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Highlighting Sessions at #BCVS21

While AHA Meetings are highly valued for their annually impressive original science presented to conference goers, these annual meetings also provide much sought-after space for highlighting and amplifying voices within cardiovascular research that historically have not been given center-stage. Over the past few years, the “Women In Science” and the “Early Career Networking” sessions have both proven to be coveted and successful highlights of the Basic Cardiovascular Sciences annual meeting.

(#BCVS21 Session 4: Women in Science Breakfast; screen capture by blog contributor)

This year the Women-In-Science session was held as the first slot on the second day of #BCVS21, and therefore it was aptly titled “Women In Science Breakfast”. The session was organized and moderated by Drs. Pilar Alcaide and Nicole Purcell, and they were joined by a panel composed of Drs. Jane Freedman, Merry Lindsey, Rong Tian and Joseph Hill, all of which are current Editors-in-Chief of various high impact journals in the cardiovascular field. This unique panel shared some timely information, such as:

  • Covid-19 has significantly increased the number of submitted manuscripts, therefore increasing the workload and pressure on the overall research publishing apparatus, from desk editors to reviewers and various journal production staff
  • For some much appreciated and applauded news, across the board journals have been increasing the number of women editors in scientific journals, many achieving over 50% of associate editors as women.
  • Journals are thinking beyond just article publishing, podcasts, social media, and other content amplifying tools are being more widely accepted and used to benefit the research being published in the journals.

The second session I’ll highlight in this blog is the Early Career Networking session, which was titled “BCVS Mix & Mingle”, and it lived up to its name even when it was 100% virtual, with impressive use of videoconferencing plans and gaming involving all attendees for the session. This session, as always, was sponsored by the BCVS Early Career Committee, chaired by Dr. Sean Wu and vice-chaired by Dr. Susmita Sahoo, and involved hosting and moderating duties by several the Early Career members (which included me, as a pseudo-game host for a BINGO! type event). The main goal of these networking events is to foster a sense of connection and community building for the early career scientists, from first-time attendees, to the annual card-carrying members of the Basic Cardiovascular Sciences community. Some of the highlights I experienced in this session include:

  • Live-video interaction with colleagues from all corners of the globe! A reminder that while virtual conferences do pose challenges and have limitations, these conferences currently provide the largest potential of bringing together the global science community.
  • A little bit of competitive drive definitely livens up a video conference room! Pairing a networking event with some gamification (even if it’s just Bingo) is an excellent way to get the conversation going and connections forming between conference attendees.
  • I personally will remember all the fun we managed to have in this one hour of video chat, and I look forward to future meetings where the early career community will continue to expand and accomplish impressive professional advancements to share at #BCVS22

(#BCVS21 Session: BCVS Mix & Mingle; screen capture by blog contributor)

Those were two of the most engaging and enjoyable sessions at #BCVS21, as expected. The value of providing a spotlight for Women In Science, especially for leaders in various roles within the cardiovascular research field (professors, program directors, Editors-in-chief, etc.) is extremely high and essential, in order to continue moving towards true equity and gender-balanced science world. #WIS efforts provide podiums for women to elevate their voices and lift up early career scientists that see themselves aiming for those podiums that are available for them, and of course continue to push the boundaries and expand the space for current and future generations. Similarly, the Early Career networking event centers on the recognition that establishing connections between scientists strengthens the community as a whole, leading to future collaborations and optimized knowledge sharing, which ultimately reflects positively on the scientific research done and benefit the general public as a whole.

 

“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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Anti-platelet therapy in STEMI

ST-elevation myocardial infarction (STEMI) is considered a medical emergency globally, where the patient must seek medical help immediately. The treatment plan for this condition involves reperfusion therapy with or without stent placement, controlling the comorbidities and using specific medications to reduce the risk of recurrence and future complications.

One of the major drug categories is the antiplatelet therapy. So we will discuss briefly the different types of anti-platelet drugs used in STEMI and the different patient scenarios in STEMI. [1][2]

A-Antiplatelet Therapy to Support Primary PCI

1- Aspirin

– Loading Dose of 162 to 325 mg should be given before primary PCI, to be chewed or crushed to establish a high blood level quickly. (More rapid absorption occurs with non-enteric-coated formulations).

– After PCI, aspirin 81 -325 mg should be continued indefinitely (81 mg is the preferred dose)

2- P2Y12 receptor inhibitors

– A loading dose of a P2Y12 receptor inhibitor should be given as early as possible before or at time of primary PCI. Options include one of the following:

  1. Clopidogrel 600 mg

US FDA has highlighted the potential impact of CYP2C19 genotype on clopidogrel pharmacokinetics and clinical response ( e.g: drug interaction with PPI ) . Nevertheless, other studies have not confirmed associations è  Future studies are needed to further clarify the risk .[3]

  1. Prasugrel 60 mg

NOT to be administered to patients with a history of stroke or transient ischemic attack and was not shown to be beneficial in patients ≥75 years of age or patients who weigh <60 kg.[4]

 

  1. Ticagrelor 180 mg

 

** Prasugrel and Ticagrelor are preferred to clopidogrel. [5] [6]

– P2Y12 inhibitor therapy should be given for at least 1 month in patients with BMS and at least 6 months in patient with DES, using the following maintenance doses: [2]

(( This duration can be extended or reduced according to the patient specific ischemic and bleeding risks )).

  1. Clopidogrel 75 mg daily
  2. Prasugrel 10 mg daily
  3. Ticagrelor 90 mg twice daily

3- GlycoProtein(GP) IIb/IIIa receptor antagonist

– these drugs are given at the time of primary PCI (with or without stenting or clopidogrel pre-treatment) in selected patients with STEMI who are receiving unfractionated heparin (UFH).

– patients who might benefit from a GP IIb/IIIa inhibitor include those who are found to have no or slow reflow, large thrombus burden, or intraprocedural bailout for distal embolization, coronary artery dissection, or hemodynamic instability.

 

Options include the following :

a.Abciximab:

-dose of  0.25-mg/kg IV bolus, then 0.125 mcg/kg/min (maximum 10 mcg/min)

b.high-bolus-dose Tirofiban :

– dose of 25-mcg/kg IV bolus, then 0.15 mcg/kg/min

– In patients with CrCl <30 mL/min, reduce infusion by 50%

c.Double-bolus Eptifibatide :

– dose of 180-mcg/kg IV bolus, then 2 mcg/kg/min; a second 180-mcg/kg bolus is administered 10 min after the first bolus.

– In patients with CrCl <50 mL/min, reduce infusion by 50%

– Avoid in patients on hemodialysis.

B-Antiplatelet Therapy With Fibrinolysis at a Non–PCI-Capable Hospital

1-Aspirin

– 162- to 325-mg loading dose

– should be continued indefinitely ( 81 mg is the preferred dose)

AND

2-P2Y12 receptor inhibitors

– Clopidogrel

– 300-mg loading dose for patients <= 75 years of age

– 75-mg loading dose for patients >75 years of age

– followed by: 75 mg daily should be continued for at least 14 days and up to 1 year

– prefer clopidogrel in this scenario over ticagrelor or prasugrel due to the increased risk of bleeding with the latter two. (( pretreatment with ticagrelor or prasugrel is considered a relative contraindication to fibrinolytic therapy )) [7]

C-Antiplatlet therapy when Transfer to a PCI-Capable Hospital After Fibrinolytic Therapy

1-Aspirin

– 162- to 325-mg loading dose

– 81- to 325-mg daily maintenance dose (indefinite)

– 81 mg daily is the preferred maintenance dose

2- P2Y12 receptor inhibitors

– Clopidogrel

– if the patient’s Age <= 75 years: 300-mg loading dose

– if the patient’s Age >75 years: no loading dose, give 75 mg

– Followed by 75 mg daily for at least 14 days and up to 1 year in absence of bleeding

D- Urgent CABG

1-Aspirin

– should not be withheld before urgent CABG

2- P2Y12 receptor inhibitors

– Clopidogrel or ticagrelor should be discontinued at least 24 hours before urgent on-pump CABG, if possible.

– Urgent CABG within 5 days of clopidogrel or ticagrelor administration or within 7 days of prasugrel administration might be considered, especially if the benefits of prompt revascularization outweigh the risks of bleeding.

3- GlycoProtein(GP) IIb/IIIa receptor antagonist

– Short-acting intravenous agents (eptifibatide, tirofiban) should be discontinued at least 2 to 4 hours before urgent CABG.

– Abciximab should be discontinued at least 12 hours before urgent CABG

–  Urgent off-pump CABG within 24 hours of clopidogrel or ticagrelor administration might be considered, especially if the benefits of prompt revascularization outweigh the risks of bleeding.

The following table discusses some differences between P2Y12 receptor inhibitors.

 

P2Y12 receptor antagonist

 

 

Mechanism of binding

 

Loading dose

 

Maintenance dose

 

Prodrug

 

Comments

 

Clopidogrel

 

 

Irreversible

Inhibitor

 

 

300 mg

or

600 mg

 

75 mg once daily

 

Yes

 

The drug needs to be metabolized into its active form

 

-Warnings/Precautions:

1-Bleeding risk

2-Thienopyridine hypersensitivity

3-Thrombotic thrombocytopenic purpura (TTP) usually occurring within the first 2 weeks

 

– to be discontinued at least 5 days before surgery

 

 

Ticagrelor

 

 

Reversible inhibitor

 

 

180 mg

 

90 mg twice daily

 

No

 

 

-Warnings/Precautions:

1-Bleeding risk

2-Bradyarrhythmias and Ventricular pauses

3-Hyperuricemia

4-dyspnea

5-Thrombotic thrombocytopenic purpura (TTP) usually occurring within the first 2 weeks

 

– to be discontinued at ≥5 days before surgery.

 

 

Prasugrel

 

 

Irreversible inhibitor

 

 

60 mg

 

10 mg once daily

 

Yes

 

The drug needs to be metabolized into its active form

-Warnings/Precautions:

1-Bleeding risk

 

[US Boxed Warning]: Do not use prasugrel in patients with active pathological bleeding or a history of TIA or stroke.

 

2-Hypersensitivity

3-Thrombotic thrombocytopenic purpura (TTP) usually occurring within the first 2 weeks

 

– to be discontinued at least 7 days before surgery

 

Table (1) : Summary of P2Y12 Receptor antagonist agents dosing, pharmacokinetics and adverse effects.

A special thank you to my sister, Rawan Ya’acoub, a clinical pharmacist and assistant professor at the University of Jordan, who helped me write this blog.

 

Reference:

[1]- 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

[2]- 2016 ACC/AHA Guideline: Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease

[3]-Society for Cardiovascular Angiography and Interventions; Society of Thoracic Surgeons; Writing Committee Members, Holmes DR Jr, Dehmer GJ, Kaul S, Leifer D, O’Gara PT, Stein CM. ACCF/AHA Clopidogrel clinical alert: approaches to the FDA “boxed warning”: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents and the American Heart Association. Circulation. 2010 Aug 3;122(5):537-57. doi: 10.1161/CIR.0b013e3181ee08ed. Epub 2010 Jun 28. PMID: 20585015.

[4]-Wiviott SD, Braunwald E, McCabe CH, Montalescot G, Ruzyllo W, Gottlieb S, Neumann FJ, Ardissino D, De Servi S, Murphy SA, Riesmeyer J, Weerakkody G, Gibson CM, Antman EM; TRITON-TIMI 38 Investigators. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007 Nov 15;357(20):2001-15. doi: 10.1056/NEJMoa0706482. Epub 2007 Nov 4. PMID: 17982182.

[5]-Wallentin L, Becker RC, Budaj A, Cannon CP, Emanuelsson H, Held C, Horrow J, Husted S, James S, Katus H, Mahaffey KW, Scirica BM, Skene A, Steg PG, Storey RF, Harrington RA; PLATO Investigators, Freij A, Thorsén M. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009 Sep 10;361(11):1045-57. doi: 10.1056/NEJMoa0904327. Epub 2009 Aug 30. PMID: 19717846.

[6]-Wiviott SD, Braunwald E, McCabe CH, Montalescot G, Ruzyllo W, Gottlieb S, Neumann FJ, Ardissino D, De Servi S, Murphy SA, Riesmeyer J, Weerakkody G, Gibson CM, Antman EM; TRITON-TIMI 38 Investigators. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007 Nov 15;357(20):2001-15. doi: 10.1056/NEJMoa0706482. Epub 2007 Nov 4. PMID: 17982182.

[7]- Sabatine MS, Cannon CP, Gibson CM, López-Sendón JL, Montalescot G, Theroux P, Claeys MJ, Cools F, Hill KA, Skene AM, McCabe CH, Braunwald E; CLARITY-TIMI 28 Investigators. Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation. N Engl J Med. 2005 Mar 24;352(12):1179-89. doi: 10.1056/NEJMoa050522. Epub 2005 Mar 9. PMID: 15758000.

 

“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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American Heart Association and California Walnut Commission Joint Initiative to Support Walnut Research

Picture from https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/fats/go-nuts-but-just-a-little

Earlier this year, The American Heart Association and the California Walnut Commission (CWC), a non-profit organization funded by mandatory assessments of the growers, announced a special award to support early career scientists pursuing human clinical or epidemiological research on walnut consumption.1 This presents an exciting opportunity to engage early scientists interested in improving public health outcomes through walnut research. This initiative with the American Heart Association opens new opportunities to increase our scientific knowledge of the benefits of walnut consumption in heart and brain health. With the ongoing efforts to pursuit a healthy lifestyles through a healthy diet, we find ourselves with nuts being inclusive in the many diet options we see these days.2-3

Walnuts provide 190 calories per one-ounce serving, which is equivalent to 1/4 cup, which is equivalent to approximately 12-14 walnut halves or a handful. They are also a good-fat food with 13 grams of polyunsaturated and 2.5 grams of monounsaturated fat of the 18 grams of total fat in one ounce of walnuts. Other benefits include its 2 grams of fiber per one ounce serving, important for heart health, gut health, and weight management. Walnuts are a rich source of Vitamin B6, Magnesium, Melatonin, Copper, and Manganese.4  The Dietary Guidelines for Americans recommends the consumption of unsaturated fats over saturated fats, thus supporting the consumption of nuts, and walnuts.5  These further present a healthy option as a non-animal source of proteins.  The 2013 American College of Cardiology/American Heart Association document on lifestyle management to reduce cardiovascular disease risk supported its inclusion due to cardiovascular benefits associated with walnut consumption in the studies.6  Given the ongoing burden from heart attacks and strokes, we will continue to see a shift towards optimization of dietary patterns as modifiable risk factors in the prevention of cardiovascular disease.

There are many benefits from the consumption of walnuts.  There is an increasing body of knowledge as a result of the studies targeting health outcomes. Study findings suggest benefits in diastolic function in young to middle-aged adults. 7 Based on results from prospective cohort studies, the consumption of peanuts and tree nuts (2 or more times/week) and walnuts (1 or more times/week) has been associated with a 13% to 19% lower risk of total cardiovascular disease and 15% to 23% lower risk of coronary heart disease.8  Most recent studies suggest that walnut consumption may benefit cognitive performance and lead to improvement in memory in adults.Other studies report maintenance of weight loss and self-reported satiety.10

Despite these research findings, additional studies are needed to further advance our understanding of the complexity of plant protein vs. animal protein comparisons.11 While many epidemiologic and intervention studies have evaluated their respective health benefits, it has been difficult to isolate the role of plant or animal protein on cardiovascular disease risk. The potential mechanisms responsible for specific plant and animal protein effects are multifaceted.11  Further investigations should test the effects of long-term consumption of nuts on cardiometabolic events.

A better understanding of its benefits may also contribute to higher consumption of walnuts. Especially when Americans do not meet the recommendations in the consumption of seafood, nuts, seeds, and soy products.5 Nuts have been shunned away for many years due to the perception as high-fat foods and promoters of weight gain. Work remains to be done to change this perception of weight gain associated with nuts, and walnuts.

The initiative as a result of joint efforts between the American Heart Association and the California Walnut Commission will provide the booster needed to support research and science on walnuts.  A better understanding of its mechanism of action, benefits, and people’s perceptions of nuts, and walnuts perhaps may contribute to their increased consumption for heart and brain health, among other outcomes.

Applications open in October, for more information visit: https://professional.heart.org/en/research-programs/application-information/career-development-award

References:

1.American Association for the Advancement of Science (AAAS). California Walnuts and American Heart Association announce first joint funding award.  EurekAlert! https://www.eurekalert.org/news-releases/589498. Jan 5, 2021. Accessed August 9, 2021.

  1. Uusitupa M, Khan TA, Viguiliouk E, et al. Prevention of Type 2 Diabetes by Lifestyle Changes: A Systematic Review and Meta-Analysis. Nutrients. 2019;11(11):2611. Published 2019 Nov 1. doi:10.3390/nu11112611
  2. Chiavaroli L, Viguiliouk E, Nishi SK, et al. DASH Dietary Pattern and Cardiometabolic Outcomes: An Umbrella Review of Systematic Reviews and Meta-Analyses. Nutrients. 2019;11(2):338. Published 2019 Feb 5. doi:10.3390/nu11020338
  3. California Walnut Commission. Walnuts Support Overall Wellness. https://walnuts.org/wp-content /uploads/2021/07/P0274-NutritionFactsHandout_8.5×11-1.pdf. 2021. Accessed August 15, 2021
  4. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. 9th Edition. December 2020. Available at DietaryGuidelines.gov.
  5. Ros E. Eat Nuts, Live Longer. J Am Coll Cardiol. 2017;70(20):2533-2535. doi:10.1016/ j.jacc. 2017. 09.1082
  6. Steffen LM, Yi SY, Duprez D, Zhou X, Shikany JM, Jacobs DR Jr. Walnut consumption and cardiac phenotypes: The Coronary Artery Risk Development in Young Adults (CARDIA) study. Nutr Metab Cardiovasc Dis. 2021;31(1):95-101. doi:10.1016/j.numecd.2020.09.001
  7. Guasch-Ferré M, Liu X, Malik VS, et al. Nut Consumption and Risk of Cardiovascular Disease. J Am Coll Cardiol. 2017;70(20):2519-2532. doi:10.1016/j.jacc.2017.09.035
  8. Chauhan A, Chauhan V. Beneficial Effects of Walnuts on Cognition and Brain Health. Nutrients. 2020;12(2):550. Published 2020 Feb 20. doi:10.3390/nu12020550
  9. Rock CL, Flatt SW, Barkai HS, Pakiz B, Heath DD. Walnut consumption in a weight reduction intervention: effects on body weight, biological measures, blood pressure and satiety. Nutr J. 2017;16(1):76. Published 2017 Dec 4. doi:10.1186/s12937-017-0304-z
  10. Richter CK, Skulas-Ray AC, Champagne CM, Kris-Etherton PM. Plant protein and animal proteins: do they differentially affect cardiovascular disease risk?. Adv Nutr. 2015;6(6):712-728. Published 2015 Nov 13. doi:10.3945/an.115.009654

“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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Data Science and Coding for Clinicians – Where to Start

Medicine is seeing an explosion of data science tools in clinical practice and in the research space. Many academic centers have created institutions tailored to integrating machine learning (ML) and artificial intelligence (AI) into medicine, and major associations including the AHA have created funding opportunities and software tools for clinicians interested in harnessing the promise of big data for their research.

While knowledge on the underlying algorithms and writing code is not necessary to lead a multidisciplinary team working in this space, there are those that want a working knowledge of what is happening under the hood. Thankfully, the computer science (CS) and AI communities have numerous free, online resources to help with this. As I embark on a Masters in Artificial Intelligence, I have used these courses as prep work and found them to be highly educational.

  1. Python for Everybody – By Dr. Charles R. Severance, University of Michigan

This course is meant to get those with no programming background up and running with Python. It focuses on understanding the underlying syntax of the language and the various data structures that come standard in Python. It also touches on web applications, SQL, and data visualization. Thorough, but approachable, this is a great place to start.

  1. CS50x – By Dr. David Malan, Harvard University

One of the most popular courses at Harvard, this course is an intensive introduction to computer science, focusing on key concepts and using various programming languages to illustrate them. The first half or so of the course teaches you to program in C, a low-level language that illustrates how a computer really functions, before moving on to Python (and various Python frameworks), SQL, and web programming. While the juice is definitely worth the squeeze, this course is a commitment and takes significant mental energy to get through.

  1. Machine Learning – By Dr. Andrew Ng, Stanford

One of the courses that popularized the massive open online course (MOOC) revolution, here AI visionary Dr. Ng takes you through a survey of ML/AI algorithms with real world examples and problem sets to work through. The main programming language is MATLAB. This course is enough to give you a basic overview of how these algorithms run and the types of data they are best at handling, serving as a solid introduction to the field.

  1. Machine Learning for Healthcare – By Peter Szolovits and David Sontag, MIT

Healthcare in general and the data it generates is unique, posing challenges distinct from other fields where ML/AI are commonly employed. This course highlights these points through a thorough investigation of healthcare data, common questions clinicians ask in routine patient care, and the clinical integration of ML. It touches on many different topics, including ML for cardiac imaging, natural language processing and clinical notes, and reinforcement learning. No coding is required for this course.

While these courses are just a start, they provide the groundwork for further investigation. in many cases, they are enough to develop an intuition of more complex material including deep learning. If these are topics that interest you, I encourage you to jump on 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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Near the End, and Preparing for a New Beginning

You’ve finally hit that point, where “comps” (comprehensive exams) has been completed. You passed. Now all you have to do is collect data, write it up and present it to your committee. The next challenge is figuring out the time to present the data you collected for the dissertation or thesis. Not to consider the biggest challenge of collecting data that is quality and timely. Thus, there is a few things to consider that might help streamline the PhD journey, or any similar terminal degree.

Thesis/Dissertation Tips

These tips need the context of a “best dissertation/thesis is a done dissertation/thesis”.

  1. Start coming up with ideas for your dissertation/thesis. The ideas evolve, be open to that. Discuss not only with potentially faculty, but also your friends and even family.
  2. Develop a rapport with all the faculty, feel out who may suit you and your journey the best. There is a fit that is needed on both the mentoring and mentee sides of the journey.
  3. Set expectations for yourself and then for your direct report or mentor. This will help ensure efficiency. The mentor has likely been in your shoes before, so he or she may view the initiative and eagerness as a positive.
    1. At the same time learn to establish a balance between work and your life. Talk to your mentor about this, he or she likely has valuable input. This is important because the majority of graduate students experiencing anxiety and or depression did not agree with the idea of their advisor being as asset to their career (shown in Figure 1) (Evans et al., 2018).

Figure 1. This figure highlights the graduate students and their experience of depression and anxiety as well as input related to perceived mentorship.
.https://doi.org/10.1038/nbt.4089.

  1. Make sure to back-up all your work. Back it up in more than one spot as well.
  2. It is never too early to start drafting up or writing down and organizing your ideas and concepts.
    1. Two sections that you really can get a jump on are the introduction and methods types of sections (Wyllie, 2021).

Future Investigator Tips:

On top of completing the thesis/dissertation, you should really be applying to jobs and considering what would be the next best step for you as a researcher.  Dr. Douglas Seals published a very informative manuscript titled “The Academic Biomedical Research Laboratory as a “Small Business”.  He provides a perspective that shows biomedical research laboratories providing services to external organizations (Seals, 2021). These services include:

“ -..manuscripts submitted for publication to scientific journals, grant applications submitted to biomedical research funding agencies; and abstracts submitted to professional organizations for presentations” (Seals, 2021).

Dr. Seals viewpoint manuscript is valuable because it highlights the need for developing a network. You learn about the future timelines and the associated potential hurdles. Furthermore, it will help address the a new type of balance, completing the work that you have obtained funding for, and beginning new work from ideas you have formulated.  Beyond understanding the dynamics of a laboratory as a small business, developing yourself as a good writer will be something that continues, and a standard that should be set high for yourself.

  1. Find a skill set you would like grow with over time
  2. Look potentially broadening your network.
  3. Understand the importance of treating a lab like a small business.

Below in Figure 2, shows what would be the priorities as a PI through a career. Understanding the frame-work over time can help you determine where you are and where you would like to be as an independent researcher. One of the skills that will need development, will be motivating a variety of people in a variety of ways (Banks, 2021).

https://febs.onlinelibrary.wiley.com/doi/epdf/10.1111/febs.15755

Finally, do your best to continue to find feedback from quality people with the network you established. Research is a process not only for sample and/or population studied, but for you and your development as an independent investigator. Develop patience and diligence.

Reference

Banks, L. (2021). Words of Advice: How to be a good Principal Investigator. The FEBS Journal, 288(13), 3973–3977. https://doi.org/10.1111/febs.15755

Evans, N. R., Shahrokni, R. O., Ferriday, D., Potter, C., Jebb, S. A., Brunstrom, J. M., & Rogers, P. J. (2018). Enhancing meal enjoyment: Evaluating the effects of flavour intensity and hedonic labelling. Appetite, 130, 304. https://doi.org/10.1016/j.appet.2018.05.184

Seals, D. R. (2021). The Academic Biomedical Research Laboratory as a “Small Business.” Journal of Applied Physiology. https://doi.org/10.1152/japplphysiol.00233.2021

Wyllie, D. J. A. (2021). Thesis write-up and manuscript preparation: Related but distinct tasks. The Journal of Physiology, 599(11), 2771–2775. https://doi.org/10.1113/JP281665

“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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Medications to Avoid in patients with Heart Failure

The number of patients being diagnosed with heart failure (HF) is increasing worldwide, and thus we need to know which medications to avoid or be cautious with prescribing that may cause or exacerbate this medical condition. So, we decided to talk about these medications, how they cause these adverse events in these patients, and their mechanism of action.

How these medications cause adverse events in HF patients?

Overall, these medications might cause these adverse effects by one of the following mechanisms: 1) causing direct myocardial toxicity; 2) by negative inotropic effect; 3) chronotropic effects; 4) by exacerbating hypertension; 5) by delivering a high sodium load; or 6) by drug-drug interactions that limit the beneficial effects of HF medications.

Here, we will talk briefly about the common medication classes that should be avoided in heart failure and their mechanism of causing these adverse events.

1. Non-dihydro Calcium Channel Blockers (CCB):

Including (diltiazem and verapamil) è have a negative inotropic effect, thus might increase adverse outcomes [1].

2. Nonsteroidal Anti-Inflammatory Drugs (NSAID) : Diclofenac , indomethacin , ketorolac ..etc AND COX-2 selective inhibitors (Celecoxib) :

Commonly Dispensed as over the counter drugs or as anti-inflammatory prescribed drugs è these medications are associated with increased risk of HF exacerbation, causing decline in renal function, and peripheral vasoconstriction; as such they can attenuate the efficacy and enhance the toxicity of diuretics and angiotensin converting enzyme inhibitors [2]. 

US Boxed Warning regarding Serious cardiovascular risk: (NSAIDs) cause an increased risk of serious cardiovascular thrombotic events, including myocardial infarction (MI), and stroke, which can be fatal. This risk may occur early in the treatment and may increase with duration of use. Celecoxib is contraindicated in the setting of coronary artery bypass graft (CABG) surgery [2].

3. Some Oral Hypoglycemic Agents:

Thiazolidinediones such as Pioglitazone è are associated with fluid retention

US Boxed Warning: Thiazolidinediones may cause or exacerbate heart failure è  closely monitor for signs and symptoms of HF particularly after initiation or dose increases. If HF develops, treat and consider dose reduction or discontinuation of pioglitazone. Initiation of therapy is contraindicated in patients with NYHA class III or IV HF [3].

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors: Sitagliptin, saxagliptin, and linagliptin

In a scientific statement from American Heart Association (AHA) , saxagliptin has been determined to be an agent that may exacerbate underlying myocardial dysfunction , 2016 . The ADA recommends avoiding the use of saxagliptin in patients with HF, 2020) [4].

Bies ( Metformin ) is associated withguanid lactic acidosis, which can be fatal in patients with CHF

US Boxed Warning regarding Lactic acidosis: Risk factors include renal impairment, ≥65 years and hypoxic states, e.g: acute congestive heart failure. Metformin may be used in patients with stable heart failure, ADA 2020 [5].

4. Tumor Necrosis Factor alpha inhibitors (Anti-TNF-alpha):

Including infliximab, etanercept, and adalimumab.

Use with caution in patients with mild HF (NYHA class I, II) or decreased left ventricular function. Infliximab doses >5 mg/kg are contraindicated with moderate to severe HF (NYHA class III/IV). In a scientific statement from AHA, TNF blockers have been determined to cause either direct myocardial toxicity or exacerbate underlying myocardial dysfunction, 2016 [6,7].

5. Antiarrhythmic medications:

Class I: Flecainide, disopyramide [8]

Class III: Dronedarone, Sotalol [8]

6. Anti- Cancer medications:

Anthracyclines: doxorubicin, Daunorubicin, Mitoxantrone

US Boxed Warning: Myocardial damage (including acute left ventricular failure) can occur with doxorubicin with incidences from 1% to 20% for cumulative doses from 300 mg/m2 to 500 mg/m2 when administered every 3 weeks è monitor LVEF before, during and after treatment [9]

Targeted therapy: Bevacizumab, Lapatinib, Trastuzumab

US Boxed Warning: Trastuzumab is associated reductions in left ventricular ejection fraction (LVEF) and heart failure; the incidence is highest in patients receiving trastuzumab with an anthracycline-containing chemotherapy regimen è  Evaluate LVEF in all patients prior to and during treatment; discontinue for cardiomyopathy [10]

7. Cilostazol

This is a selective inhibitor of phosphodiesterase type 3, antiplatelet and vasodilatory agent used primarily in patients with intermittent claudication and peripheral arterial disease [11].

US Boxed Warning: Cilostazol is contraindicated in patients with heart failure of any severity è causing decreased survival in patients with class III to IV heart failure [11].

8. Anti-depressant drugs:

Citalopram, Tricyclic antidepressants (TCA) such as amitriptyline, Imipramine … etc.

  • TCAuse with extreme caution in patients with a history of CVD or family history of sudden death, dysrhythmias, or conduction abnormalities. In a scientific statement from AHA, TCA has been determined to exacerbate underlying myocardial dysfunction,2016 è monitor EKG [12]
  • Citalopram risk of dose-dependent  QT prolongation ECG and torsade de pointes (TdP) . Risk factors include Structural heart disease, e.g: MI or HF [12]

9. α1 -Blockers:

Such as prazosin and doxazosin

In a scientific statement from the AHA, -Zosin has been determined to exacerbate underlying myocardial dysfunction , 2016 [13].

10. Pregabalin

Peripheral edema may occur in patients with or without a prior history of heart failure, which may result in acute decompensated heart failure. Risk factors: Pre-existing heart failure (NYHA Class III or IV) (cautious use recommended due to limited data in this patient population [14]

11. Beta-blockers (except those approved for HF treatment: Metoprolol, Bisoprolol, Carvedilol) [15]

12. Selected Intravenous and Oral Medications High in Sodium content:

  • Oral meds: Alendronate effervescent tablet, Sodium polystyrene sulfonate suspension, Polyethylene glycol powder for solution, erythromycin
  • Injection meds: Piperacillin/tazobactam, Metronidazole, Ticarcillin/clavulanate, azithromycin

13. Trimethoprim-sulfamethoxazole (TMP/SMX)

==> by increasing the risk of Hyperkalemia which can be life-threatening [16].

Figure 1: Summary of medications to avoid in heart failure patients.
AAA: anti-arrhythmic agents

 

A special thank you to my sister, Pharm.D Rawan Ya’acoub, Clinical pharmacist and Research assistant at Jordan university .

References:

[1] Kostis JB, Lacy CR, Cosgrove NM, Wilson AC. Association of calcium channel blocker use with increased rate of acute myocardial infarction in patients with left ventricular dysfunction. Am Heart J. 1997 May;133(5):550-7. doi: 10.1016/s0002-8703(97)70150-9. PMID: 9141377.

[2] Ungprasert P, Srivali N, Kittanamongkolchai W. Non-steroidal anti-inflammatory drugs and risk of heart failure exacerbation: A systematic review and meta-analysis. Eur J Intern Med. 2015 Nov;26(9):685-90. doi: 10.1016/j.ejim.2015.09.012. Epub 2015 Oct 1. PMID: 26427540.

[3] Singh S, Loke YK, Furberg CD. Thiazolidinediones and heart failure: a teleo-analysis. Diabetes Care. 2007 Aug;30(8):2148-53. doi: 10.2337/dc07-0141. Epub 2007 May 29. PMID: 17536074.

[4] Scirica BM, Braunwald E, Raz I, Cavender MA, Morrow DA, Jarolim P, Udell JA, Mosenzon O, Im K, Umez-Eronini AA, Pollack PS, Hirshberg B, Frederich R, Lewis BS, McGuire DK, Davidson J, Steg PG, Bhatt DL; SAVOR-TIMI 53 Steering Committee and Investigators*. Heart failure, saxagliptin, and diabetes mellitus: observations from the SAVOR-TIMI 53 randomized trial. Circulation. 2014 Oct 28;130(18):1579-88. doi: 10.1161/CIRCULATIONAHA.114.010389. Epub 2014 Sep 4. Erratum in: Circulation. 2015 Oct 13;132(15):e198. PMID: 25189213.

[5] Kinsara AJ, Ismail YM. Metformin in heart failure patients. Indian Heart J. 2018 Jan-Feb;70(1):175-176. doi: 10.1016/j.ihj.2017.05.009. Epub 2017 May 15. PMID: 29455774; PMCID: PMC5902828.

[6] Behnam SM, Behnam SE, Koo JY. TNF-alpha inhibitors and congestive heart failure. Skinmed. 2005 Nov-Dec;4(6):363-8. doi: 10.1111/j.1540-9740.2005.04502.x. PMID: 16276152.

[7] Chung ES, Packer M, Lo KH, Fasanmade AA, Willerson JT; Anti-TNF Therapy Against Congestive Heart Failure Investigators. Randomized, double-blind, placebo-controlled, pilot trial of infliximab, a chimeric monoclonal antibody to tumor necrosis factor-alpha, in patients with moderate-to-severe heart failure: results of the anti-TNF Therapy Against Congestive Heart Failure (ATTACH) trial. Circulation. 2003 Jul 1;107(25):3133-40. doi: 10.1161/01.CIR.0000077913.60364.D2. Epub 2003 Jun 9. PMID: 12796126.

[8] Køber L, Torp-Pedersen C, McMurray JJ, Gøtzsche O, Lévy S, Crijns H, Amlie J, Carlsen J; Dronedarone Study Group. Increased mortality after dronedarone therapy for severe heart failure. N Engl J Med. 2008 Jun 19;358(25):2678-87. doi: 10.1056/NEJMoa0800456. Erratum in: N Engl J Med. 2010 Sep 30;363(14):1384. PMID: 18565860.

[9] Songbo M, Lang H, Xinyong C, Bin X, Ping Z, Liang S. Oxidative stress injury in doxorubicin-induced cardiotoxicity. Toxicol Lett. 2019 Jun 1;307:41-48. doi: 10.1016/j.toxlet.2019.02.013. Epub 2019 Feb 25. PMID: 30817977.

[10] Nemeth BT, Varga ZV, Wu WJ, Pacher P. Trastuzumab cardiotoxicity: from clinical trials to experimental studies. Br J Pharmacol. 2017 Nov;174(21):3727-3748. doi: 10.1111/bph.13643. Epub 2016 Nov 25. PMID: 27714776; PMCID: PMC5647179.

[11] Wu CK, Lin JW, Wu LC, Chang CH. Risk of Heart Failure Hospitalization Associated With Cilostazol in Diabetes: A Nationwide Case-Crossover Study. Front Pharmacol. 2019 Jan 7;9:1467. doi: 10.3389/fphar.2018.01467. PMID: 30666197; PMCID: PMC6330376

[12] Teply RM, Packard KA, White ND, Hilleman DE, DiNicolantonio JJ. Treatment of Depression in Patients with Concomitant Cardiac Disease. Prog Cardiovasc Dis. 2016 Mar-Apr;58(5):514-28. doi: 10.1016/j.pcad.2015.11.003. Epub 2015 Nov 10. PMID: 26562328.

[13] Hundemer GL, Knoll GA, Petrcich W, Hiremath S, Ruzicka M, Burns KD, Edwards C, Bugeja A, Rhodes E, Sood MM. Kidney, Cardiac, and Safety Outcomes Associated With α-Blockers in Patients With CKD: A Population-Based Cohort Study. Am J Kidney Dis. 2021 Feb;77(2):178-189.e1. doi: 10.1053/j.ajkd.2020.07.018. Epub 2020 Sep 11. PMID: 32920153.

[14] Lund M, Poulsen G, Pasternak B, Worm Andersson N, Melbye M, Svanström H. Use of Pregabalin and Worsening Heart Failure: A Nationwide Cohort Study. Drug Saf. 2020 Oct;43(10):1035-1044. doi: 10.1007/s40264-020-00969-6. PMID: 32651945

[15] Kotecha D, Flather MD, Altman DG, Holmes J, Rosano G, Wikstrand J, Packer M, Coats AJS, Manzano L, Böhm M, van Veldhuisen DJ, Andersson B, Wedel H, von Lueder TG, Rigby AS, Hjalmarson Å, Kjekshus J, Cleland JGF; Beta-Blockers in Heart Failure Collaborative Group. Heart Rate and Rhythm and the Benefit of Beta-Blockers in Patients With Heart Failure. J Am Coll Cardiol. 2017 Jun 20;69(24):2885-2896. doi: 10.1016/j.jacc.2017.04.001. Epub 2017 Apr 30. PMID: 28467883.

[16] Michel A, Martín-Pérez M, Ruigómez A, García Rodríguez LA. Risk factors for hyperkalaemia in a cohort of patients with newly diagnosed heart failure: a nested case-control study in UK general practice. Eur J Heart Fail. 2015 Feb;17(2):205-13. doi: 10.1002/ejhf.226. Epub 2015 Jan 10. PMID: 25581138.

“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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In pursuit of power productivity: key mindsets for career success from an MD MBA director (part 1)

In Santa Clara County, 75.6% of individuals (12 years+) are currently fully vaccinated. With cases of COVID-19 down and street traffic on the rise, it is clear that the “normal” I once dreamed of is quickly approaching. I am a postdoctoral researcher at Stanford University. In the laboratory, most restrictions are gone; there are no shifts, no distancing limits, and no limited room capacities. Yet, I still feel like I’m struggling. I still feel like I’m functioning at reduced productivity levels. While I completely acknowledge that my pre-pandemic lab hours were a bit crazy, and I should be okay with where I am, I want to get back to where I was. To help me with this, I spoke with an expert on productivity and stress, Dr. Steven Chan. Dr. Chan is on faculty at Stanford University, has taught students at the School of Business and School of Medicine, and has spoken and written on mental health at venues such as Google, NPR, and the American Psychiatric Association.

Please describe yourself and your pursuit of improved productivity? 

I am currently a medical director at a busy service in Northern California. I also work on healthcare technology, focusing on projects in the area of digital mental health. I am interested in the application of mental health on technology, and how this can improve people’s lives.

Productivity has always been a lifelong pursuit for me. Growing up, I was always very busy with extracurriculars: music, martial arts, exam prep, newspaper, the list goes on. There was always a lot to do that required a lot of time to excel at it. Then, when I went to college, the pattern continued. Same thing again with work life.

Over time, I’ve realized that it’s not only important to understand how the right tools can help you get more done, but also how to identify the right work to tackle.

What do you mean by “right work?” How do you decide where to invest your time?

When I am approached with a new opportunity, I choose to take on new projects based on three criteria:

  1. Enjoyment. Is this something I enjoy doing? Do I have good feelings?
  2. Skills. Am I good at this task? Or, is this an opportunity to learn new skills?
  3. Returns. Is there a return on investment (ROI)? This return doesn’t have to be purely financial and monetary; it could be rich in social connections. It could be valuable for your organization and yourself.

Ideally, new projects would have all three. Otherwise, a project would be imbalanced. Take enjoyment, for example. If a project involved evaluating pizza, well, I enjoy eating pizza, but it doesn’t take much skill and it’s unlikely someone would pay me to eat pizza.

Time is your most precious commodity. In careers such as medicine and science, there is an abundance of work and projects. Choose to do things that you enjoy, you are skilled at, and are worth your time.

I find myself saying “yes” to a lot of things — and I get overwhelmed! How do you say “no”? How do you deal with feelings that you are passing up on an opportunity?

Anytime you say “yes” to something, you have to be aware that you are saying “no” to other opportunities.

When people think about the Fear of Missing Out (FOMO) or the fear of disappointing others, they think that they are permanently closing the door on an opportunity. This is simply not true.

In the past, I used to say “yes” to a lot of opportunities because I didn’t know where to best invest my time. The key to choosing good opportunities is to first have a good bird’s eye view of the opportunities out there. This requires some work and reflection. Know all the things going on in your life, identify your goals and values, and then get to know all the opportunities available to you. And after doing all this, make commitments using the three criteria we discussed earlier.

One final point, have regularly-scheduled reviews of your commitments. Do a weekly assessment, think about all the things you want to accomplish in a week, a month, and a year. Then adjust your commitments to ensure your maximal efforts line up with your long-term goals.

I feel like I am always short on time. What are the top 3 things I can do to help me with my productivity?

There are a lot of calendar hacks and to-do tips out there. But having the right mindset is critical before taking on new apps and new techniques:

Keep experimenting. There is no one perfect solution or single app that will organize your life. However, there is a whole community out there devoted to time optimization and productivity. These solutions and best practices evolve and change as you move through life. For example, when I transitioned from medical school to the work world, I quickly realized that it was no longer sufficient to write things down on paper. So, I turned to automated calendars. Now I use Busycal and Google Calendar, with Outlook at my main job.

Do reflections and get to know yourself. You can’t understand what you are good at, what you enjoy, and what you want in life without self-reflection. I remember going through the motions of classes and training, and it wasn’t until I got to stop and reflect that I truly was able to ensure a better balance between work and self-care.

Know your energy levels. For example, I know that I can’t get anything done in the evenings because I’m exhausted. When I was in medical school, I used to beat myself up over this because I felt the need to study every evening. But, now I know that I have much more energy in the mornings and commit more time to getting work done then. In addition to knowing when you work best, you can hack your energy levels by optimizing caffeine intake and exercise to boost energy levels when required.

Lastly, adjust your surroundings. Equip yourself with the right technology — fast, reliable computers; fast, reliable internet; and fast, reliable smartphones. Surround yourself with the right people to maximize your output. The energy levels of your peers matter. Establishing an environment with minimal toxicity and drama is essential. Do this at work, at home, and in your relationships.

How do you quiet that inner critic? How do you deal with feelings that you are not doing enough or not making enough progress?

Recontextualize or reframe this to determine if this feeling of inadequacy is true. Again, make time for reflection. List out all your projects and accomplishments, and then assess if you really are not doing enough. Ideally, a therapist, counselor, or coach can help you with this reflection — but there are so many worksheets and courses on the internet to guide you in doing the same.

Every year, instead of making New Year’s resolutions, I assess all the things I have done and the things I have failed at. Yes, I keep a failure list, which sounds horrifying. I can’t tell you how many internships, jobs, relationships, and projects of mine have failed! But, I feel having a list of failures is an important step in beating perfectionism. A failure isn’t a bad thing. It means you are experimenting! Experimentation is good, leads to growth, and helps you learn. While failure can be a brutal blow to self-esteem, we need to fail in life. Failure provides feedback. In fact, if we have repeated failures, this tells us that we need to make significant changes in what we’re doing!

Are there resources that you would suggest to help with improved productivity and mental health?

Take a look at articles published in the business world regarding productivity and human performance. In business, people want to get the most out of their precious resources: time, money, and human resources. Read up on project management techniques, as these will help you run efficient labs, manage clinical teams, and even run research papers and grant-writing projects.

Where can you find these? A major resource is a library or even your HR team: many universities and workplaces have access to LinkedIn Learning and Skillshare. And, Mental Power Hacks — the website I run — plus my social media feeds at @mpowerhacks, also feature a lot of these techniques. I know this is a lot, and you won’t conquer it all in one sitting, but incorporate this learning in your routines to build these skills over time.

Thank you so much for these! In our next blog entry, we’ll talk about how to improve your productivity by managing relationships in both work and social life.

 

“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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Bridging the Disparity Gap in Cardiovascular Health in Transgender and Gender Diverse Population: Insight into the Scientific Statement from the American Heart Association

In recent years, there has been increased attention to health-related disparities experienced by the transgender and gender diverse population (TGD).  In fact, it has become a public health priority to improve the health, safety, and well-being of lesbian, gay, bisexual, and transgender people in the U.S. Therefore, one of the Healthy People 2030 goals is to target the collection of data on LGBT health issues to help inform effective health promotion strategies for LGBT people.1  The topics of adolescents, drugs and alcohol use, mental health issues, sexually transmitted infections, and our public health infrastructure are highlighted as key objectives for the Healthy People 2030 Goals.1

Nearly a decade ago, the 2011 report from The Institutes of Medicine (IOM) highlighted the need to look at the distinct health concerns and needs of the TGD community and its subgroups. It also reported on the importance of understanding differences based on race, ethnicity, socioeconomic status, geographic location, age, and other factors among lesbians, gay men, bisexual men and women, and transgender people.2  Based on the 2011 IOM report, lesbians and bisexual women encounter higher rates of breast cancer than heterosexual women. The data on whether lesbians had a higher risk for cardiovascular disease was conflicting at the time. Limited research suggested that transgender groups may experience negative health outcomes, because of long-term hormone use.2

Recent studies suggest that trans people appear to have an increased risk for myocardial infarction and death due to cardiovascular disease when compared to cisgender people.  In studies that followed trans people on hormone therapy, the rates of myocardial infarction and stroke were consistently higher in trans women than trans men. Estrogen therapy for trans women has been reported to increase their risk for venous thromboembolism.3  This presents opportunities for screening TGD groups for cardiometabolic risk factors in much the same way as their cisgender counterparts.4  A recent scientific statement from the American Heart Association emphasizes on the importance of screening and risk reduction for cardiovascular disease in TGD people.

In this scientific statement, distal and proximal minority stressors are presented, which may contribute to higher overall stress levels that can increase the risk for poor mental and physical health outcomes in TGD individuals.  The Gender and Minority Stress Resilience model is presented and highlights these factors, as well as the presence of resilience factors that may counteract the effects of transphobic violence and stigma, and promote TGD health equity.5   This Scientific Statement is definitely a step in the right direction to address cardiovascular related health disparities for TGD people.  It addresses the value of Life’s Simple 7 (tobacco use, physical activity, diet, weight status, blood pressure, glycemic status, and lipids), targeting key risk factors towards the reduction of cardiovascular disease.  Other factors such as HIV infection status, vascular dysfunction, alcohol use, lack of sleep, stigma, discrimination, violence, lack of affordable housing and access to health care are also discussed.5

Advancing the cardiovascular health of people who are TGD will require a multifaceted approach that integrates best practices into health promotion, cardiovascular care, and research for this understudied population.  This presents opportunities for innovation in areas such as the electronic health record, especially to capture sociocultural factors relevant to heart health among TGD groups. Longitudinal research examining psychosocial, behavioral, and clinical determinants of optimal cardiovascular health in TGD people at the individual, interpersonal, and structural levels is also advocated. Healthcare professionals and clinician training on the proper assessment of sex and gender in healthcare settings, and identification of TGD health disparities will also be necessary to the identification of interventions and the reduction of disparities experience by TGD groups.5

In conclusion, the recent Scientific Statement from the American Heart Association on TGD people highlights the unique, health care needs of TGD individuals. It also highlights opportunities to improve their health status though screening and preventive lifestyle practices incorporating Life’s Simple 7. Clinician education and training on the psychosocial, cultural, behavioral, and biological factors in TGD people may help bridge the gaps in cardiovascular care for these groups.

References:

  1. S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2030. LGBT: Goal: Improve the health, safety, and well-being of lesbian, gay, bisexual, and transgender people. https://health.gov/healthypeople/objectives-and-data/browse-objectives/lgbt. Published 2020. Accessed July 13, 2021.
  2. Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington (DC): National Academies Press (US); 2011. https://www.ncbi.nlm.nih.gov/books/NBK64806/ doi: 10.17226/13128. Accessed July 12, 2021.
  3. Irwig MS. Cardiovascular health in transgender people. Rev Endocr Metab Disord. 2018;19(3):243-251. doi:10.1007/s11154-018-9454-3
  4. Slack DJ, Safer JD. Cardiovascular health maintenance in aging individuals: the implications for transgender men and women and hormone therapy. Endocr Pract. 2021;27(1):63-70. doi:10.1016/j.eprac.2020.11.001
  5. Streed CG Jr, Beach LB, Caceres BA, et al. Assessing and Addressing Cardiovascular Health in People Who Are Transgender and Gender Diverse: A Scientific Statement from the American Heart Association [published online ahead of print, 2021 Jul 8]. Circulation. 2021; CIR0000000000001003. doi:10.1161/CIR.0000000000001003

“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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Goodbye Self-Inflicted Intimidation and Hello Learning: A fellow’s experience working with Dr. Rick Nishimura

“Don’t speak out, you may answer incorrectly and embarrass yourself.” This thought was not uncommon during my first two years of fellowship. Yes, I evolved out of this which is why I am sharing my experience. At the same time, I am here to tell you to not make this mistake early in fellowship.

You may or may not have heard of Dr. Rick Nishimura, a master clinician, and educator of cardiovascular hemodynamics. You may have seen his name authored in many of the national guidelines or his face at national and international conferences. Now, imagine him (or your own respective master clinician-educator at your own program) leading weekly hemodynamic sessions and asking escalating difficult questions to the audience. Would you answer? How confident would you need to be to articulate this out loud?

I am about a month away from completing my general cardiology fellowship (my 3 years were slightly extended from two maternity leaves) and I have had time to reflect on my clinical experience. I remember my first year sitting in our auditorium and can vividly recall answering a question about x and y descents incorrectly in front of everyone. I rarely spoke out again for the rest of that year.

As a third-year at the Mayo Clinic, I had the opportunity to work in “Nish” clinic amongst a handful of other fellows and participate in his hemodynamic sessions. Every fellow before me, alongside me, and after me all feel the same way: to work with him requires a great deal of preparation and meticulous chart review of patients, repetitive review of all the guidelines, and an attempt at reading published research relevant to each case. The more I thought about it, it became clear that I had a unique opportunity to challenge myself before graduating. I’m glad I did.

I’d like to share reflections, learning pearls, and takeaways from my experience working with and learning from Dr. Nishimura:

  1. Find passionate clinician educators early in training and don’t be timid about learning from them.

The way he lectures to hundreds of people in a room is the exact way he teaches you and it is incredibly motivating. By explaining complicated pathophysiology with such simplicity, I became deeply entrenched in the learning process. I cannot overemphasize the hours I spent preparing for the potential questions he might ask yet I still left clinic with at least 4+ things to look up, feeling inspired and motivated to be a better learner and educator. This is the art of teaching.

  1. Do a good physical exam and use it to determine whether the rest of the workup is concordant or discordant.

One example I learned was the location of the P2 component of S2 on the chest can tell you the degree of elevated pulmonary pressure.

  1. Look at the data (i.e. echocardiograms) yourself.

Avoid only reading reports as they can sometimes mislead you into making life-altering management decisions for patients. For example, do not accept pulmonary artery systolic pressures without looking at the tricuspid valve regurgitant Doppler profile yourself. Confirm if this was measured correctly because it can change management.

  1. Know the guidelines but understand that not all patients fit perfectly in them.

An elderly woman with severe aortic stenosis may be eligible for both SAVR and TAVI, which stresses the importance of individualization and shared decision-making with the patient and heart valve team.

  1. Communication with the referring provider and follow up with the patient cannot be overstated.

Reaching out to referring providers via letter and phone will develop your communication skills, professionalism, and collaborations. Following up with the patient is not only the right thing to do but also allows you to learn whether your management decision resulted in the best outcome for your patient or if there is a learning opportunity for the next patient who presents similarly.

  1. Teach one another.

Create an environment where you are sharing cases with your co-fellows and colleagues and practice teaching to one another with the hope that one day with dedication you will also inspire trainees.

  1. Lastly, do not be afraid to ask questions and answer questions. Even when you are intimidated.

I eventually told Dr. Nishimura how intimidated I initially felt. If you haven’t had the privilege of meeting him, he is one of the most down-to-earth and welcoming teachers you will ever come across. He laughed and said there was nothing to be intimidated about. Many of the questions you have in your head are also questions others have. In that light, more learning, engaging, and teaching can occur if you allow yourself to.

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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AHA Early Career Voice Vlog: an interview with Dr. Rakesh Gopinathannair

I am excited to interview Dr. Rakesh Gopinathannair, MD for this AHA Blog. We will be discussing “Management of Atrial Fibrillation in Patients with Heart Failure and Reduced Ejection Fraction”. Dr. Gopinathannair was the lead author on the recent AHA Scientific Statement on this topic and will share his valuable insights about this document.