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

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

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

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

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

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

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

 

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

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Management of Acute Myocardial Infarction Complicated by Cardiogenic Shock

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

Key points:

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

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

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

 

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

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

– Norepinephrine is your first go-to pressor.

– In unstable bradycardia, Epinephrine or dopamine is recommended.

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

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

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

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

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

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

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

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

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

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

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

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

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

References:    

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

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

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Top 10 Tips for Incoming Cardiology Fellows

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

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

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

 

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

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Should interventional cardiologists perform thrombectomy?

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

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

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

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

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

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

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

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

REFERENCE

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

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

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

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

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

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

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

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

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

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

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

Apricots for the win!

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

 

References:

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

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

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

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

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

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Updates to the NIH Biosketch

For this week’s blog, I wanted to focus on a central component of any NIH grant — the biosketch. Did you know that the NIH is updating the biosketch format for all applications due on or after May 25th, 2021? Did you know that your application can get rejected if a biosketch in your grant application is formatted incorrectly? Regardless of where you are in your research career, if you are planning to apply for an NIH grant, it’s a great time to either get started on your biosketch or update what you have.

 What is an NIH biosketch?
An NIH biographical sketch (or biosketch) is a five-page resume of your scientific work. A biosketch is required for all NIH grant applications and renewals. Like a resume, the goal of the biosketch is to communicate to the reviewers that you are the ideal person to undertake the research proposed. In its current form, the biosketch consists of four sections: (A) Personal Statement, (B) Positions and Honors, (C) Contributions to Science, and (D) Additional Information: Research Support or Scholastic Performance.

How to get started writing your NIH biosketch?
There are two major types of biosketches: Fellowship (for F-awards) and Non-Fellowship (for most other awards, including K-awards and R-awards). The NIH biosketch needs to be written in a specific format. The format varies a tiny bit between Fellowship and Non-Fellowship types, so first determine which kind of biosketch you want to prepare. There are two options to get started:

  1. Download the appropriate biosketch sample from the NIH Grants and Funding website and modify it as needed.
  2. Use the NIH SciENcv website (linked to your My NCBI account) to create your biosketch. I love this website and highly recommend giving this approach a try. The NIH SciENcv website is a joy to work with and incredibly simple to use. All you need to do is create a personal NIH bibliography, input all your information, and then export your biosketch as either a Word Document or PDF. The NIH SciENcv website automatically formats your citations and correctly inserts your data into the biosketch layout.

What are the major changes to the new biosketch?

For a complete list of changes, read more about the upcoming changes to the biographical sketch and other support format page in the NIH notice here: NOT-OD-21-073. As you will read, the changes are few but significant. I’ve highlighted a few of the major changes here in bolded italics.

  1. Section B has been renamed. Instead of “Positions and Honors” it is now “Positions, Scientific Appointments, and Honors.” In this section you now need to include both domestic and foreign positions and scientific appointments. The NIH is asking that individuals now list any affiliations with foreign entities or governments. If this applies to you, definitely read through this section carefully as titles can include full-time, part-time, or even voluntary positions.
  2. In Section B, the “Positions, Scientific Appointments, and Honors” should now be listed in reverse chronological order. In the past, these materials were listed in chronological order.
  3. For non-Fellowship biosketches, Section D (Additional Information: Research Support) has been removed. In its place, details about ongoing and completed research projects from the past three years should be included in Section A (Personal Statement).

What are the major changes to the “Other Support” section?

While the changes to the NIH biosketch are minimal, in the same notice (NOT-OD-21-073) the NIH will now require more documentation for the “Other Support” section of your grant. These changes include:

  1. Inclusion of all resources, including in-kind contributions (i.e. office/laboratory space, equipment, supplies, or researchers supported by an outside source).
  2. Addition of a signature block (for the Principal Investigator and Other Senior/Key Personnel) to certify the accuracy of the information.

“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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Listen to Your Heart: How to Prepare Yourself for A Career in Cardiology

The road to Cardiology fellowship can be a confusing one. Residency, with its breakneck pace and punishingly long hours, is already a Herculean challenge in and of itself. Simply completing residency is its own feat. Attempting to set yourself up for the next stage in your career in a hyper-competitive specialty adds an entirely new layer of complexity. Trainees on this path towards post-residency training in Cardiology often find themselves asking critical questions: How can I figure out if Cardiology is truly the right field for me? How can I prepare myself for fellowship? What can I do to make myself a competitive applicant?

As you can imagine, the real answer here is that there is no one right way to approach the journey of becoming a cardiologist. Everyone must forge their own path. Still, I would like to share some lessons I have learned from my experiences as a Cardiology-bound resident.

Trade into Cardiology rotations

The only way to find out if you like Cardiology is to ensure that you actually have exposure to it. Sometimes, this means trading into additional Cardiology rotations and increasing your exposure to both cardiologists and potential Cardiology mentors who can talk to you about this career. Only by rotating in Cardiology rotations can you decide if this is a field that you would like to pursue further!

Seek out outpatient Cardiology experiences

Much of the exposure that Internal Medicine residents have to Cardiology during residency comes in the form of inpatient Cardiology rotations (Cardiology wards, Cardiac ICUs). While these are wonderful entry points into the field, they represent only a fraction of the breadth and depth of Cardiology. They may even erroneously lead you to think that most Cardiology happens inside of the hospital (surprise: much of it happens in the outpatient setting). I did not realize this myself until I participated in an ambulatory Cardiology elective. I strongly encourage you to explore the world beyond the CCU or Cardiology wards, so that you can develop a more realistic view of how you will spend the majority of your clinical time later in your career.

But don’t do too much Cardiology!

A common misconception among residents, regardless of their intended career, is that they should only pursue experiences in their field of interest. While this is admirable and might make you feel more prepared for fellowship, you must remember that nothing can truly prepare you for a career in a subspecialty except for fellowship itself. You will have entire years of your academic life set aside to learn how to be a cardiologist. However, after residency, you will no longer have the opportunity to improve upon your weaknesses in other areas of Internal Medicine. One of my mentors once told me that I should use my spare elective time to learn about other subspecialties so that I can become a better and more well-rounded internist. You will have plenty of time to learn about Cardiology during the fellowship. Use this precious extra time to learn about other things that will make you a better doctor, and ultimately, a better cardiologist.

Seek mentors out early

One common mistake that I see people make is that they wait too long connect with potential mentors. Applying to Cardiology fellowship applications is an extremely competitive process.  Thus, it can only help to have mentors in your corner who help you think about your career goals, give you feedback about your fellowship application, help you plan research projects, connect you with other mentors, write letters of recommendation on your behalf, and go to bat for you when the time comes. However, mentor-mentee relationships are not born overnight. You need to dedicate time to building a relationship with mentors that understand you and advocate for you. Allow time to see if you and a mentor hit it off and give your mentor a chance to get to know the real you. The only way to accomplish this is to start early.

Find projects that excite you

It can be really tempting to fall into the trap of taking on as many research projects as possible with the sole purpose of “fluffing” your resume, without regard to a project’s value or quality. Remember that everything you put out into the world is a reflection on you; you should be willing to stand proudly by any work that you produce. Be judicious. Select only those projects in which you are genuinely invested. Don’t just pad your resume with countless meaningless abstracts or manuscripts. Quality will always triumph over quantity.

Set realistic research goals

At the end of the day, your primary job in residency is to be a resident. Sometimes you will be too busy to do research. Sometimes you will be too drained to do research. Sometimes you need to recharge instead of doing yet more work. That’s OK. You cannot do it all. During my first meeting with one of my mentors, we talked about pursuing smaller projects that I could realistically complete during residency rather than trying to take on huge untenable projects. In retrospect, it was incredibly thoughtful and kind of my mentor to be so deliberate. It helped me set more realistic goals about what I could accomplish during residency and it made my research experience more fulfilling. You are a very busy resident. You should accordingly select realistic, sustainable and completable projects.

Join the online Cardiology community!

There is a very active Cardiology community on social networks such as Twitter, talking about the latest high-profile articles, debating new guidelines, and sharing amazing tweetorials or interesting clinical experiences. Social media offers a great opportunity to get to know and make connections with people in the field. I “met” some people on Twitter before I formally met them on the interview trail. It was nice to already have that connection with others in Cardiology. It made me feel from the very beginning that I belonged to a larger Cardiology community. Moreover, it has enhanced both my learning and my excitement about becoming a cardiologist!

Integrity is everything

No matter what you do, put your best foot forward every time. Your reputation really does matter. Though it seems large, Cardiology is also a tightly knit community and people do talk. You will want to develop a reputation as a hardworking, honest, conscientious and reliable person. Actions always speak louder than words. Remember that everything you do will be a reflection on you and your character. When in doubt, ask yourself, can I proudly stand by this decision a month or a year from now? Do the right thing every time. Don’t cut corners. Work hard and be kind. Whether you do good or bad things, people will take notice, and they won’t forget.

 

“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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Ramadan, COVID-19 and the cardiac patient

With the dawn of the Islamic lunar month of Ramadan, many Muslims around the world begin observing an absolute fast from dawn to dusk, abstaining from food, drink, and oral medications. The fast naturally also entails a change in lifestyle, sleeping patterns, and adjustments of salt and fluid intake, all of which have implications for the cardiac patient. Furthermore, as they are generally known to be on multiple medications, depending on the number of hours of fasting, there might be a need for adjusting drugs, doses, and timings.

Cardiac patients span across a wide range of diseases and differ in terms of symptoms, acuity, and hemodynamic stability. As such, while it might be entirely appropriate for stable patients to observe the fast, with adjustments to lifestyle, others who are less so may need to be advised against fasting, particularly as the sick are exempted. There is a paucity of data on best practices for fasting among cardiac patients. This blog provides a brief summary of the available data, some general suggestions, and links to useful resources pertinent to patients with common cardiac conditions on fasting during Ramadan.

Stable Coronary artery disease: Few observational studies suggest that with good monitoring, fasting may be safe in patients with stable treated coronary artery disease (CAD), particularly with normal left ventricular ejection fraction (EF), provided they adhere to medications.1-3

In fact, among stable patients with a previous history of cardiovascular disease (CVD), fasting during Ramadan has been shown to significantly improve 10-year Framingham cardiac risk score, as well as cardiovascular risk factors such as lipid profile, body mass index (BMI), and systolic blood pressure.4

Acute myocardial infarction (MI): Unlike stable CAD, however, in patients with a recent acute MI or immediate post-cardiac surgery, abstinence from fasting following the 6-week period of either of these events has been advised.5,6

Heart failure (HF): A prospective observational study examining the effect of Ramadan fasting on patients with chronic HF and reduced ejection fraction (< 40%), noted that as many as 92% of the patients that fasted had no changes or improved symptoms, while symptoms worsened in a minority of patients (8%).7 Furthermore, those with worsening symptoms were significantly less likely to have adhered to fluid and salt restrictions, and heart failure medications (p<0.0001). This clearly underscores the need for ensuring compliance with appropriately timed medications, particularly diuretics, in order to prevent acute decompensation of HF.

The British Islamic Medical Association has a structured guideline of recommendations based on risk for fasting among patients with heart failure:6

  • HF with preserved ejection fraction (HFpEF), and HF with reduced EF (up to an LV EF 35%) are at low/moderate risk for fasting (i.e. decision not to fast at the discretion of medical opinion and patient’s ability).6
  • Severe, but not advanced, heart failure is at high risk for fasting and should be advised not to fast. This would include patients on Cardiac Resynchronization Therapy (CRT) .6
  • Patients with advanced heart failure (including those on Left Ventricular Assist Devices), decompensated HF requiring large doses of diuretics 5, and those with severe pulmonary hypertension, are deemed very high risk, and MUST be advised against fasting.6

Hypertension: Fasting during Ramadan is generally well-tolerated in patients with well-controlled essential hypertension on the continuation of previous drug treatment 5,8, supported by ambulatory BP measurement (ABPM) data in observational studies.9-10. However, patients with resistant hypertension should be advised not to fast until their blood pressure is reasonably controlled.5 The key to blood pressure maintenance during Ramadan lies in compliance with medications, and non-pharmacological measures such as a low-salt diet.11. In those with fluctuating BP, home blood pressure monitoring with medication adjustment may be a feasible option.

Adjustment of medications: Cardiac medications are vital, and non-compliance has the potential to be life-threatening. Patients should be advised on adherence to medication, and efforts be made to ensure compliance, by adjusting dose and timings, or switching to a class of medication that might be a more compliant alternative.8 For drugs with two daily doses, it’s advisable to take them with as wide a gap as possible during non-fasting hours.8 In case a medication requires more than twice daily dosing, an adjustment that allows for better compliance may be preferred.

Antihypertensive drugs: For twice-daily medication, dose timings may need to be changed to coincide with the early morning meal (Suhoor) and the breaking-of-fast meal (Iftar).8 A switch to a once-daily medication with long-acting preparations may be preferred.8,11

Diuretics: Diuretics are particularly unpopular among patients who either stop or reduce its doses during Ramadan. Diuretics may also worsen fasting-associated dehydration (especially in hot weather), with non-compliance resulting in uncontrolled hypertension and decompensation of heart failure. If the indication is hypertension, switching to a suitable alternative is reasonable.6 However, strict compliance with diuretics must be advised among those with HF especially those with reduced EF. They may also be prescribed during the non-fasting period of the day (i.e. early evening), where there is minimal risk of associated dehydration.5 Alternatively, patients may consider taking it at dawn (suhoor) to prevent frequent micturition and disturbed night sleep.6

Anticoagulants: Compliance must be ensured for those requiring therapeutic anticoagulation, irrespective of indication, with patients being advised of the risks of stroke or systemic embolism in case of non-adherence.12,13 Some older small-scale observational studies have reported that Ramadan fasting does not appear to adversely influence the efficacy or safety of warfarin.14, 15 However, more recent data suggest that Ramadan fasting does in fact influence the therapeutic effect of warfarin in terms of lowered time spent in therapeutic range (TTR) with a reduced proportion of patients achieving therapeutic PT-INR and consequent increased risk of poor anticoagulation control.16, 17 As such, closer monitoring or dosage adjustments are necessary for patients maintained at the higher end of INR target ranges.16 This should extend to the post-Ramadan period, particularly in the elderly as they are more prone to over-anticoagulation and consequently the risk of bleeding.17, 18 ).

There is no randomized evidence on dosing adjustments for Novel oral anticoagulants (NOACs) with fasting during Ramadan.12 However, clinical practice suggests that drugs are taken once or twice daily, such as NOACs, do not require an adjustment.12 . Among patients on twice-daily NOACs such as apixaban, a switch to once-daily rivaroxaban might be feasible.6 Those taking rivaroxaban should be asked to take the NOAC with food even during the month of Ramadan.12

Antiplatelet medications: Patients must be strictly advised to continue dual antiplatelet therapy (DAPT), especially in case of a recent MI or percutaneous coronary stent implantation, with clear information on the adverse outcomes of non-compliance such as acute stent thrombosis, MI, and even death.6 In terms of P2Y12 inhibitors, given pharmacokinetics of ticagrelor, if twice-daily dosing proves challenging, a switch to single-dose P2Y12 inhibitors such as clopidogrel or prasugrel (if appropriate), may be considered.6

Ramadan, COVID-19, and vaccine uptake: With the rollout of vaccines currently underway globally, there are concerns about vaccine hesitancy, based on whether the intramuscular injection invalidates the fast, any possible side-effects, and if indeed the fast may have to be broken.19  Scholars have clarified that vaccination does NOT invalidate the fast and such clarifications must be widely disseminated among both cardiac patients and the general public in order to maximize vaccine uptake.20

The bottom line to good heart health during Ramadan remains in good communication and preemptive discussions. Although the current climate of the COVID-19 pandemic poses challenges to in-patient visits and physical examinations, virtual consultations must be leveraged to optimize cardiac care during the month of fasting. Some useful resources have been linked in the references. This blog is by no means exhaustive, and decisions regarding individual patients’ suitability for fasting and medication adjustments must be made following individualized discussions with their respective physicians, particularly as the duration of the fast varies in different geographical locations and as such, not all data derived from studies can be extrapolated generically.

References

  1. Salim I, Al Suwaidi J, Ghadban W, et al. Impact of religious Ramadan fasting on cardiovascular disease: a systematic review of the literature. Curr Med Res Opin. 2013;29(4):343-54.
  2. Al Suwaidi J, Zubaid M, Al-Mahmeed WA, et al. Impact of fasting in Ramadan in patients with cardiac disease. Saudi Med J. 2005;26(10):1579-83
  3. Mousavi M, Mirkarimi S, Rahmani, Get al. Ramadan fast in patients with coronary artery disease. Iran Red Crescent Med J. 2014;16:e7887.
  4. Nematy M, Alinezhad-Namaghi M, Rashed MM, et al. Effects of Ramadan fasting on cardiovascular risk factors: a prospective observational study. Nutr J. 2012;11:69.
  5. Chamsi-Pasha H, Ahmed WH, Al-Shaibi KF. The cardiac patient during Ramadan and Hajj. J Saudi Heart Assoc. 2014;26(4):212-5.
  6. Ramadan Rapid Review & Recommendations – British Islamic Medical Association. Available at: https://britishima.org/wp-content/uploads/2020/05/Ramadan-Rapid-Review-Recommendations-v1.2.pdf (Accessed on 10th April 2021)
  7. Abazid RM, Khalaf HH, Sakr HI, et al. Effects of Ramadan fasting on the symptoms of chronic heart failure. Saudi Med J. 2018;39(4):395-400.
  8. Aadil N, Houti IE, Moussamih S. Drug intake during Ramadan. BMJ. 2004;329(7469):778-82.
  9. Perk G, Ghanem J, Aamar S, Ben-Ishay D, Bursztyn M. The effect of the fast of Ramadan on ambulatory blood pressure in treated hypertensives. J Hum Hypertens. 2001;15(10):723-5.
  10. Habbal R, Azzouzi L, Adnan K, et al. Variations tensionnelles au cours du mois de Ramadan [Variations of blood pressure during the month of Ramadan]. Arch Mal Coeur Vaiss. 1998;91(8):995-8.
  11. Chamsi-Pasha M, Chamsi-Pasha H. The cardiac patient in Ramadan. Avicenna J Med. 2016 ;6(2):33-8.
  12. Hersi AS, Alhebaishi YS, Hamoui O, et al. Practical perspectives on the use of non-vitamin K antagonist oral anticoagulants for stroke prevention in patients with nonvalvular atrial fibrillation: A view from the Middle East and North Africa. J Saudi Heart Assoc. 2018;30(2):122-139.
  13. Batarfi A, Alenezi H, Alshehri A, et al. Patient-guided modifications of oral anticoagulant drug intake during Ramadan fasting: a multicenter cross-sectional study. J Thromb Thrombolysis. 2021;51(2):485-493.
  14. Saour JN, Sieck J, Khan M, et al. Does Ramadan fasting complicate anticoagulation therapy?. Ann Saudi Med 1989; 9: 538– 40.
  15. Chamsi‐Pasha H, Ahmed WH. The effect of fasting in Ramadan on patients with heart disease. Saudi Med J 2004; 25: 47– 51.
  16. Lai Y, Cheen M, Lim S, et al. The effects of fasting in Muslim patients taking warfarin. J Thromb Haemost 2014; 12: 349– 54
  17. Sridharan K, Al Banna R, Qader AM, et al. Does fasting during Ramadan influence the therapeutic effect of warfarin? J Clin Pharm Ther. 2021 Feb;46(1):86-92.
  18. Awiwi MO, Yagli ZA, Elbir F, et al. The effects of Ramadan fasting on patients with prosthetic heart valve taking warfarin for anticoagulation. J Saudi Heart Assoc. 2017;29(1):1-6.
  19. Ali SN, Hanif W, Patel K, Khunti K; South Asian Health Foundation, UK. Ramadan and COVID-19 vaccine hesitancy-a call for action. Lancet. 2021:S0140-6736(21)00779-0.
  20. Sharifain H. COVID-19 vaccine does not invalid the fast during Ramadan: Abdul Rehman Al Sudais. Available at: https://www.haramainsharifain.com/2021/03/covid-19-vaccine-does-not-invalid-fast.html. (Accessed on: April 12 2021)
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5 Daily Struggles of an Early Career Physician

For this month’s blog entry, I’ve decided to share a more reflective piece. In now just over six months into my young career, my early morning routine is pretty set in stone. Wake up. Shower. Scrubs. Coffee. Mask. Keys. Go! But what happens from approximately 8 am – 5 pm is still evolving.

This blog will briefly go over my daily struggles, but I could just as easily share five daily rewards/positives/joys of an early career physician … and maybe next month I will.

  • I’m the attending (physician). Part of being fresh out of training is that nobody knows. Whether you stay at your home institution or move to a new setting, you’re likely the new kid on the block in the Doctors’ Lounge or the EMR’s attestation text box. Despite proudly wearing my “attending physician” ID badge, I find myself constantly having to reiterate that I’m the supervising doctor. I recently entered the room to begin time out for a transesophageal echo and was stopped by the anesthesiologist because we couldn’t begin the case without the cardiologist present. Another time, I was asked if I was the fellow doing the case with Dr. X, a well-known echocardiographer. Despite how this may sound, I quite like the shocked look on my patient’s faces when I walk in and introduce myself as the person who will be managing their complex cardiovascular disease – or my ability to walk through the medical center unbothered and largely unnoticed while taking in some much needed Miami sun.
  • One of my daily struggles is not knowing how to say “no.” As a medical trainee, you’re often the person called upon to do the tasks that no one else wants to take on. Whether it be consent for a procedure or calling the pharmacy to correct a prescription, you’re often faced with the rhetorical question of “can you please…?” or “ would you mind…?” Well, this doesn’t really stop when you’re a newly appointed faculty. I often reply to emails first or make phone calls because I’ve been there and I know that I CAN help in that way. Eventually, though, I will need to learn when this is impinging on time that could be well allocated to more important tasks.
  • To do or not to do. From the moment my first patient shares with me the reason for their visit, there is a tug-o-war in my head between doing something and doing nothing. A wise professor once told me that 70% of medical conditions resolve without the doctor doing anything. We’re tasked with identifying the 30% of the time when we can make an impactful difference in the disease course. I once read a Wall Street Journal article titled “When Doing Nothing is the Best Medicine.” This is much easier said than done, but I’ve found that many patients just want reassurance that what ails them will not lead to their untimely demise. Explaining my thought process, and clearly stating that we can always order more tests or perform more studies at a later date if things don’t get better, has served me well so far.
  • Leaving work at work. It’s not uncommon to find a trainee spending extra time in the hospital or in the clinic finishing tasks that their attending doesn’t want to find undone in the morning. When you’re the attending, the decision as to what can wait until later lies with you. When I first started my new job, I often stayed up late replying to emails or finishing notes, or making calls from home. What I’ve found is that not everything needs to be done now. I have frequently reminded myself of the following diagram, as it has helped me leave work at work and not take it home with me.

Source: https://luxafor.com/the-eisenhower-matrix/

  • Work/Life Balance. As physicians, we’re tuned to work work work until you can’t work anymore. It’s commonplace for physicians to work well past the retirement age, and sometimes until they are no longer with us. My mentors have shared with me that the decision to prioritize family, vacation, rest starts NOW. It is a lot harder to put into practice. There is always something that needs to be attended to, whether your “out of work” auto-reply is posted or not. I’ve made it a goal of mine to fully utilize the ample paid time off afforded to me by my employer, and to truly disconnect during these times. It’s still very hard, and I haven’t perfected it, but making it a priority is the first step.

Thank you for reading, and please share with me some struggles that you’re having as an early career physician. I can be reached on Twitter @DrDapo. Until next time!

 

“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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Bias

A middle-aged black woman presents to her local emergency department via emergency medical services (EMS) with chest and back pains, nausea, and vomiting. She has a history of IV drug abuse and is disheveled in appearance. Prior to her arrival, EMS notes that her chest pain appears non-cardiac and provides supportive care while en route to the hospital. She is triaged to the appropriate care and an emergency provider assesses the patient. 

The patient continues to have chest discomfort and nausea. The emergency team agrees with the EMS assessment and deems her symptoms as atypical for a cardiac etiology. An EKG is performed which demonstrates subtle ST-segment elevations in her inferior leads as well as faint reciprocal changes. However, the catheterization lab was not activated at this point. 

High sensitivity troponin ultimately revealed a modest enzyme leak and the cardiology team was consulted. The patient was urgently taken to the cath lab to reveal an acute lesion of her proximal right coronary artery. There were no complications during the procedure and she ultimately had an uneventful hospital course. 

Implicit bias refers to the attitudes or stereotypes that affect our understanding, actions and decisions in an unconscious manner. These biases are activated involuntarily, without an individual’s awareness or intentional control. Unfortunately, we are all susceptible to bias and there is extensive evidence showing how bias can lead to differential treatment of patients by race, gender, age, weight, language, socioeconomic status, and insurance status. As such, it begs the question, if our patient had no history of drug abuse or was white, would their acute myocardial infarction been treated faster? 

A seminal 2007 study of internal medicine and emergency medicine residents found that, while the participants reported no explicit racial bias, Implicit Association Tests (IATs) indicated an implicit preference towards White Americans. Further, the higher the preference, the more likely that physician was to treat Whites and not treat Blacks with early thrombolysis in the setting of acute myocardial infarction. 

While it is clear the effects of implicit bias in medicine, it is also clear that implicit bias is malleable. There are a number of leading strategies for combating implicit bias including stereotype replacement, counter-stereotypic imaging, individuation, perspective-taking, and increasing opportunities for contact with individuals from different groups. Further, new research must be conducted to find more innovative techniques for managing implicit bias. As clinicians, it is our responsibility to be constantly aware of our bias and to actively work to address that bias in every patient encounter. 

References 

  1. Green AR, Carney DR, Pallin DJ, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med. 2007;22(9):1231-1238. doi:10.1007/s11606-007-0258-5

“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.”