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Women’s History Month: Cardiology Edition

Somehow it’s already March, which means it’s Women’s History Month, so I wanted to take this opportunity to highlight some of the many amazing cardiologists and researchers (who also happen to be women) who have shaped our field.

Last month, I wrote about the importance of science outreach, especially with regard to promoting science and cardiology to young girls and women, because women still make up around only a third of scientific researchers and only around 13% of cardiologists are women. To learn more, Renee P. Bullock-Palmer’s most recent blog is a great resource.

This month I wanted to highlight some of the women who paved the way for the rest of us.


Now, unsurprisingly, simple Google searches for things like “scientists who shaped cardiology” or “most famous cardiologists” provide results that are pretty male and pale. There weren’t that many pieces that included women in their lists of cardiologists/researchers, and there were only a handful of sources I found that focused specifically on women. Lucky for you, I’ve collected what I found here! I’m also going to highlight several of the brilliant women who shaped our field – this is by no means an exhaustive list of amazing women in cardiology (or their accomplishments) because there are too many to fit on one list.

 

Maude Abbott, MD was a Canadian physician who invented an international classification system for congenital heart disease in the 1930’s. Her work the Atlas of Congenital Heart Disease became the definitive reference guide on the subject.

 

Helen B. Taussig, MD, FACC is widely regarded as the Founder of Pediatric Cardiology. In the 1940’s she developed the operation to correct the congenital heart defect that causes “blue baby” syndrome. She received the Medal of Freedom from President Lyndon B. Johnson and was the first female president of the American Heart Association.

 

Myra Adele Logan, MD was the first woman (and only the 9th person!) to operate on a human heart in 1943.

 

Marie Maynard Daly, PhD was first African American woman to obtain a PhD in chemistry in the United States, whose research in the 1950’s was invaluable in demonstrating the relationship between high cholesterol levels and heart attacks.

 

Celia Mary Oakley, MD was one of the first women cardiologists in the United Kingdom and was part of the team that coined the term hypertrophic cardiomyopathy in the late 1950’s.

 

Sharon A. Hunt, MD was just one of seven women in her 1967 medical school class and she went on to revolutionize the field of heart transplantation by working to improve survival rates by identifying and treating rejection and determining how to reduce the side effects of the drugs.

 

Nanette Kass Wenger, MD, was among the first cardiologists to focus on heart disease in women, and to evaluate the different risk factors and manifestations of the condition, specifically coronary artery disease, in women and men. I was lucky enough to talk with her about her work at AHA Sessions 2018, which I wrote about here. You can also follow her on twitter @NanetteWenger.

 

Christine Seidman, MD, is a researcher who transformed the field of cardiovascular genetics with her research that uncovered the genetic basis of many human cardiovascular disorders, including cardiomyopathy, heart failure and even congenital heart malformations.

 

Elizabeth O. Ofili, MD, MPH, FACC is a clinical scientist who led the effort to implement the landmark African American Heart Failure Trial (AHEFT), whose findings improved the practice guidelines for the treatment of heart failure in African Americans. She also became the first woman president of the Association of Black Cardiologists in 2000.

 

Ileana Piña, MD, MPH, FACC is a nationally renowned cardiologist known for her work in heart failure and improving patient rehabilitation outcomes. Her work has also upturned preconceived notions about women in the medical community and she works tirelessly to get more women into clinical trials.

 

Rong Tian, MD, PhD is a leader in the field of cardiac metabolism whose work has been translated to clinical trials. Among her many contributions, she was the first to demonstrate that AMP-activated protein kinase (AMPK) acted to remodel cardiac energy metabolism, which critically informed the heart failure field. You can also follow her on twitter @Rongtian2.

 

I want to note, that these cardiologists and researchers are not important just because they are women – they are talented scientists and cardiologists who happen to also be women. But pieces like this are important because representation matters. It’s important for everyone, especially young girls and women, to see that it’s possible not just to be successful in this field, but also to revolutionize it.

 

Helpful sources & suggested reading:

 

 

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Coronary Slow Flow Phenomenon: Myth or Fact?

One of the most challenging clinical scenarios to a cardiologist is the patient presenting with symptoms suggestive of obstructive coronary artery disease (i.e. angina), in whom coronary angiography reveals patent coronary vessels. Due to the seemingly ‘normal’ arteries, current clinical practice tends to underestimate the impact of these presentations, but there are subsequent difficulties in their management. To many cardiologists, angina in the absence of CAD is a myth rather than a fact — “what you don’t know, you don’t miss.” One such presentation often being missed or ignored is the “coronary slow flow phenomenon.” A classic example of slow flow angiogram is shown here.

 

What is coronary slow flow?

Nearly 50 years ago, Tambe and colleagues1 initially described this angiographic entity in patients with angina symptoms where they noted the injected contrast during coronary angiography moved very slowly through the coronary arteries, and aptly named “coronary slow flow phenomenon.” The prevalence is estimated at approximately 1-7% of elective angiograms2,3. The condition was largely neglected until Professor John Beltrame identified the distinct clinical features associated with this intriguing entity and thus concluded the coronary slow flow phenomenon was a new coronary disorder rather than angiographic curiosity. Evidence suggests that the coronary slow flow phenomenon leads to clinical manifestations of ischemia, arrhythmias, acute coronary syndromes and even sudden cardiac death.

 

How is coronary slow flow diagnosed?

Coronary slow flow phenomenon is usually identified subjectively by visual judgment.

  • Thrombolysis in myocardial infarction (TIMI) flow grade reflects the speed and completeness of the passage of the injected contrast through the coronary tree. In the setting of coronary slow flow, diagnosis can be made on the basis of TIMI 2 flow grade (ie: requiring ≥ 3 beats to opacify the vessel)4.
  • Corrected TIMI frame count (CTFC) facilitates the standardization of TIMI flow grades and flow assessment. It represents the number of cine-frames required for contrast to first reach standard distal coronary landmarks. TIMI frame count > 27 frames have been frequently used to diagnose slow flow5.

 

What is the underlying cause of this presentation?

The coronary circulation consists of epicardial vessels and microvasculature. In the absence of epicardial stenosis, microvascular dysfunction may explain the pathophysiology of coronary slow flow phenomenon. Supporting this hypothesis, biopsy studies have revealed structural microvascular coronary abnormalities in slow flow patients. Reduced endothelium dependent flow-mediated dilatation (FMD) of the brachial artery has been detected in patients with coronary slow flow phenomenon, suggesting that endothelial dysfunction is implicated in the aetiology. However, there are still multiple questions and controversies regarding the underlying pathophysiology and whether this pathology is limited to coronary arteries or is a manifestation of systemic vascular or endothelial disease remains to be answered.

 

What is the medical management for coronary slow flow phenomenon?

Although coronary slow flow phenomenon patients have good overall prognosis, ongoing anginal episodes results in considerable impairment of their quality of life. Professor Beltrame has been long fighting the battle of identifying appropriate management for these patients, in particular, therapies that limiting the anginal episodes. His group has shown dipyridamole and mibefradil has some benefit in this setting, yet larger studies are required to confirm these findings. Currently available anti-anginal agents are of limited clinical value. To date, no large trial testing pharmacological approaches has been conducted, and the evidence available is derived from small studies, some with inhomogeneous inclusion criteria.

 

So, is it a myth or fact?

Over the past 50 years, the coronary slow flow phenomenon has evolved from a curious ‘myth’ to an identified coronary disease entity. Despite this progression of thinking, significant efforts are still required to unpack this intriguing condition, particularly in relation to effective therapies to improve symptoms and quality of life.

 

References:

  1. Tambe AA, Demany MA, Zimmerman HA and Mascarenhas E. Angina pectoris and slow flow velocity of dye in coronary arteries–a new angiographic finding. Am Heart J. 1972;84:66-71.
  2. Beltrame JF, Limaye SB and Horowitz JD. The coronary slow flow phenomenon–a new coronary microvascular disorder. Cardiology. 2002;97:197-202.
  3. Hawkins BM, Stavrakis S, Rousan TA, Abu-Fadel M and Schechter E. Coronary Slow Flow– Prevalence and Clinical Correlations &ndash. Circulation Journal. 2012;76:936-942.
  4. Chesebro JH, Knatterud G, Roberts R, Borer J, Cohen LS, Dalen J, Dodge HT, Francis CK, Hillis D, Ludbrook P and et al. Thrombolysis in Myocardial Infarction (TIMI) Trial, Phase I: A comparison between intravenous tissue plasminogen activator and intravenous streptokinase. Clinical findings through hospital discharge. Circulation. 1987;76:142-54.
  5. Gibson CM, Cannon CP, Daley WL, Dodge JT, Jr., Alexander B, Jr., Marble SJ, McCabe CH, Raymond L, Fortin T, Poole WK and Braunwald E. TIMI frame count: a quantitative method of assessing coronary artery flow. Circulation. 1996;93:879-88.

 

 

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The Powerful Role of Social Media in the Field of Cardiology

The growth and use of social media have grown exponentially over the last decade with an eight fold increase since 20051. Social media is generally defined as an Internet-based platform that allows individuals and/or communities to gather virtually to communicate ideas, collaborate, share information, share pictures and videos, either as a direct message or general post in real time1. There are several social media platforms that healthcare professionals may use, such as Twitter, LinkedIn, Doximity, and Facebook. Twitter has been a very popular platform in the field of Cardiology with many Cardiologists, Cardiovascular research scientists, Cardiology providers, professional journals and Cardiology-based professional societies using this platform to expand their reach to their colleagues, professional society members, and the public in an effort to educate, advocate and raise awareness. There are several powerful roles that social media serves in the Cardiology field. These include networking, sharing meaningful opinions, fostering educational discussions centered around a cardiology topic or paper of interest, promoting or raising awareness of the latest research or guideline publication, promoting a professional meeting or event, promotion of healthy initiatives, collaboration among colleagues and support of colleagues.

 

Beneficial Uses of Social Media

a) Networking

Social media platforms allow many professionals in the cardiology field to connect with other colleagues and follow prominent cardiologists and research scientists. This connection transcends geographic borders, and therefore allows users to extend their networking reach internationally. This ability to network provides a sense of community and serves as one’s professional village where colleagues are able to share their professional ideas and share opinions on various topics.

b) Sharing important opinions and educational discussions on topics or publications relevant to Cardiology

Twitter also allows users to discuss topics and publications relevant to cardiology. Many times these are threads of a conversation joined by several colleagues. However, several professional organizations such as the American Society of Echocardiography (ASE) and the American College of Cardiology (ACC) have virtual tutorials, called “tweetorials,” which allows users to present and discuss a topic of interest in real time. These discussions can be very educational and serve as great learning tool. These discussions may also include reference to relevant publications and allows users to stay up to date with the scientific literature, as well.

c) Promotion of professional meetings and events

Many professional societies, such as the American Heart Association (AHA), American College of Cardiology (ACC), American Society of Echocardiography (ASE), American Society of Nuclear Cardiology (ASNC), Society of Nuclear Cardiology (SCCT), and the Society of of Cardiac Magnetic Resonance Imaging (SCMR), use social media platforms to promote their annual scientific meetings and events at these meetings. In fact, many of these meetings have social media (SoMe) ambassadors to help in promoting their meeting and to share important educational slides and messages from the meeting with other social media users, which is an excellent educational tool in getting important points out to the the rest of the cardiology community and the public.  Additionally, these professional meetings allow for cardiology colleagues who have connected virtually on Social Media to meet in person, as well. A hashtag (#) is a metadata tag that is used on social media platforms that allows posted content associated with a specific theme or content to be easily found2. Useful and popular hashtags used in the field of cardiology on Twitter are #CardioTwitter and #Cardiology. In fact many of the annual scientific meetings for several professional organizations will use hashtags for their meeting to allow social media users to readily identify posted social media content related to the meeting. This usually generates a significant degree of social media traffic and commentary related to the meeting and this further promotes the meeting and the professional organization globally. In fact at the 2018 annual American Heart Association’s Scientific Sessions, (#AHA18) there were over 300 million impressions generated globally2 on Twitter using the #AHA18 hashtag.

d) Discussion and promotion of latest research papers and guidelines

Many professional medical journals post important publications such as research papers and guidelines on social media to assist in promotion of important educational documents. In addition social media users also post their latest research papers and invited talks to help in promoting their scientific work and in the sharing of important educational information. With regards to posted research papers, it has been suggested that citations of research papers on Twitter can increase the citation rate of the paper and can also increase the impact factor of the the publication journal2. A prior analysis3 has shown that social media activity related to a publication paper increases the citation rate of the paper and therefore helps to promote published academic work. In fact the latest 2018 AHA/ACC Cholesterol management guidelines4, as well as the latest Physical Activity guidelines5, were released at the recently concluded American Heart Association meeting (#AHA18) and there was a significant amount of social media activity and discussion related to these two manuscripts. This therefore assisted to raise awareness of these guidelines within the cardiovascular community.

e) Starting healthy initiatives and sharing health promoting information with peers and the public

Promotion of healthy initiatives, such as heart healthy eating and increasing physical activity, have also been done on social media. Many cardiologists have used social media to share health educational material with the public and their colleagues.

f) Collaboration with and Providing Support for colleagues

Social media, especially Twitter, can help to create your professional community with colleagues who have similar professional interests. It provides a platform for collaboration with peers for various initiatives and opens the door for opportunities to collaborate with colleagues on research projects. This social media village creates a network that can be supportive with regards to helping to promote your professional interests and your academic publications through retweets and commentary.

 

Responsible use of social media

Responsible use of social media is very important, Always ensure that there is adherence to patient privacy regulation and ensure that social media posts are free of any patient identifying information. It is also vital that you maintain a high level of professionalism and avoid posting any social media information or pictures that can be professionally and ethically compromising for both yourself and others. It is very important not to tarnish your professional brand.6

 

Conclusion

The benefits of social media platforms such as Twitter are numerous and proves to be an increasingly relevant  learning tool that assists in keeping one abreast of the medical literature. Twitter is also very useful for one’s career  growth and provides a great opportunity for networking with peers globally. Social media helps in building your professional brand.

 

References:

  1. Ventola CL. Social Media and Health Care Professionals: Benefits, Risks, and Best Practices. P T. 2014 Jul; 39(7): 491-499, 520.
  2. American Heart Association Scientific Sessions 2018 meeting metrics provided by the AHA
  3. Eysenbach G. (2011) Can Tweets predict citations? Metrics of social impact based on Twitter and correlation with traditional metrics of scientific impact. J Med Internet Res 13:e123.
  4. Grundy SM, Stone NJ, Bailey AL, Beam LT, Birtcher KK, et al. 2018AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol. JACC Nov 2018, 25709; DOI: 10.1016/j.jacc.2018.11.003
  5. The Physical Activity Guidelines for Americans: THe HHS Roadmap for an Active Healthy Nation. Second Edition. ADM Brett P. Giroir, MD
  6. Bullock-Palmer RP. You Are Now a Board-Certified Cardiologist and Cardiac Imager…Now What? The Importance of Lifelong Learning and Career Growth
    May 2018 https://www.acc.org/membership/sections-and-councils/imaging-section/section-updates/2018/05/17/09/44/you-are-now-a-boardcertified-cardiologist-and-cardiac-imager

 

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Deep Learning in Cardiology

Thirteen years ago in my first anatomy class of Med School, the instructor asked us to make sure our learning is “deep.”

“You need to memorize the names of every single tiny nerve and muscle, because they all will be on your exam. One day you could be surgeons and if you cut out the wrong structure, you can kill someone!” he asserted as we all stood there in fear.

Later in Med School, we were told that half of what we’re learning will be wrong by the time we practice. But one thing we were not told is that the way we learn and the entire premise of what makes a good doctor would also change. For example, “deep learning” itself now means something different to me and to most healthcare professionals. If you are reading this article so far, then you are likely to have seen the term floating around in medical journals.

Deep learning is a type of machine learning in which the computer uses multiple layers of processing to extract features from otherwise vague data input, such as an ECG or a slice of an MRI.  Each layer uses outputs from the previous layer. Through deep learning, the computer simulates the neural network of the brain and is able to learn and make sense of abstraction.

Working at the Broad Institute of Harvard and MIT allowed me to recently be part of a team that uses deep learning to solve important problems in cardiology.  Over several weeks, cardiologists, scientists, and machine learning experts worked in teams to train computers on deep learning models so that they understand data such as medications, ECGs, genomic architecture, and cardiac MRIs of tens to hundreds of thousands of people.

The insights I gained were incredible.  Just like medical students perform better on their exam if they learn “deeper,” the longer you train a computer model, the more it learns and the better it performs in predicting – but it does so at much faster rates than any doctor could ever match. For example, in only two days, we trained a computer to read the ejection fraction from a cardiac MRI as good as a doctor would. Using the MRI, the computer could also predict with reasonable precision the presence of hypertension and coronary artery disease, without knowing anything else about the patient. The power of computer vision is beyond imagination. While it could take you a full day to read 100 ECGs, a well-trained deep learning model could read them in only few seconds. It could also identify patterns in the data that the human eye could not discern, which might or might not be biologically or clinically relevant.

As data availability and computing power continue to grow, we will be seeing more and more applications of deep learning in cardiology.  While we do so, we should stay mindful that human supervision and our role as doctors in charge of our patient’s health is more important than ever. This requires us to understand how computers work and how those models are built through working with multidisciplinary teams. If we do this right, we can probably do less deep learning ourselves by delegating to computers, and gain a whole lot of extra time that we can invest in taking care of our patients.

 

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Sports Cardiology: Experts’ Advice for Trainees

As the AHA’s largest meeting of the year kicked off today in Chicago, the AHA Early Career / FIT Lounge, with its prime position at the main entrance to the exhibition hall, was the venue for the first ever Sports Cardiology session dedicated to early career trainees at Scientific Sessions. With the bustling crowd of Sessions attendees lining up alongside the FIT Lounge as they awaited registration check-in, many peered in to the first Early Career / FIT session of this year’s conference, in which an expert panel of Sports Cardiologists shared their insights on this emerging field within cardiology.

This session’s faculty panel consisted of:

  • Ben Levine – Professor of Cardiology and Exercise Sciences at UT Southwestern in Dallas, Texas
  • Rachel Lampert – Professor of Cardiology and Electrophysiologist at Yale University in New Haven, Connecticut
  • Eugene Chung – Associate Professor of Cardiovascular Medicine and Director of the Michigan Medicine Sports Cardiology Clinic in Ann Arbor, Michigan

Sports Cardiology Early Career / FIT Session at #AHA18 Scientific Sessions

Along with Dr. Beth Hill (@BethHillDO, Cardiology Fellow at Scripps Clinic), I was fortunate to moderate the discussion from this distinguished group. They shared their stories about their varied paths towards Sports Cardiology, which included influential encounters with athletic patients, personal experience as a high-performing athlete, and sheer passion for sports and exercise physiology.

As Sports Cardiology is a relatively nascent sub-specialty, there currently is no distinct path for interested trainees to follow. At this time, only one formal training program in Sports Cardiology exists – the well-established Cardiovascular Performance Program at Massachusetts General Hospital, directed by Dr. Aaron Baggish. However, with the recent publication of a Sports Cardiology Core Curriculum by the ACC Sports and Exercise Cardiology Council (Baggish et al., JACC 2017) and rising interest in the field among trainees (Afari, JACC 2017), the field appears primed for growth.

The panel offered many salient pieces of advice for trainees interested in pursuing a career in Sports Cardiology, which I have done my best to distill into the following points:

  • Choose What You Love: Fellows seeking to become Sports Cardiologists often ask which sub-specialty they should choose (i.e., EP, Imaging, Heart Failure) to best position themselves to enter this field. The panelists agreed that the answer is to choose the area that best suits one’s own interests. More importantly, they advised to not forget that Sports Cardiologists are, by definition, Cardiologists, and to not lose sight of the importance of a thorough grasp of General Cardiology when practicing as a Sports Cardiologist.
  • Seek Specialized Training in Exercise Physiology: “What distinguishes a Sports Cardiologist from a General Cardiologist?” Dr. Levine made the argument that Sports Cardiologists offer the extra expertise in exercise physiology and understand the physical demands imposed on the cardiovascular system by elite athletes. Assessment of athlete physiology must go “beyond the Bruce protocol.” Indeed, the 2015 AHA/ACC Guidelines specifically state that “the exercise testing protocol [of athletes] should be based on maximal performance rather than achieving 80% to 100% of the target heart rate to come as close as possible to the level of exertion achieved during competitive sport” (Zipes et al, Circulation 2015). Every effort should thus be made to recapitulate this degree and mode of exertion. Further, the elite athlete’s response to various maneuvers, such as tilt table testing, may be different, and a deep understanding of these nuances are incredibly important in this unique population.
  • Educate and Network: While there has been increasing awareness of the specialized cardiovascular care needs of the athletic population, it remains important for budding Sports Cardiologists to educate those providers in their network who tend to be the first contacts with athletes. This group includes primary care and sports medicine physicians, sports trainers, and student health centers, as these providers are often the first ones to hear about potentially concerning cardiac symptoms in athletes. Along these lines, athletes themselves can benefit from education on their own cardiovascular health, as they are not immune from disease regardless of their level of fitness. Trainees are encouraged to consider giving educational talks to athletes in the community (e.g., cycling and running clubs) and volunteer at athletic events to help disseminate these important issues.

While the session was filled with many more helpful tips for interested trainees, the panel’s ultimate recommendation was to make every effort to attend the ACC’s Care of the Athletic Heart meeting next year, which will take place in June 2019 in Washington, D.C. As a participant in last year’s Athletic Heart meeting, I strongly agree.

Overall, the panelists engaged the audience in an excellent discussion, and this topic served as an excellent segue for the eagerly awaited release of the AHA’s physical activity guidelines, which will be announced this Monday, November 12th at Scientific Sessions.

(Left to Right) Faculty Panelists: Eugene Chung, Rachel Lampert, and Ben Levine;
Session Moderators: Beth Hill, Jeff Hsu

 

For more information on the rest of my experience at #AHA18, please follow my Twitter feed (@JeffHsuMD) as well as the hashtag #AHAEarlyCareerBlogger.