 status. Importantly, rescuers should always balance the immediate needs of patients with their own safety. Several recently published articles have demonstrated that many patients with COVID-19 can present with cardiac arrest or experience cardiac arrest while hospitalized. In this post, I am going to share a few points on recommended modifications in order to ensure a safe yet effective CPR protocol for our patients.

  • Reduce Provider Exposure to COVID-19

Resuscitations carry added risks to rescuers and healthcare workers for many reasons. CPR involves performing numerous aerosol-generating procedures, including chest compressions, positive-pressure ventilation, and establishment of an advanced airway [1]. It is important to keep in mind that these viral particles can remain suspended in the air with a half-life of around 1 hour per some reports and can be inhaled by those nearby [1]. In addition, resuscitation efforts require numerous providers to work in close proximity to each other and to the patient; thus, the advised social distancing protocols may not be applicable.

Strategies

  • Before entering the scene, all rescuers should don personal protective equipment (PPE) to guard against both airborne and droplet particles.
  • Limit personnel on the scene to only those essential for patient care.
  • In settings with protocols in place and expertise in their use, consider replacing manual chest compressions with mechanical CPR devices to reduce the number of rescuers whenever it is available and in patients who meet the manufacturer’s height and weight criteria.
  • It is important to clearly communicate the COVID-19 status to anyone arriving to the scene and when transferring patients to another setting.

 

  • Prioritize Oxygenation and Ventilation Strategies with Lower Aerosolization Risk
Strategies
  • Attach a high-efficiency particulate air (HEPA) filter securely [Figure 1], if available, to any manual or mechanical ventilation device to lower the risk of aerosolization before giving breaths.
  • After healthcare providers assess the rhythm and defibrillate any ventricular arrhythmias, patients in cardiac arrest should be intubated with a cuffed tube at the earliest feasible opportunity. Connect the endotracheal tube to a ventilator with a HEPA filter when available.
  • Minimize the likelihood of failed intubation attempts by doing the following:
    • Assign the provider/approach with the best chance of first-pass success, and
    • Pause chest compressions while intubating with minimal disruption.
  • Video laryngoscopy may reduce exposure to aerosolized particles and should be considered.
  • Once on a closed circuit, minimize disconnections in order to reduce aerosolization.
  • Barriers can be used to minimize spread of the particles during aerosol-generating procedures (Figure 2).

Figure 1: A high-efficiency particulate air (HEPA) filter (arrow) is securely attached to any manual or mechanical ventilation device to lower the risk of aerosolization before giving breaths [2].

Figure 2: Example of barriers potentially used to minimize the spread of the particles during aerosol-generating procedures [2].

  •  Consider the Appropriateness of Starting and Continuing Resuscitation

Like any cardiac arrest, it is important to know when resuscitation efforts are likely to be futile. Although the outcomes for cardiac arrest in COVID-19 are still unknown, the mortality for critically ill patients with COVID-19 is high, especially with increasing age and comorbidities, particularly cardiovascular disease. As such, it is critical to consider all these factors in determining the appropriateness of initial and continued resuscitation efforts, to weigh the likelihood of success against the risk to rescuers.

Strategies
  • Address goals of care with patients, or their proxies, in anticipation of the potential need for increased levels of care.
  • Healthcare systems and Emergency Medical Services (EMS) agencies should institute policies to guide frontline providers in determining the appropriateness of starting and terminating CPR for patients with COVID-19 on the scene, early in the process. The risk stratification and potential policies should be communicated to patients (or proxy) during discussions of goals of care.

In conclusion, there have been modifications to the routine CPR protocols in patients with suspected or confirmed COVID-19. With the increasing number of COVID-19 cases, it is very important, for us as physicians and for the general public as well, to review recommended modifications to BLS protocols and apply them where possible, in a step to win the battle against this virus during these unprecedented times!!

References

“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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Evidence: What’s good, What’s good enough, What’s dangerous? Lessons for now and later.

COVID-19 has created a complex environment for health research. In an evidence vacuum with a clinical imperative to act, we have few choices. They include relying on analogues (such as SARS or MERS), trying treatments based on theoretical biological plausibility, relying on anecdotal evidence and case reports, and rushing evidence from small studies that may have significant limitations into print. There is a need for answers that are definitive but also rapid: a condition that science as we currently practice it can’t satisfy. Additionally, peer review relies on content-area experts, which are hard to find for a rapidly evolving area when potential experts are also stretched thin with clinical and research roles. The result is that evidence may look different from what we are accustomed to.

Some healthcare practitioners and scientists have reacted with alarm when low-quality studies have been published by normally meticulous journals. Are we abandoning the RCT, they ask? Is appropriate statistical analysis no longer required? Does the name of a prestige journal no longer guarantee rigor? Is low-quality evidence worse than no evidence at all? Is it wise to publish clinical observations in a newspaper rather than a medical journal? Who is responsible when a public (or public official) not equipped to recognize the limits of early evidence spreads misinformation? Are resulting adverse events or medication shortages partially the responsibility of the publication? The researcher?

These are debates worth having, and there will be compelling arguments on both sides. No matter your stance, though, there will be an impact on the future of science.

Lessons include:

  • Critically reading studies and understanding their strengths and limitations remains a valuable skill. Just because something is in print doesn’t mean it should be in practice. Scientific education in all disciplines needs to continue to focus on this skill.
  • Perhaps the standard glacial pace of evidence dissemination can, in fact, improve. Faced with undeniable urgency, the mechanisms of publication are adapting. Turnaround time measured in days or weeks rather than months or years is possible.
  • Lots of content related to COVID-19 from academic and lay publications alike is open-access— because it is seen as for the public good. Perhaps that perception can broaden, and alternative payment structures will make science more accessible.
  • The translation of basic science to clinical application (bench to bedside) can move rapidly when needed. As my fellow blogger Sasha Prisco has noted, there are currently administrative barriers that hinder this work, and their long-term necessity may need to be reevaluated.
  • Real-time information sharing and collaboration occurs through multiple channels beyond academic journals, including social media sites.

Have you considered the potential impact of this pandemic on the future of scientific publication and knowledge dissemination? Has it changed your ideas about publishing, research, evidence-based practice?

“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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COVID-19 Pandemic: 5 lessons about the way we (should) debate in medicine

In my previous blog, I shared five lessons about the way we practice medicine, which I believe were highlighted by the unprecedented circumstances of the COVID-19 pandemic. I would like to share five more COVID-19-inspired reflections, but this time it’s about the way we, as physicians, debate our medical opinions and the thought processes through which we form these opinions to begin with. While these thoughts came as a result of following scientific debates on social media, I believe they apply to all sorts of debates in other contexts as well:

  1. Opinions are not principles.  Principles are ethical codes we live by and cherish for our whole life. Opinions, on the other hand, are impressions and ideas that we make as we go, based on information that is available to us (with some emotional influences as well). That being said, while it might take a major life event for someone to change their principles; opinions can, and should, change quite often. There is nothing wrong about changing one’s opinion based on new information or on changing circumstances. In fact, this only reflects a healthy and dynamic thought process. Keeping that in mind makes it easy for us to admit when we’re wrong and to accept that others are allowed to change their position without being accused of hypocrisy.
  2. Debate is not an aim. With the urge to prove our point and support our convictions, we often forget the real aim of any debate; reaching the truth through exploring alternative interpretations. Social media has opened unprecedented venues for endless debate, and the field of medicine has remarkably caught up to this. Unfortunately, we sometimes forget that proving our point often gets in the way of actually finding the truth.
  3. Absence of evidence is not evidence of absence. As physicians, we adopt a scientific thought process. We always strive to find evidence to support any medical claim. Nonetheless, it is important to remember that just because something is not supported by evidence, it does not necessarily mean that it’s not true. It often only means that “we don’t know”. In the midst of scientific debates, we tend to forget this simple fact and start to proclaim that a certain medical intervention doesn’t work simply because it hasn’t yet been assessed by clinical trials. The more accurate way to address this is to say that we don’t know if it works or not, otherwise, we would be committing the same error we were criticizing in the first place.
  4. Bias is vulnerability. Bias and prejudice are human flaws. And we are all human. We tend to be a lot less rigorous in our scrutiny of the methodology and the validity of the results of an article (scientific or otherwise) when the findings are consistent with our own bias. We tend to drop our most important defense mechanism against gullibility—our ability to think systematically and to critically appraise the evidence. This becomes particularly obvious on social media where we are quick to enthusiastically share (and sometimes praise) studies that support our viewpoints, without properly examining the content. Eliminating this bias requires a conscious effort when assessing data that align with our opinions to be even more careful.
  5. We know very little, so be humble. Every day, nature shows us that no matter how much our medical knowledge increases over time, we still know relatively very little about the world we live in. COVID-19 is just another reminder. It’s true that some of us know more than others, but in the big scheme of things, none of us is in a position to brag or be condescending. So no matter whom or what we’re debating, let’s remember to be humble, be kind, and be respectful.

 

“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 a Pandemic Worsens Overall Cardiovascular Health in the U.S.

The novel coronavirus pandemic, currently holding the global population hostage in their homes, has killed over 150,000 people and infected over 2 million. The US leads all nations in both categories. One only needs to look out the window, or visit the local grocery store, to understand the overwhelming sentiment amongst the people.

Afraid.

Lonely.

Stressed.

In a pre-COVID blog post, I reviewed a paper by Brewer et al. that investigates the deleterious affects of chronic stress, minor stresses and major life events on one´s overall cardiovascular health, as determined by the AHA´s Life´s Simple 7 initiative.1 In summary, the authors found that the study participants performed worst in diet, BMI, physical activity and smoking metrics. They reference research studies of depression, CVH and smoking when proposing a theory as to why this profound correlation exists. The studies identify binge eating and smoking to be adverse behavioral responses to psychosocial stress, as well as decrease in physical activity.

The current pandemic is an acute stressor, and major life event, for us all. Unemployment claims in the U.S. have topped 20 million, stock prices are 40% lower than their 2019 highs, one third of the world´s school-aged children are home, local and international businesses are closed, flights are grounded and this graduation/wedding season will be like none we´ve ever witnessed. Psychiatric telehealth consultations are at an all-time high because this is not our steady state; we are social by nature. The current pandemic´s acute stress on our society will inevitably affect its overall cardiovascular health.

I like this illustration of the effects of psychosocial stress on the hypothalamic-pituitary-adrenal axis, and how that translates to increased cortisol level and the subsequent worsening of many cardiovascular risk factors.2

When juxtaposed with the graphic below, illustrating AHA´s Life´s Simple 7, it is quite clear that our current state of stress is antithetic to our goals of reducing cardiovascular death and improving cardiovascular health by 20% by the end of 2020.

With no clear end in sight, but promising figures showing flattening of the disease curve, we must begin tackle the deleterious effects of this acute but soon to be chronic stress on our patient population. Otherwise, we will awake from this pandemic with clinics full of less healthy patients at higher risk of succumbing to an already deadly disease.

At home strategies for exercising, healthy eating, meditation etc will be discussed in my next blog post. For now, be safe, stay home and keep hope alive!

References:

1) Brewer LC, Redmond N, Slusser JP, Scott CG, Chamberlain AM, Djousse L, Patten CA, Roger VL, Sims M. Stress and Achievement of Cardiovascular Health Metrics: The American Heart Association Lifes Simple 7 in Blacks of the Jackson Heart Study. Journal of the American Heart Association, 7(11). doi:10.1161/jaha.118.008855

2) Iob, Eleonora & Steptoe, Andrew. (2019). Cardiovascular Disease and Hair Cortisol: a Novel Biomarker of Chronic Stress. Current Cardiology Reports. 21. 10.1007/s11886-019-1208-7.

“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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Changes to CPR and Response to Cardiac Arrest with COVID-19

When it comes to survival of out of hospital cardiac arrest (OHCA), many advances have been made over the years, 1 early and high-quality chest compressions and defibrillation are key components of this. However, even prior to coronavirus and COVID-19, many bystanders are still hesitant to perform CPR for a variety of reasons; fear of litigation, fear of causing harm, or due to concerns about infectious disease transmission.2 In the new age of social distancing and a highly infectious disease causing stress on our world, the hesitancy may increase. In addition, many programs who have been key in providing education, such as CPR training, have come to a halt during this time.

CPR is generally considered an “aerosolized” procedure, 3 a procedure conveying high risk of transmission of disease via respiratory droplets. Resuscitation efforts in and out of hospital require multiple people in close proximity to each other to respond. In addition, COVID-19 has been reported to cause myocardial injury and ventricular arrhythmia that may predispose someone to cardiac arrest, 1 and despite a pandemic, sudden cardiac arrest and other causes of death do not decline. A concern rising in the medical community since shelter-in-place laws and changing stresses on our medical system, is a notable decrease in visits to the Emergency Departments for common complaints and concerns, such as chest pain, syncope and other things that may dispose someone to a cardiac arrest. We need to be aware of this happening in the community and the potential need for lay and EMS response in these situations.

Lay persons and dispatchers play a key role in survival efforts such as initiating CPR and early defibrillation. There has been documented success with telephone CPR and CPR guidance by dispatchers. An important component of ensuring the best survival of the community and those with COVID-19 or potential COVID-19 is communication and a well-developed community plan to ensure timely and quality resuscitation to patients while protecting rescuers. Recently, Circulation has released Interim Guidance and Advanced life Support in Adults, Children, and Neonates with Suspected or Confirmed COVID-19,1 a quick review is here. Resources from King County EMS in Washington are available for establishing a community response and plan here.

Overall, the common themes are aimed at adequate personal protective equipment (PPE), reducing the number of people responding to an event, and in the case of OHCA for lay people, focusing on hands-only CPR.

For lay persons, the majority of SCA occurs at home. The likelihood of already being exposed to a household contact is high and should be considered when responding to an arrest; for adults hands-only CPR with high-quality compressions is encouraged with early activation of EMS and defibrillation(not an aerosolizing procedure), if available. In the case of pediatric resuscitation, due to the high likelihood of respiratory arrest causing cardiac arrest, it is advised that if willing, after weighing the risk and benefit, that rescue breaths are provided along with compressions. You may use a cloth or mask covering over the victim’s mouth to help reduce transmission in the event it is not a household member.1

For EMS providers, dispatch is crucial in screening calls for any possible risk of exposure to COVID-19, based on symptoms in the victim or any recent contact or household members, and advising whether doing PPE is recommended to the EMS team.1 In Seattle, they have shown a very low rate of transmission to EMS providers when wearing the appropriate PPE.4

For in-hospital cardiac arrest, it is again important to reduce the personnel involved in the resuscitation, close the door when possible, and consider adding PPE to the code carts.  It is also important to use HEPA filters and closed circuit ventilation strategies when it comes to ventilation. The guidance also encourages early intubation by the provider with the highest qualification with the best chance for successful intubation, and use video laryngoscopy when able to minimize aerosolizing the virus while securing a closed circuit airway. The guidance also suggests that if patients are prone and intubated to perform CPR without moving the patient in the standard T7-10 vertebral bodies, however, if they are not intubated to attempt to place them supine and proceed with resuscitation.1

The article also discusses the importance of clarifying goals of care and advanced directives upon arrival, as well as proposes a careful evaluation in the cases of out of hospital cardiac arrest with inability to obtain ROSC, suggesting in some cases, this may be a reason to avoid transport to the hospital due to low likelihood of survival. However, it is important to take into consideration with the benefit, risk and ethics involved.1, 3

Another important update is in regards to maintenance of certification such as BLS/ACLS/PALS. As of March 13, the AHA has offered a 60 day extension for instructor cards and also recommends extension of provider cards for the same length, this allowance is open to be extended based on the evolving threat and CDC/public health recommendations, read the statement here. 5

Many people are looking for things to do in this time of sheltering in place, perhaps this could be an opportunity for education and learning on CPR and AED’s. There are many online resources available, and with the advent of telemedicine, zoom learning and video visits increasing, perhaps we could use this as an opportunity to increase our virtual presence for CPR education.

If you’re interested in some online resources, check out the ILHR website, or your local education center’s website.

  1. Edelson, Dana P, et al. “Interim Guidance for Life Support for COVID-19.” Circulation, ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.120.047463.
  2. Scquizzato, Tommaso, et al. “The Other Side of Novel Coronavirus Outbreak: Fear of Performing Cardiopulmonary Resuscitation.” Resuscitation, vol. 150, 2020, pp. 92–93., doi:10.1016/j.resuscitation.2020.03.019.
  3. Defilippis, Ersilia M., et al. “Cardiopulmonary Resuscitation During the COVID-19 Pandemic: A View from Trainees on the Frontline.” Circulation, Sept. 2020, doi:10.1161/circulationaha.120.047260.

“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 is the COVID-19 pandemic affecting cardiac patients and the cath lab?

Amongst the uncertainty of the future and how this pandemic will end, there comes a huge responsibility on all healthcare workers to care for the sickest patients while staying safe, to lead their healthcare systems and to come together as one unit against this crisis. Seeing how this pandemic has affected our healthcare system, from the evolving utility of telehealth to canceling elective procedures in multiple specialties, I decided to share a few thoughts on COVID-19 and the cardiovascular manifestations associated with this infection and how COVID-19 has affected our approach to commonly performed procedures in the cardiac catheterization lab.

Cardiovascular manifestations of COVID-19

Although coronavirus predominantly affects the respiratory system, causing a variety of symptoms from flu-like symptoms to acute respiratory failure requiring intubation, it can affect other organs, and patients may present with non-respiratory complaints [1]. The cardiovascular manifestations of COVID-19 have a wide range of clinical presentations (Figure 1), from pericarditis, myocarditis, pericardial effusion, and decompensated heart failure to tamponade, cardiogenic shock and ST-elevation myocardial infarction (STEMI) [1-2]. In addition, right ventricular strain should raise suspicion for pulmonary embolism as these infected patients tend to be hyper-coagulable with a high incidence of venous thromboembolism for currently unclear reasons. It is important to recognize these cardiovascular manifestations of COVID-19, as it is thought that cardiovascular involvement is associated with a worse prognosis [1].

Figure 1: Potential risk factors and cardiovascular manifestations of COVID-19 patients.

Approach to Acute Coronary Syndrome (ACS) and Structural Procedures in the Cath Lab in COVID-19 Pandemic

Like any procedural field, interventional cardiology has been affected by this pandemic. All elective procedures are being postponed until the crisis settles down per recommendations from the Centers for Disease Control and Prevention (CDC), with emergent, urgent, time-sensitive procedures still being performed, in an attempt to preserve hospital beds and personal protective equipment (PPE) for COVID-19 patients [2]. This pandemic has led to several changes in the ACS approach across the world, with the main goal of reducing un-necessary exposure to health care workers and limiting the spread of this highly contagious disease [1,2].

To summarize, some of the key changes many hospitals have applied in their approach to some of the most commonly performed percutaneous cardiac procedures in COVID-19 patients:

  • ACS patients
  • Thrombolytics are considered standard therapy in many hospitals for many STEMI patients with symptoms <12 hours and no contraindications: signs of success are resolution of symptoms and/or >50% decrease in ST elevation. If thrombolytics fail, coronary angiogram and percutaneous coronary intervention (PCI) should be considered in an isolated cath lab (Figure 2) and the benefit versus the exposure risk should be carefully evaluated.
  • For patients with low risk Non-ST elevation myocardial infarction (NSTEMI): medical therapy is reasonable. For those with high risk NSTEMI or failure of medical treatment, coronary angiogram and/or PCI should be performed. These coronary procedures are usually performed in isolated cath labs with only limited staff in the cath lab room, to avoid unnecessary exposure (Figure 2).
  • Structural heart disease patients
  • For patients who are unstable and have severe aortic stenosis (AS), balloon aortic valvuloplasty (BAV) should be performed emergently to stabilize the patient if this is thought to be the cause of the hemodynamic instability. For those who develop significant aortic regurgitation after BAV, transcatheter aortic valve replacement (TAVR) should be performed.
  • Patients with severe symptomatic AS, TAVR is considered a time-sensitive procedure. The benefit of TAVR and risk of infection exposure should be discussed.It is important to note that this change in policy, in part, could explain the decrease in cath lab activation rates for STEMI during this pandemic [2]; as many STEMI patients are receiving thrombolytics. In addition to that, many patients are not seeking medical care, or if they do, they are presenting late, possibly due to fear from contracting the virus in the hospital, potentially leading to late STEMI complications [2]. Thus, it is important to counsel our patients in our virtual clinic visits that if significant symptoms develop, they should seek medical care.

Lastly, I want to thank all of my colleagues and healthcare workers across the nation and across the globe for risking their lives for patients and for their continued dedication. This is a critical time for everyone in the health care system. In light of this pandemic, I hope we continue to learn and share our experiences in this global crisis in order to improve our patient’s care, safety for our healthcare workers and the dynamics of our healthcare system.

Figure 2: Simplified Set-up of an Isolated Cath Lab during the COVID-19 pandemic.

References

“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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Another (Louder) Call to Improve the Care We Provide Heart Failure Patients

I am always taken aback when I recommend a switch to sacubitril/valsartan in a patient with heart failure with reduced ejection fraction (HFrEF) and the response is “my patient feels fine”. This is a common response and certainly not a good enough reason to not optimize guideline directed medical therapy (GDMT) in patients with HFrEF. Optimization of GDMT in HFrEF, known to improve morbidity and mortality (1,2), is dismal. The Change the Management of Patients with Heart Failure (CHAMP-HF) registry included patients in the United States with chronic HFrEF receiving at least one oral medication for management of HF and showed >25% of eligible patients are not prescribed angiotensin converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor, >33% are not prescribed a beta blocker, >50% are not prescribed a mineralocorticoid receptor antagonist. Remarkably, even among those receiving GDMT fewer than 25% are prescribed target doses and only 1% of eligible patients are simultaneously on target doses of all 3 classes of GDMT (3,4).

The mechanisms for suboptimal prescription of GDMT in HFrEF are complex and undertreatment is even more evident among women, minority patient populations, and patients from economically disadvantaged backgrounds, among others. Cost is certainly an issue, especially with more novel HF therapies and co-pay assistance programs are not always available to our most vulnerable patients. There are not enough HF cardiologists to take care of the continuously increasing population of HF patients and therefore, optimization of GDMT needs to be done by general cardiologists and primary care clinicians as well. We should also become creative and use telemedicine to optimize GDMT more efficiently. We do our patients a disservice by not optimizing GDMT that improves HF morbidity and mortality.

And just as optimization of GDMT is not ideal, neither is our evaluation of etiology of HF. Optimization of GDMT and determination of etiology of HF whose management may change disease trajectory should be undertaken in all patients with new-onset HF. This begins with a fundamental understanding of the various etiologies of HF, the laboratory and imaging testing needed, and the best treatment strategy for the underlying etiology discovered- if any (cue, “idiopathic” cardiomyopathy). O’Connor and colleagues’ observational cohort study from the Get With The Guidelines- Heart Failure (GWTG-HF) registry demonstrates the need to improve the testing we perform to exclude coronary artery disease (CAD) as the underlying etiology of new-onset HF.4

Why is this important? Well, of course for treatment, which involves deciding whether medical therapy (aspirin, statins) or revascularization (surgical or percutaneous) is a more optimal strategy. And most important to improve disease trajectory as continued ischemia will lead to worsening HF. O’Connor and colleagues found that the majority of  17,185 patients hospitalized for new-onset HF did not receive testing for CAD either during the hospitalization or in the 90 days before and after, despite data demonstrating that 60% (!!!) of HF patients have concomitant significant CAD.4 And consistent with disparities I mentioned earlier regarding the undertreatment of women with GDMT, men were more likely to be tested for CAD.

Diagnosing and treating CAD provides an opportunity to discuss risk factor modification with patients such as smoking cessation, diabetes control, exercise, healthy diets etc.… to further mitigate future risk. The importance of optimization of GDMT in patients with HFrEF cannot be understated and analogous to this, is the importance of examining the underlying etiology of HF in patients with new-onset HF with preserved, borderline, or reduced EF to improve disease trajectory. Furthermore, inequities in both aspects of the care of HF patients in terms of identification of etiology and optimization of GDMT, must be addressed on a national level. We have plenty of data illustrating suboptimal optimization of GDMT in those with established HFrEF and suboptimal testing for CAD in those with new-onset HF. The next steps are understanding the mechanisms and implementing strategies to improve care. The need for this is critical to reduce morbidity and mortality in all HF patients.

References

  1. Yancy CW, Jessup M, Bozkurt B et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation 2017;137.
  2. Yancy CW, Januzzi JL, Allen LA et al. 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction. Journal of the American College of Cardiology 2017.
  3. Greene SJ, Butler J, Albert NM et al. Contemporary Utilization and Dosing of Guideline-Directed Medical Therapy for Heart Failure with Reduced Ejection Fraction: From the CHAMP-HF Registry. Journal of the American College of Cardiology 2018.
  4. O’Connor, Kyle D., et al. “Testing for Coronary Artery Disease in Older Patients With New-Onset Heart Failure.” Circulation: Heart Failure, vol. 13, no. 4, 2020, doi:10.1161/circheartfailure.120.006963.

“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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Future Planning in the Time of Corona

(Image from pixabay.com CC-0)

Let me ask you this: How many articles related to COVID-19 did you read, in the past few weeks? Just like most of us, medical science professionals of all kinds, the content we have been consuming most of has been related, directly or indirectly, to the biggest pressing issue the world is dealing with presently. And I’m here to say this is totally fine & appropriate. After all, when was the last time a biomedical issue became the worldwide number 1 topic of interest. SARS-CoV-2 is harming the healthy, and vulnerable patients. It’s also harming society, economy, policy, and more, both in predictable ways and in ways we still have no solid forecast ability for yet. This is why present efforts towards containment, mitigation, and other management actions are so vital and require the buy-in from all individuals in society. In parallel, this is also why the biomedical, and more broadly, the life science field in general, is very much pivoting their attention at the moment, vigorously brainstorming and planning future directions (while #StayingHome of course) in an effort to better understand, deal with, and avoid future similar scenarios that will inevitably happen again.

One of the more crass and unpalatable statements that get thrown around in times like these, especially within the halls of certain types of political and financial power brokers is “Never let a crisis go to waste”. The point being, while people are distracted by the overwhelming day to day events that unfold in times of struggle, some individuals use the cover provided and make certain that some of their goals and demands that normally get blocked in more orderly times, can be enacted and their aims can be realized. The prevalence and precision of this type of maneuver is so well-honed and practiced that a lot of folks refer to it as part of the “playbook” in political and financial writing. And the reality is, it works! And while historically it’s been used for ways to benefit the few over the many, “Never let a crisis go to waste” is, at its core, a useful and effective strategy, that can be implemented to benefit the many, the society, and everyone in it.

A global pandemic is one of the few causes that truly brings to attention the uniting themes and areas of need that a vast majority of the world population face. Whether it’s the instability and vulnerability of the supply chains of food and goods, or the imbalance of economic status-quo that we all come to take for granted. These and many other angles that require addressing are perfect opportunities to utilize that play from the playbook “Never let a crisis go to waste”. I sincerely hope altruist economists and politicians are brainstorming, or bringing out and dusting off old shelved plans that have not had a chance to be enacted in the status-quo times. I hope they’re doing their best to ensure that once we, as world citizens, are able to turn the tide on COVID-19, we have a chance to achieve a course correction and a new balance that puts us on a path for a healthier, more egalitarian world.

To focus on the biomedical side of this equation, and the needs that should be addressed, we should face some of the facts unfolding right in front us, in real time. Looking at the healthcare systems of many cities and countries around the world, we right now see the vulnerability our healthcare providers are made to experience. Lack of personal protective equipment, lack of numbers of health care workers needed in a particular city or country, difficulty in coordination of testing and acquiring enough medicine and lifesaving equipment, and a number of other vital issues that have been uncovered by this pandemic. These are the types of factors that must be addressed so that they can be avoided in the future. These are just a handful of examples, and many others are getting documented. If I can state this in one sentence (severely oversimplifying it, but the point remains true): Cities need to have healthcare infrastructures that won’t get overwhelmed when more than 5% of the population served requires attention in a short period of time. There needs to be plans, equipment, and available reserve workforce that can quickly (in a matter of days, not weeks or more), expand and enlarge the healthcare infrastructure to accommodate the needs of the population.

And while it’s obvious now, it must be said that support and focus on research geared towards coronavirus specifically, and more broadly infectious disease, must be bolstered and elevated to higher priority, which it definitely was not, prior to this latest health crisis. Additionally, let’s not forget that biomedical research of all types is constantly working to investigate, and help defend the world from exactly this type of burden. Research if fields such as cardiovascular diseases (still the #1 cause of mortality worldwide, WHO data), or cancer, or any other field in bioscience or medicine is our way to avoid a future similar to this moment. Maybe (hopefully) the physicians and scientists that are in a position to “Never let a crisis go to waste” can find a way to make their causes more of a priority, and their efforts can be more widely acknowledged, and their research more efficiently utilized, to help us all in avoiding similar future healthcare challenges.

 

“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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Thoughts from a Physician Scientist Trainee During the COVID-19/SARS-CoV-2 Pandemic

I had a very difficult time figuring out a blog topic for this month. It has been difficult to think about topics other than COVID-19. Like a lot of you, my usual routine has dramatically changed over the last couple of weeks. Additionally, I find myself having a difficult time concentrating with emotions sometimes fluctuating from fear, anger, grief, and frustration, to hope and pride. Some of my recent days have been occupied by reading a plethora of articles, blogs, or social media posts about COVID-19, being anxious about the next time my husband or I see patients, urging people to practice social distancing and to donate PPE, and contacting family and friends to check on their physical and emotional well-being along with trying to complete some work.

I am currently a Cardiology postdoctoral fellow who has protected time to complete basic science research. I started my postdoctoral research fellowship this academic year and my hope was to immerse myself in basic science research over the next couple of years. I was hoping to have a productive lab experience and find an area that I could ultimately build my future research career. These few years of protected research time are critical to my development as a physician-scientist. From a research perspective, I have recently experienced a multitude of failures and disappointments this year (with some intermittent successes): failed experiments that have required an extensive amount of troubleshooting, rejected papers, triaged grant applications, etc. I know that I am not alone in experiencing the frequent failures that one encounters in research. My usual strategy is to be persistent, keep busy, and continue to move all research projects forward in the hopes that at least one of the projects will be fruitful which is currently difficult to do. A few weeks ago, we were informed that all non-essential experiments should stop and that no new experiments should be started. Fortunately, my lab mentor respected this request and prioritized our health and safety. However, as we reduced our wet lab work to only essential animal experiments that were already started, I could not help but feel grief for the loss of potential research milestones.

The COVID-19 pandemic has further emphasized the societal importance of investing in research endeavors and researchers longtime. There are many articles and commentaries on early career investigators being disheartened by the challenges of an academic research career along with the diminishing pool of physician scientists. The presence of the COVID-19 pandemic has further highlighted the below changes that should be made:

  1. Increased funding for research: The study of mechanisms of disease along with development of therapies requires extensive time and effort. Multiple valiant researchers are currently studying COVID-19/SARS-CoV-2 with the fundamental goal of saving lives. Continuous societal investment in research will hopefully lead to the prevention of pandemics and earlier development of therapies for various diseases in the future.
  2. Increased financial and other support for trainees and early career investigators: Supporting early career investigators through training/career development grants, travel awards, local/national/international workshops, and opportunities to present work at national/international meetings will decrease attrition from academic research careers.
  3. Consideration of changes to the peer review process: The COVID-19 pandemic has emphasized the importance of rapid dissemination of information. While the peer review process is important in trying to only publish scientifically valid results, the process is imperfect. Frequently, the peer review process is inefficient (which is difficult since reviewers and editors are busy). Often there are many additional experiments that are requested for. During a time where completing additional experiments is difficult, I think reviewers should consider whether the request to complete additional experiments is necessary and would change the conclusion or validity of the study. In order to more quickly disseminate findings, many investigators are now putting their publications in preprint servers. However, some investigators have reservations about putting unpublished material on preprint servers while their papers are simultaneously undergoing the peer review process.
  4. Improve the efficiency of translating basic science research to the bedside: There are several bureaucratic and administrative barriers that impede translating basic science findings to the bedside. Processes that balance patient safety and improve efficiency are needed.

We will continue to learn a lot about how about to improve science and medicine during this time. Stay safe and be kind!

“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 World versus COVID-19

To whom it may concern,

 We are 4 months into 2020. #24 passed away. May he rest in Peace. #19 is trending upwards. Mamba mentality is much needed in our lives in ‘’the time of the corona”. On March 11th 2020, the World Health Organization (WHO) declared the coronavirus disease of 2019 (COVID-19) a pandemic. Today is April 7th 2020, around 1.4 million COVID-19 cases have been confirmed with almost 74 thousand deaths and counting worldwide. The health care system is bending to the point of collapse. Physicians, nurses and everyone involved are in this fight. Mamba Mentality it will be.

COVID-19 has not only impacted our individual lifestyle and health but has also harmed our global economy to the brink of destruction. Politics can’t fix this is now. Have we failed the health care system or has the health care system failed us? Public health crisis you say? Social distancing is proposed, knowing in some parts of the world it’s a privilege that cannot be afforded. COVID-19 is without discrimination, a pandemic that does not only involve me as individual, my home and my country but the world that has become a small place with globalization. It is about time to end disparities of care which have always been and will always be a matter of social justice. Justice hasn’t been just. We have failed years before COVID-19. Failure sometimes is what it is needed for success. #23 GOAT said, “I have failed over and over again in my life and that is why I succeed’’. We will rise. We must rise. We owe this to our planet.

Today, I am writing this blog not as a Cardiovascular Medicine Fellow in training, not as a General Internal medicine physician, not as a health care provider but as a citizen of the world. One world, one heart. Let’s beat strong, together and overcome COVID-19 and the chaos it brings. To quote Batman in the Dark Night Rises: “A hero can be anyone. Even a man doing something as simple and reassuring as putting a coat around a little boy’s shoulders to let him know that the world hadn’t ended”. It doesn’t matter if you are cardiology trained, dermatology, it doesn’t matter if you are just coming out of medical school, or without experience in health care, we can all be heroes and make a difference in this fight against the totalitarianism of COVID-19.

Thank you,

Michel

“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.”