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How will COVID-19 Affect Return to High School Sports and ECG Screening?

August is traditionally very busy month in the pediatric cardiology office; visits for “sports clearance” flood the schedule due to something picked up on a high school sports physical such as chest pain. Most of these will be non-cardiac and receive reassurance; however, the cardiac causes in the pediatric population can be quite distressing. With the current COVID-19 pandemic we are seeing many cardiac effects of the virus— myocardial inflammation, dysfunction and coronary artery dilation or MIS-C (multisystem inflammatory syndrome in children). There has also been a reported increase in out of hospital cardiac arrest in the adult population, which could be attributed to those afraid to seek care, but none the less, a concern.

Cardiac effects play an important part in the recent discussions on return to school, as eventually return to school will mean return to school sports. Sports cardiologists have been following this closely and have been working to establish a safe way for return to sports in competitive athletes who have had COVID-191(click here for recommendations and see flowchart below), which may include extensive cardiac testing of those who had symptomatic COVID-19, most of which is based on the return to play myocarditis guidelines.2 These important decisions require individualization, knowledge of risk and what is happening in the community.

So what does this mean for the high school athletes? There is no doubt that exercise is great for everyone, especially with the rising obesity and the sedentary lifestyle. Organized sports participation has shown to have a positive impact on mental and physical health that extends beyond childhood.3 Many have raised concerns about the development and health of children by not attending school, along with decrease in social interaction and activity from organized sports during the stay-at-home orders and while we work to defeat COVID-19 spread.

Prior to the pandemic, the question of universal ECG testing for high school athletes always started a conversation, but could that change? Critics say that the false positives create distress and extra healthcare cost, that follow up is problematic and that it has not been shown to change outcomes. Others argue saving one child from the devastating event of collapsing and dying on the field is worth it, and a recent study showed ECG with H&P is more likely to detect a condition associated with sudden cardiac arrest (SCA) than H&P alone, and also improved cost efficiency when interpreted in the right hands.4 All agree it is important to have a good plan in place for SCA at all sporting events, including an emergency response plan in place specific to cardiac arrest.

With so many affected by the virus, at varying severity, I can’t help but wonder if this will change the way we assess our young athletes for participation in sports when it is safe to do so. While healthcare costs are always a problem, with a new virus and unclear long-term outcomes, we must be conservative. Perhaps this may provide an opportunity to learn more about ECG screening, as we will likely see a larger amount of patients who have had COVID-19 coming to our offices for clearance. This may provide an opportunity to gather evidence on the continued debate of whether ECG screening is effective.

Until we know more, what we do know is it is safer to be conservative, to assess benefit and risk and provide appropriate counseling to families on signs and symptoms of SCA. We also must continue to reassess and stay up-to-date on new knowledge and testing related to COVID-19 recovery and sports. Most importantly, it is important that we continue to advocate for heart safe schools which include having AEDs, training in CPR, and emergency response plans related to Sudden Cardiac Arrest. With more kids participating in school from home, this could be a great opportunity to engage the whole family in CPR and AED education to improve the safety and survival of our communities and at home.

 

References

  1. Phelan, Dermot, et al. “A Game Plan for the Resumption of Sport and Exercise After Coronavirus Disease 2019 (COVID-19) Infection.” JAMA Cardiology, 2020, doi:10.1001/jamacardio.2020.2136.
  2. Maron, Barry J., et al. “Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task  Force 3: Hypertrophic Cardiomyopathy, Arrhythmogenic Right Ventricular Cardiomyopathy and Other Cardiomyopathies, and Myocarditis.” Journal of the American College of Cardiology, vol. 66, no. 21, 2015, pp. 2362–2371., doi:10.1016/j.jacc.2015.09.035.
  3. Logan, Kelsey, and Steven Cuff. “Organized Sports for Children, Preadolescents, and Adolescents.” Pediatrics, vol. 143, no. 6, 2019, doi:10.1542/peds.2019-0997.
  4. Harmon, Kimberly G, and Jonathan A Drezner. “Comparison of Cardiovascular Screening in College Athletes” Heart Rhythm, 2020, www.heartrhythmjournal.com/article/S1547-5271(20)30406-9/pdf.

“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 AHA leading the way in Cardiopulmonary resuscitation (CPR)?

In writing this last post as a junior blogger, I decided to highlight the tremendous efforts by the American Heart Association (AHA) to improve cardiovascular care in the field of cardiac arrest and cardiopulmonary resuscitation (CPR). As we know, the AHA is a worldwide leader in first aid, CPR, and Automated External Defibrillator (AED) training – educating millions of people globally in CPR every year. Here, I will share some fun facts about CPR, and you can refer to the AHA website for further details about this important topic.

Important CPR statistics

  • Majority of cardiac arrests occur outside of the hospital, with estimated 475,000 Americans dying from cardiac arrests every year [1]
  • Bystander CPR is a key component in the out-of-hospital “chain of survival” [Figure 1] and studies have shown it improves survival in cardiac arrest [1-3].

Figure 1: The adult out-of-hospital “chain of survival”. Each link of the chain from left to right is numbered 1 through 5: 1- Recognize cardiac arrest and activate the emergency response system, 2- early CPR with high-quality chest compressions, 3- Use AED for rapid defibrillation, 4- basic and advanced emergency services and 5- post-cardiac arrest care and advanced life support [2].

  • Bystander CPR has been increasing over the recent years in both men and women. Despite that, survival improved in men only, but not women [2]. This is important as it highlights that more work is needed to identify additional predictors of survival in women with cardiac arrest.
  • Efforts mandating CPR training in high schools in multiple states [5] and availability of AED in public places, including airports [Figure 2], have helped in increasing the awareness and familiarity of bystander CPR in cardiac arrest [4].

  • Figure 2: A photo of Automated External Defibrillator (AED) in one of the airports.

Personal Experience

From a personal experience, I have visited multiple high schools in my home country as well as in the United States, and have participated as an organizer in the sessions teaching high school students how to perform effective CPR. It is inspiring to see junior students interested in learning and saving lives. The takeaway from my experience is that engagement plays a major role in spreading the word and encouraging the general public to take the extra step and learn how to perform basic and advanced life support techniques.

In conclusion, it is important to remember that the general public are oftentimes our first “link” in the chain of survival; making them an important part of our efforts to improve survival and cardiovascular care in patients with cardiac arrest. A strong chain of survival improves survival and recovery after cardiac arrest. Although there have been improvements in CPR and advanced life support, there remains room for further improvement, and perhaps we can do our part by encouraging our patients, friends and relatives to take the first step and learn how to perform effective CPR and possibly how to use AEDs!!

I have added a few online references for those interested in sharing this with their patients and encouraging them to sign up for both the online and class programs [3,6]!!

References:

  • Meaney PA, Bobrow BJ, Mancini ME, et al. Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association [published correction appears in Circulation. 2013 Aug 20;128(8):e120] [published correction appears in Circulation. 2013 Nov 12;128(20):e408]. Circulation. 2013;128(4):417-435. doi:10.1161/CIR.0b013e31829d8654
  • Malta Hansen C, Kragholm K, Dupre ME, et al. Association of Bystander and First-Responder Efforts and Outcomes According to Sex: Results From the North Carolina HeartRescue Statewide Quality Improvement Initiative. J Am Heart Assoc. 2018;7(18):e009873. doi:10.1161/JAHA.118.009873
  • CPR facts and stats:

https://cpr.heart.org/en/resources/cpr-facts-and-stats

  • Chain of Survival:

https://cpr.heart.org/en/resources/cpr-facts-and-stats/out-of-hospital-chain-of-survival

  • Mandatory CPR training in high school:

https://www.sca-aware.org/schools/school-news/mandatory-cpr-training-in-us-high-schools

  • CPR AED and first aid classes:

https://cpr.heart.org/en/course-catalog-search

“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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Leadership Through Unprecedented Uncertainty

Being an early career professional in health and science means moving along a continuum of learning and leading. The moment you clear a hurdle, you’re a mentor for people following you. Remember “see one, do one, teach one”? There’s the learning-leading continuum in action. Every day of our working lives, we are becoming leaders as we continue to learn.

For the past month, give or take, the U.S. has been in the midst of a panicked response to the global COVID-19 pandemic. Institutions have been scrambling to respond to rapidly changing conditions with scarce information and mixed messages from government and global bodies. Schools and healthcare organizations, where many of us work, have been particularly impacted. I have felt this stress acutely, as I’m sure many of you have. Will we be caring for affected patients? Will our PPE and medical supplies last? Will our research be put on hold? Will our students be able to graduate? Will we or our loved ones fall ill?

Even as our own anxiety ramps up, we may find ourselves needing our fledgling leadership skills more than ever. The public looks to us as experts. Patients look to us for guidance and comfort. Our students look to us for direction. Staff who work in our facilities look to us for instructions. How can we be there for these folks, even if we don’t feel all there ourselves? Here are some ideas:

  • Be present: find safe ways to be available, whether you’re on the ground, on video chat, sending emails, or anything else you dream up. Let people know they can talk to you and you’re there.
  • Be informed: Stay up to date, find sources of information you trust, and read with intention. This practice can help you be a source of authority and comfort when so much around us is chaotic.
  • Be honest: it’s OK to say “I don’t know” when you don’t know— especially if the next part is “but I promise to do my best.”
  • Be kind: Every person you interact with is facing stress now. Treat them kindly. Ask how they are, and listen to the answer. Allow a little grace where you might otherwise stick to strictly business.
  • Be transparent: If you are working on a plan, say so. If things might change, say so. If you are waiting on a person or a step that can’t be rushed, say so.
  • Be human: you don’t have to be a robot. People can see that you, too, are anxious or uncertain, and that doesn’t undermine your ability to lead. People can see that you have kids, or pets, or a partner, or dirty dishes. Sharing your self can be one of the most powerful ways to connect.

Ultimately, everyone is seeking stability, comfort, and connection. Much of this is beyond our control, but even a little leadership presence goes a long way.

Stay safe, friends, and may you come through these hard times with grace and wisdom.

 

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

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A Paycheck Away: Financial Fitness in Medicine Part II

In the first installment of this three-part series, I summarized the current state of financial fitness among early-career medical professionals in the United States. I also reviewed a few general changes in philosophy that can help you begin to improve your financial health starting today. The response to that blog has been largely positive; and in the days after its posting, I received text messages from friends/colleagues expressing their desire for specific measures to take in the last year of fellowship — or first few years of independent practice. This blog post will, therefore, focus on specifics.

LAST YEAR OF TRAINING: “FINISH STRONG”

(Image: ESPN)

  • Buy individual disability insurance before June 30th. Health is wealth, and you should protect your most valuable financial asset (as a resident/fellow, this is plainly your future earning potential) in the event that you’re incapacitated in any way. Disability insurance essentially pays you a set amount of income per month while you are unable to work. This set amount depends on the plan you choose – typically expect to spend 2-4% of the income insured. Premiums depend on your current age, health, income, etc. This is why it’s important for you to lock yourself into a plan now, while you’re making significantly less income and still exercising 4 times a week. Most university-based hospitals offer group policies that are essentially generic plans from one insurer for all employees who opt-in as part of their compensation plan. I advise you, however, to find an insurance agent on your own. This individual will find provide you with all the options on the marketplace, with specialty-specific plans that can travel with you if you leave your current/future employer. You can also increase your policy (i.e. the monthly payout) as your income increases throughout your career without having to repeat a medical exam or questionnaire. (further reading)
  • Have a lawyer review your contract/offer. One way to really start off on the wrong foot is to have a contract that limits your earning potential and adversely affects your work-life balance. Have a legal professional who deals specifically with physician contracts in your state, and better yet in your county/region of the state. Some employers, for instance, will offer an attractive base pay with an unattainable RVU requirement in order to receive that shiny new base pay. Things to ask about: fairness of non-compete clause, stipulations regarding with/without cause termination, work RVU requirement, bonus structure, and feasibility, 401k match, tuition/education benefits. Things to look up: MGMA DataDive survey results for your specialty and city, AMA Physician Practice Benchmark survey results for your specialty and city.
  • Open a low fee, high-interest checking/savings account. If you’re like me and you’ve had the same checking account since you were a freshman in college, it may be time to reevaluate if that’s the best option for you. There are so many great low/no-fee options out there for you to direct deposit your new paychecks into. There are also options that allow you to invest in the market easily, or offer credits for doing so. Ultimately, what you want is for your bank accounts to protect and grow your money rather than slowly bleed you of it. I personally recommend taking a look at Charles Schwab but here are some other outstanding options for you to consider.

FIRST YEAR AS ATTENDING: “GET YOUR LEGS UNDER YOU”

(Image: Attack of the Cute)

  • Enjoy it. You’ve put in years and years of tireless effort to finally get to this point. While your college roommates were buying homes, cars and building investment portfolios, you were spending endless nights in the library or on the wards. Make a bucket list today, and make an effort to check one of those things off each year. Maybe it’s a safari in Tanzania, or it’s the Rolex that your grandpa/grandma always wore. Go for it. You deserve it.
  • Physician mortgage loan. Most people want to own a home eventually. It’s part of the American dream. It also makes sense financially (let’s play a game: calculate the total amount of rent you’ve paid from age 18 until now…then keep track of that number each month until it stops growing). So what exactly is a physician mortgage loan? It’s a special benefit provided by banks across the country that allows early-career physicians (usually < 5 years out of training) to secure mortgages of up to ~$900k with 0-5% down payment. In any other situation, with such a low down payment, the borrower would pay a fee to the bank to ensure that they won’t default on the loan; this is called a PMI (Private Mortgage Insurance). In order to secure one of these mortgages, you need to typically have a credit score of 700 and a signed contract showing your anticipated salary. That’s right, NO PAY STUBS. Many physicians actually close on their home before they even begin working. With the 15-20% that you’re saving on a down payment, go ahead and pay down those student loans.
  • If married with loans, file taxes as separate. It always comes up during tax season whether married couples should file jointly or separately. For most couples reading this, one or both partners is a physician. The average physician income in somewhere around $200,000 per year. The average physician’s student loan debt is also somewhere around $200,000. Assuming that your situation is somewhere around the average, it usually makes sense to file separately. The main downside to filing separately is that the current tax code includes credits that are only available to couples filing jointly. However, most or all of these credits only pertain to household incomes well below that of even a single income physician household. The benefits of filing separately pertain to income-driven loan repayment programs and other income-based plans you may have. If you file your taxes separately, your lender will consider only your income (not your spouse’s) in calculating your monthly payments. This can significantly reduce your monthly payments!

It’s important for physicians to tend to our financial fitness as we tend to our physical fitness. Just like everything in life, practice makes perfect. Try saving 20% of your resident/fellow salary this month. Practice trading stocks using a simulator like Investopedia’s.

If you’re going to be an attending in July 2020, plan out how the rest of the year looks for you financially, so it won’t be such a surprise when you get there. Lastly, read about the mistakes that these financially savvy physicians made here. Learning from others’ mistakes is just as good as learning from your own.

That’s all for now! Please feel free to tweet me or email me any particular questions you have, and I’ll try to answer right away as well as incorporate them into future posts.

 

“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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Peripartum Cardiomyopathy: Go Red & Recognize!

This one is dedicated to all women and their families who have been affected by Peripartum Cardiomyopathy (PPCM). Seldom detected, systolic heart failure can come as a surprise especially in young women. Developing heart failure during pregnancy, in the post-partum period or any other time throughout a subsequent pregnancy is not something any woman wants to worry about specially around the birth of their child.

The 2010 Heart Failure Association of the European Society of Cardiology Working Group defines PPCM to “an idiopathic cardiomyopathy presenting with Heart Failure (HF) secondary to Left Ventricular (LV) systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause of heart failure is found”1, hence a diagnosis of exclusion.

The annual incidence of PPCM continues to increase. Women present with wide range of HF symptoms. Although some have complete recovery with guideline directed medical treatment, others have persistent myocardial dysfunction, advance heart failure and death which subsequently leads to devastating consequences for an entire family.  Delays in diagnosis usually occur because the symptoms and signs of PPCM can mimic the normal findings of pregnancy.  Early recognition and treatment of PPCM could lead to improvements in maternal and fetal mortality and morbidity. Easier said than done.

By the time a patient with PPCM sees a cardiovascular specialist, they often have worsening symptoms of heart failure with moderate to severe depressed left ventricular systolic function which means it was later recognized by either a primary care physician and/or an obstetrician-gynecologist prior to referral.

Awareness is key in early detection of PPCM. If you see something, say something. Think PPCM in all pregnant women. Since we mentioned that survival and recovery are both improved by early diagnosis, there is a validated self-test that can help with discerning heart failure from pregnancy related symptoms from Fett et al2. (Table 1.)

 

  1. Self-Test for Early Diagnosis of Peripartum Cardiomyopathy
Symptoms 0 points 1 point 2 points
Orthopnea None Need to elevate head Need to elevated 45 degrees or more
Dyspnea None Climb 8 or more steps Walking on level
Unexplained cough None At night Day and night
Excessive weight gain during last month of pregnancy None 2-4 pounds per week Over 4 pounds per week
Lower extremity edema None Below the knee Above the knee
Palpitations None When Laying down at night Day and night or any position

  The present of 4 or more points should prompt additional investigation.

 

Fett’s self-test can be an essential tool for the PCP and OB-GYN to aid in early detection of PPCM. Think about PPCM and use the self-test on all patients at risk to help guide further next steps in the diagnosis and management. In support of awareness of heart disease in women, think PPCM in which case the battle is half way won.

 

References:

  1.  Sliwa K, Hilfiker-Kleiner D, Petrie MC, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur J Heart Fail 2010;12: 767–78.
  2. Fett, JD .Validation of a self-test for early diagnosis of heart failure in peripartum cardiomyopathy. Crit. Pathw. Cardiol. 10(1), 44–45 (2011).

 

“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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Learning on the Go – Some Podcast Recommendations

As researchers, clinicians, and/or trainees, there never seems to be enough time in the day to get all the stuff done that we want to get done. There seems to always be more papers that we want or should read. One of my favorite ways to try to stay up to date with the latest research publications is listening to podcasts. I enjoy listening to podcasts while commuting and doing chores, and sometimes while working in the lab when no one else is around. Depends on my mood whether I can listen to a podcast while exercising or would prefer to listen to more energetic music.

Below is a list of some of my favorite cardiology podcasts. This is not a comprehensive list and I am not affiliated with any of these podcasts. I also am not endorsing any of the content discussed in the below podcasts. This list is also biased towards those podcasts that are easily accessible via smartphone podcast/listening applications and do not require downloading individual episodes from specific websites. These podcasts are not listed in any particular order.

  • Circulation on the Run: Summarizes the articles published in a specific issue of Circulation and has a more in-depth discussion of a featured article.
  • Discover CircRes: Summarizes the articles published in a specific issue of Circulation Research and also has a more in-depth discussion of a featured article often with the article’s corresponding author as well as the trainee involved in the article.
  • The Bob Harrington Show: Interviews and discussions of various topics in cardiology and the practice of medicine.
  • This Week in Cardiology: Dr. John Mandrola summarizes and provides his insight on some of the top news in cardiology for the week.
  • JACC Podcast: Dr. Valentin Fuster, editor-in-chief of the Journal of American College of College (JACC) provides an overview and summary of the articles published in a specific issue of JACC.
  • Eagle’s Eye View Your Weekly CV Update from ACC.org: A weekly cardiovascular update from Dr. Kim Eagle, editor-in-chief of ACC.org.
  • ACCEL Lite Features ACCEL Interview on Exciting CV Research: Interviews and summaries of some of cardiology’s most interesting research topics, hosted by Dr. Spencer King III.
  • Heart: Summaries of original research, editorials, and reviews from the BMJ’s Heart
  • Heart Sounds with Shelley Wood: Discusses some of the top stories in cardiology covered by the TCTMD reporters.
  • CardioNerds: This is a podcast that I just started listening to. It discusses high yield cardiovascular topics in a case discussion format.
  • AP Cardiology, ACC CardiaCast, Cardiac Consult A Cleveland Clinic Podcast for Healthcare Professionals: Three different podcasts that provide summaries of various cardiology topics.
  • JAMA Editors’ Summary, JAMA Clinical Reviews, JAMA Medical News Interviews and Summaries: Three different podcasts which provide summaries of various medical topics.
  • Annals of Internal Medicine Podcast: Highlights and interviews from a specific issue of Annals of Internal Medicine. The American College of Physicians has another podcast, Annals On Call Podcast, which features Dr. Bob Centor discussing influential articles that are published in Annals of Internal Medicine. I have not yet started listening to Annals on Call, but hope to do so in the near future.
  • ED ECMO: Discusses resuscitative extra-corporeal membrane oxygenation (ECMO) and extra-corporeal life support (ELS). At the University of Minnesota, cardiologists manage veno-arterial ECMO (VA-ECMO). More to come about this during an upcoming blog!

I am always open to hearing suggestions for new podcasts related to science/medicine or other topics!

 

“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 American Heart and Go Red for Women Month!

It is February: The American Heart and Go Red for Women Month!

February has just started with all its excitement and optimistic thoughts!! I would like to talk about some of the amazing initiatives, including American Heart Month and Go Red for Women initiatives, that are in place to inspire and encourage more of my colleagues, women and men equally, to step up and be proactive about women’s health and education!

  • When was the first American Heart Month?

It was in February 1964, proclaimed by President Lyndon B. Johnson, and Congress subsequently requested the President to issue a proclamation designating February as American Heart Month annually.

  • What is the Go Red for Women Initiative?

It is an initiative, launched in 2004, to end heart disease and stroke in women; by increasing awareness of these diseases in women and removing barriers women face to achieve a healthy life. Here is what GO RED means:

  • G: GET YOUR NUMBERS

Ask your doctor to check your blood pressure and cholesterol.

  • O: OWN YOUR LIFESTYLE

Stop smoking, lose weight, exercise, and eat healthy.

  • R: REALIZE YOUR RISK

Know your risk; heart disease is responsible for 1 in every 5 female deaths [1].

  • E: EDUCATE YOUR FAMILY

Make healthy food choices for you and your family.

  • D: DON’T BE SILENT

Tell every woman you know that heart disease is our No. 1 killer [1].

  • How about “Research Goes Red” initiative?

It is an initiative to increase women’s participation in scientific research. Both healthy women and those with acute or chronic diseases are encouraged to participate.

  • What impact have these initiatives achieved?

The impact of these initiatives has been remarkable and quite impressive!! Here are some of their achievements:

  • More than 25,000 women registered for the Research Goes Red initiative!
  • Around 19 million women interact with Go Red through digital platforms annually.
  • $600 million raised to support research, education, advocacy, prevention and awareness programs.

Seeing the impact of these initiatives, I am hopeful not only that these initiatives continue to include and support more women, but also I am optimistic that more initiatives are launched to: (1) increase awareness of different heart diseases in women, (2) empower women to know the differences in the clinical presentations of different diseases, (3) implement strategies to avoid health care disparities based on gender and race, and (4) help more women and minorities access health care, not only across the nation but also across the globe.

 

Reference

 

“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 Health Costs of Hunger

I hope someday we will be able to proclaim that we have banished hunger in the United States, and that we’ve been able to bring nutrition and health to the whole world. –Senator George McGovern

Food. Nothing is more basic to our existence than eating. However, in our modern era of plenty, we often take the presence of food for granted. That is, we take it for granted until we no longer have access to it or it makes us sick.

Food insecurity, when individuals lack access to adequate and safe food due to limited resources, is pervasive in the United States. In 2018, 37.2 million Americans were food insecure and of that, 6 million were children. A recent analysis found that 20-50% of college students were food insecure and hunger affects their ability to learn, be economically stable, and navigate social situations. While food insecurity tends to be higher in rural areas, it affects people of every gender, age, race and ethnicity throughout the United States.

The health consequences of food insecurity are well-described and have a disproportionate impact on cardiovascular health. In children, food insecurity is associated with birth defects, cognitive and behavioral problems, increased rates of asthma, depression, suicide ideation, and an increased risk of hospitalization.  In adults, food insecurity is linked to mental health problems, diabetes, high blood pressure, and high cholesterol. Food insecurity affects health in multiple ways (Figure 1). Conceived of as a cyclical process (in which people have periods fluctuating between food adequacy and inadequacy), fewer dietary options lead to increased consumption of cheap, energy dense, but nutritionally poor foods. Over-consumption of these foods during periods of food adequacy can lead to weight gain and high blood sugar, and reduced consumption of food during food shortages can lead to weight loss and low blood sugar. These cycles are exacerbated by stress and result in obesity, high blood pressure, and ultimately diabetes and coronary artery disease. The cycle continues until access to adequate, safe, high-nutrition foods stabilizes.

As a driver of poor nutritional intake, food insecurity is among the leading causes of chronic disease-related morbidity. As such, there is increasing recognition that for many food insecurity is not behavioral challenge but a structural one. Indeed this is the reason for the creation and continued re-authorization of the supplemental nutritional assistance program (or SNAP) that in 2018 provided $60.8 billion to more than 40 million Americans. SNAP was initially conceived during the Great Depression as a strategy to stave off mass starvation while providing American farmers with a fair price for their surplus agricultural products. It has gone through many legislative and administrative updates since the 1930’s (for a full history, please see Dr. Marion Nestle’s recent review in the American Journal of Public Health) and today remains the 3rd largest, and one of the most effective anti-hunger programs in the United States. Yet, despite its success at reducing food insecurity, today, proposals to reduce the monthly benefit levels and impose restrictions to limit access to SNAP are gaining political traction.  If the proposed SNAP reforms were enacted, 2.2 million American households would no longer be eligible for SNAP and an additional 3.1 million households would receive reduced benefits–many of those affected would be elderly and disabled. Thus, the cycle of food insecurity and chronic disease would worsen.

Food nourishes us and provides the sustenance we need to get through each day with our health, livelihood, and dignity intact.  While I have outlined the public health case for mitigating food insecurity; it is clear that food insecurity is not just a health issue, or even just a political issue. Above all else, it is a moral issue and one that we that we cannot be on the fence on. We must decide if today, in the richest country on the planet, at its most prosperous time in history, our friends, patients, and neighbors – men, women, and children who are just like us – should be hungry.

If your answer is no, then thankfully there is much that we can do about it. Check back for next month’s blog on strategies that health care providers, neighbors, citizens, and professional associations can do to help address food insecurity in America. In the meantime, please share your experiences addressing food insecurity in your own practice or community with me at @AllisonWebelPhD.

“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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Nutrition in the New Year: What is Our Role as Cardiologists?

As we embark on this new year, we are bound to field questions from our patients (and likely, family members) centered around the most popular new year’s resolution: Eating healthier. Reflecting upon my own answers to these questions in clinic over the years, I realize they have been some combination of:

“Eat smaller portions.” “Eat less meat.” “Cut out soda or juice.” “Don’t eat for 3 hours before going to bed.” “Have you heard of the Mediterranean diet?”

And the basis for my recommendations? While I’m sure my years of medical training were factored in somewhere, I feel like these suggestions were largely based on a combination of my own experiences with managing my nutrition, anecdotes from colleagues and friends, and quite possibly my favorite podcasts.

Upon further reflection, though, this is not all too surprising. For all the years that we spend in medical school, residency, and fellowship learning about pathophysiology and pharmacology, we receive much less structured education on nutrition.1 In four years of medical school, one study estimates that the average medical student receives approximately only 19 hours of didactic lectures in total on nutrition, with most of this education focusing on the manifestations of nutritional deficiencies (thiamine, vitamin C, etc.).2 If your recollection is like mine though, 19 hours seems like an overestimation, and it only declines in post-graduate medical training. In a recent study published in the American Journal of Medicine, 31% of cardiologists reported receiving no nutrition education in medical school, 59% reported none during residency, and 90% reported receiving no or minimal nutrition education during fellowship.3

Nutrition Education from Medical School to Fellowship. (From Devries et al.3)

Figure 1: Nutrition Education from Medical School to Fellowship. (From Devries et al.3)

“But we are cardiologists, not nutritionists,” one might say. Yet in the same study, 95% of cardiologists believed that their role is to provide their patients at least basic nutrition information (68.6% believed they should personally provide detailed nutrition information to patients).3 While many of our cardiovascular care teams include dieticians specifically trained to counsel our patients on their nutrition habits, we as cardiologists often find ourselves directly answering these questions from our patients.

Indeed, some physicians have made names for themselves by proselytizing specific diets for their patients. Yet what I find a bit unsettling is the variability of the messages we deliver to our patients when it comes to nutrition. While the AHA provides dietary recommendations we can share with our patients, new diets continue to pop up and gain traction in the headlines, inevitably leading to questions from our patients about whether it is safe for them to adhere to these diets. Notably, (1) intermittent fasting, (2) plant-based or vegan, and (3) ketogenic or “keto” appear to be the diets du jour.

While I personally have experimented with intermittent fasting and a plant-based diet, I am a bit uncomfortable fully endorsing one or the other to my patients, each with his or her own metabolic profile and potential list of glucose-lowering medications. When it comes to diet, more than anything, individualization is key. More so than exercise and medications, diet has deeper roots in the cultural, financial and societal environments in which our patients live. Helping them navigate a healthy lifestyle through these obstacles requires not only more time in clinic but also a deeper, more evidence-based foundation in cardiovascular nutrition.

Fortunately, we are entering an era in which we are gathering more evidence in nutrition science. A recent study published earlier this month in Cell Metabolism studied “time-restricted eating” (AKA intermittent fasting with a 10-hour eating window) in patients with metabolic syndrome,4 finding that it had beneficial effects on weight loss and metabolic profile in its albeit small sample size. (Figure 2) Additionally, a New England Journal of Medicine review article published over the holidays highlighted the existing evidence we have, both in animals and in humans, of intermittent fasting on health, longevity, and various disease states (including cardiovascular disease and cancer).5 Importantly, these recent publications and the responses they have elicited in the news and on social media have called attention to the need for more dedicated studies to address the safety and efficacy of specific diets and dietary patterns in our patients with metabolic and/or cardiovascular diseases. Indeed, more clinical trials are underway: a quick search on ClinicalTrials.gov shows that 24 registered clinical trials with an “intermittent fasting” intervention are actively recruiting participants, including the LIFE AS IF trial from the University of Chicago.

Graphical Abstract from Wilkinson et al study on Time-Restricted Eating in Metabolic Syndrome.4

Figure 2: Graphical Abstract from Wilkinson et al study on Time-Restricted Eating in Metabolic Syndrome.4

In a prior blog post on “Wearables in Medicine,” I recommended that we consider trialing wearable devices ourselves before counseling patients based on data obtained from them. While I do think our own experiences with diets and dietary patterns may be informative, our personal experiences should not be the sole pillar upon which we base our nutritional recommendations to our patients. Again, individualization is key, and a nuanced approach, factoring in living environments, medications, and metabolic profiles, is necessary.

So what should we do as members of cardiovascular care teams? Well, to provide basic nutrition recommendations to our patients, we can use the AHA Diet & Lifestyle Recommendations. However, we must acknowledge our own limitations regarding the lack of formal training on nutrition during our medical education. As such, my resolution this year is to further my education on nutritional science and attempt to understand how these popular diets may fit within modern cardiovascular disease management. To achieve these goals, I will:

  • Read: Some books recommended by my attendings that I plan to read include The Obesity Code by Jason Fung, MD and The Plant Paradox by Steven Gundry, MD. Additionally, for those interested in learning more about the role of a “keto” diet in cardiology, the ACC.org Sports and Exercise Cardiology section recently published a series of high-yield, informative articles (Link 1 and Link 2).
  • Collaborate: We have a dietician in our cardiovascular care team with whom I regrettably had not spoken directly with until recently. I previously had just referred patients to her, but I did not necessarily know exactly what advice she was giving to our shared patients. Opening and maintaining this channel of communication is essential to delivering a consistent message from our team.
  • Ask: I am now making it a habit to include a simple question in my clinic encounters: “How’s your diet?” I have found the open-endedness of the question to be quite enlightening, often helping me to uncover a new aspect of the world my patient lives in and their own perspective on how their nutrition impacts their health.

I would love to hear your input on this topic. What do you feel our roles are in nutrition counseling for our patients? What are reliable resources to learn more about this topic? How can we be better at delivering appropriate nutrition information to our patients? Please reach out to me on Twitter (@JeffHsuMD) with your thoughts and ideas.

References:

  1. Devries S, Willett W, Bonow RO. Nutrition Education in Medical School, Residency Training, and Practice. JAMA. 2019;321:1351–1352.
  2. Adams KM, Butsch WS, Kohlmeier M. The State of Nutrition Education at US Medical Schools. Journal of Biomedical Education. 2015;2015:357627.
  3. Devries S, Agatston A, Aggarwal M, Aspry KE, Esselstyn CB, Kris-Etherton P, Miller M, O’Keefe JH, Ros E, Rzeszut AK, White BA, Williams KA, Freeman AM. A Deficiency of Nutrition Education and Practice in Cardiology. Am J Med. 2017;130:1298–1305.
  4. Wilkinson MJ, Manoogian ENC, Zadourian A, Lo H, Fakhouri S, Shoghi A, Wang X, Fleischer JG, Navlakha S, Panda S, Taub PR. Ten-Hour Time-Restricted Eating Reduces Weight, Blood Pressure, and Atherogenic Lipids in Patients with Metabolic Syndrome. Cell Metab. 2020;31:92-104.e5.
  5. de Cabo R, Mattson MP. Effects of Intermittent Fasting on Health, Aging, and Disease. N Engl J Med. 2019;381:2541–2551.

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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To Stent or not to Stent?

In the wake of the ISCHEMIA trial results being published, and the media firestorm that ensued, I’ve run into some interesting scenarios, including STEMI patients saying they don’t want to be revascularized because they heard on the news that stents are useless (oh boy!). However, after a robust discussion with an intern, I decided to do a quick n dirty rundown of who does and does not need immediate revascularization, and which strategy to go with.

If there’s one thing you should know about the ISCHEMIA trial, it is that this study sought to answer the question of whether or not STABLE ischemic heart disease would benefit from an aggressive revascularization strategy vs a conservative strategy of goal-directed medical therapy. This had nothing to do with patients who had ACS. I will also add that with long-term followup, the results might change, nobody knows for certain. The reason I say this is because the PCI arm had a signal towards harm in the first 6 months after revascularization, but as they approached 4 years, the mortality curves started to separate in favor of the aggressive revascularization arm. As it stands, their conclusions were not in favor of an aggressive strategy over a conservative one. Interestingly, these results didn’t differ very much from the COURAGE trial, where they found no significant difference between optimal medical therapy vs PCI for stable ischemic heart disease. Differences to note include the fact that COURAGE did NOT use FFR, and did not have routine use of DES.

Keep in mind, patients with left main stenosis > 50% were excluded from both of these trials, as were those who had recent revascularization within the past 6 to 12 months (PCI or CABG). The reason I mention this is because some people thought these results contradicted the findings of the COMPLETE trials – but no, these trials looked at different sets of patients altogether!

A few big wins for the ISCHEMIA trial:

  • CT-angiography was shown to be very reliable
  • FFR-guided PCI is becoming more routinely accepted as the preferred method of PCI
  • Optimal medical therapy really helps…even if there turns out to be a mortality benefit in favor of early-PCI, the fact that it takes several years to emerge is a statement about how helpful these medications truly are.

 

With regards to stable ischemic heart disease, clear indications for revascularization include left main stenosis > 50%, proximal LAD with >50% stenosis, or multi-vessel disease with signs of impaired ventricular function. Typically, cardiologists will employ the SYNTAX score, which is a validated system used to grade the severity and complexity of lesions. Typically, SYNTAX scores < 23 are amenable to PCI and non-inferior to CABG. The typical scenario for PCI is when you have isolated disease in only 1 or 2 vessels, and this is amenable to stenting.

Once you have significant left main disease, especially in conjunction with 2-3 vessel disease, the SYNTAX score is > 32, and CABG is superior.

Until very recently, it was generally accepted that isolated left main disease could be treated by PCI or CABG. However, some controversy has erupted recently after the results of the EXCEL trial were published. Specifically, the EXCEL trial had a composite endpoint of stroke, MI, or death, and there was no statistically significant differences between the two groups. Surgeons will tell you that the higher rates of the composite endpoint were driven by excess all-cause mortality in the PCI arm, as compared to peri-procedural MI in the CABG arm…in other words, while the composite endpoints were similar in both groups, the individual endpoint of mortality was higher with PCI, whereas peri-procedural MI was higher with CABG. This can certainly be a bit contentious, especially if you wonder what the clinical significance of a troponin elevation is after CABG. Nonetheless, the trial was powered to detect differences in the COMPOSITE endpoint, not in the individual endpoint of mortality.

The STICH trial demonstrated a significant benefit (albeit 10 years out) in favor of revascularization (this study only looked at CABG) for patients with ischemic heart failure. The FREEDOM trial took it one step further and tried to compare DES to CABG for mutli-vessel CAD in diabetics. The findings were strongly in favor of CABG over PCI, and this has become the accepted paradigm.

 

When you’re not sure, if they have funky looking anatomy AND they’re diabetic, you can make a safe gamble and ask your attending if they think this patient is a CABG candidate. 9 times out of 10, you’ll look like a genius.

In Conclusion:Stable ischemic heart disease has some controversy surrounding the role of revascularization, but ALL patients should be on optimal medical therapy

Patients with significantly reduced EF, Left main, proximal LAD disease, all should warrant a closer look at whether or not they would benefit from revascularization

Always try to involve a multi-disciplinary team when thinking about revascularization, at the end of the day, we are in the business of do no harm, so a second set of eyes can be beneficial.

 

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.

 

References:

https://www.ischemiatrial.org/

Boden, W. E., O’rourke, R. A., Teo, K. K., Hartigan, P. M., Maron, D. J., Kostuk, W. J., … & Chaitman, B. R. (2007). Title LM, Gau G, Blaustein AS, Booth DC, Bates ER, Spertus JA, Berman DS, Mancini GB, Weintraub WS; COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med356(15), 1503-16.

Campos, C. M., van Klaveren, D., Farooq, V., Simonton, C. A., Kappetein, A. P., Sabik III, J. F., … & Serruys, P. W. (2015). Long-term forecasting and comparison of mortality in the Evaluation of the Xience Everolimus Eluting Stent vs. Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial: prospective validation of the SYNTAX Score II. European heart journal36(20), 1231-1241.

Stone, G. W., Kappetein, A. P., Sabik, J. F., Pocock, S. J., Morice, M. C., Puskas, J., … & Banning, A. (2019). Five-year outcomes after PCI or CABG for left main coronary disease. New England Journal of Medicine381(19), 1820