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Housing and Health Equity in Cardiovascular Disease

So far, 2020 has been a year of public health crises. By early spring, it was apparent that people living in socio-economically disadvantaged areas were being hit hardest by Covid-19 [1]. In these same areas, people across the United States took to the streets protesting the murder of George Floyd, an unarmed Black man – in police custody [2]. In the words of James Baldwin, “It demands great spiritual resilience not to hate the hater whose foot is on your neck, and an even greater miracle of perception and charity not to teach your child to hate.”, and we as a country are still looking for this resilience [3]. Among the many consequences of this year’s events, these tragedies have really prompted a long, hard look at our healthcare system. One recently published article that was particularly heartening to read was the American Heart Association’s Council on Epidemiology and Prevention and Council on Quality of Care and Outcomes Research Scientific Statement on “Importance of Housing and Cardiovascular Health and Well-Being”. It outlines how housing stability, quality, affordability, and neighborhood environment are linked to cardiovascular disease. The statement doesn’t shy away from evidence of how increased psychosocial stress in the Black community and other social determinants of health are associated with cardiovascular health disparities.

The world has changed profoundly over the past year and while we continue to strive to show charity to others in our everyday encounters, I look forward to reading more research that will help inform how we as a community can better address health inequity.

References:

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

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Keep Out The Rain

cvd umbrella

It has been well established that cardiovascular disease (CVD) is a condition that leads to chronic symptoms that are generally thought of as a primary disease. However, vascular injury leads to subsequent disease such as metabolic disease, obesity, high blood pressure and kidney disease. There are several contributing factors starting a person on the path of having cardiovascular disease. Some of these include:

  1. Oxidative (ox)stress—potentially results in DNA damage
  2. Increased low density lipid (LDL) that can become oxidized into oxLDLs
  3. Overeating/over-nutrition leads to hormonal imbalances and subsequently obesity and/or metabolic disease
  4. Distress/Eustress is controversial, but the body does not know the difference and they can both lead to shear stress due to increased blood flow through laminar areas of the vascular system.
  5. Toxins that come produced within the body (endobiotics) or enter the body from outside source (xenobiotics). Environmental effects have strong impacts on how the body responds. It is important to manage the things that are within one’s control such as smoking, exercise, and consuming a well-balanced diet.

With people livings becoming busier, it is easy to miss the warning signs. A slight weight gain here or a headache there. What then can be done about the progression of CVD and other disease states such as hypertension? I am glad you asked. Controlling hypertension for example can be maintained by making lifestyle changes consisting of exercising at least 150 minutes per week, modifying one’s diet to potentially include the dash diet, and reducing stress levels. This sounds like a lot but planning ahead is key. Often times I find myself going to a fast food restaurant because I have gotten too hungry to cook, or because I have not had time to go shopping. When I plan ahead and purchase my food for a week and pack healthy snacks, I evade the urge to go for those french fries (my go-to weapon against hunger). Additionally, I find I am less stressed if I spend some time performing rigorous exercises or get moving throughout the day. I attempt at least 250 steps every hour and 10,000 steps over the course of the day.

However, the symptoms are not the same for everyone, thus one should know what to look for to identify vascular disease early as well as forming a trusting relationship with a primary care provider because, “You’re the Cure”!! Let’s keep this conversation going. Follow me on Twitter (@AnberithaT) or on my site. I will take a deeper look at each of these topics and discuss what, if anything, can be done to combat or control these symptoms.

 

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Paradigms and Progress in HIV and Cardiovascular Health

 “Led by a new paradigm, scientists adopt new instruments and look in new places” – Thomas S. Kuhn

For a lot of rational (and some irrational) reasons, hearing the word HIV evokes fear, anger, and sadness. When I first heard about HIV, I was an elementary school student in late 1980’s and at that time, HIV was almost always a death sentence.  But today that is not the case.  Today, due to the hard work of scientists, patients, volunteers, advocates, and countless others, HIV is a chronic, manageable disease. An accomplishment epitomized by the oldest known person living with HIV recently turning 100 years old.

living with HIV graph

While this progress and longevity should be celebrated, the flip-side of age is that it is the primary driver of cardiovascular disease (CVD). In fact, this longevity has ushered in a new era where adults living with HIV are at exceptionally high risk of cardiovascular diseases including heart attacks, heart failure, and stroke. A recent meta-analysis by Anoop Shah, MD, from the University of Edinburgh, found that the global burden of HIV-associated cardiovascular disease has tripled in the past 20 years, especially in low and middle-income countries. Now, after more than two decades of accumulating evidence in this field, the American Heart Association released earlier this month a Scientific Statement on the characteristics, prevention and management of cardiovascular disease in people living with HIV.

Directed at all who support adults living with HIV, this statement is a general roadmap for raising awareness about the increasing burden of CVD in this population. However, it offers few new tools for providers to use, due primarily to the lack of high-quality “clinical trial data on how to prevent and treat cardiovascular diseases in people living [and aging] with HIV investigating cardiovascular endpoints” said Matthew J. Feinstein, M.D., M.Sc., chair of the writing group for the statement and assistant professor of medicine at the Feinberg School of Medicine, Northwestern University.

Still, what the existing (mostly observational) evidence allowed the writing group to do was to develop a pragmatic approach to assessing and preventing cardiovascular disease in treated HIV (Figure above). This approach includes the following:

  • Ensure all patients living with HIV are on effective HIV treatment
  • Determine risk of cardiovascular disease using tools such as ACC/AHA 10-year ASCVD risk estimator and a family history
  • Optimize lifestyle approach to prevention (e.g., smoking cessation, physical activity, healthy diet intake)
  • If at high risk and between the ages of 40-75 years, talk with the patient about the risks and benefits of lipid-lowering therapy while exercising caution for drug-drug interactions

Yet, while the new AHA Scientific Statement will be an important catalyst for the field, in many ways it creates more questions than answers. For example, are we shifting to a new paradigm in HIV care? Do we need new tools to help reduce CVD in this population or are the general recommendations for risk stratification and lifestyle optimization sufficient?  What is the most effective way to get either existing or new clinical tools to the high-risk patients living with HIV?

Fortunately, some of these questions are starting to be answered. The REPRIEVE study is the first large scale (>8,000 people) clinical trial to test if a daily statin reduces cardiovascular disease in adults living with HIV. Results are expected in the next 3-4 years. Additionally, the PRECluDe grants at the National Heart, Lung, and Blood Institute have stimulated new implementation science research focused on understanding how to best adapt effective CVD prevention studies to the real-world settings where people living with HIV receive their health care. These initiatives, coupled with ongoing research on the discovery of mechanisms of CVD and the testing of CVD prevention interventions in people living with HIV, will eventually allow for the development of guidelines on the prevention and management of CVD in HIV—the true instrument needed to help improve cardiovascular health for all adults living with HIV.

 

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Five Lessons From My Heart Attack Patients

In only few months, I leave my clinic where I have been seeing patients with heart disease for the past three years. It was not until I started discussing with them the transition to a new cardiologist that I appreciated the unique relationship we have built.  It has only been few years since we first met in in the Emergency Department in the middle of the night as they were having a heart attack, but somehow this journey feels longer.  I witnessed their heart attacks change their lives in many different ways, as they learned to cope, recover and carry on in life with a story to tell. Being one of the characters in their stories, I learned five lessons about life that will stay with me.

 

1- You can make any terrible event a wake up call or the beginning of the end.

A big heart attack or sudden cardiac arrest is arguably the most terrible event one could experience. As my patients recovered from such an event and came to see me in clinic, I could tell that the event changed them, either to the better or to the worse. While some lost weight, started training regularly, left their high stress jobs, or decided to travel the world, others became even more sedentary, gained weight, and started lamenting their bad luck and “missed opportunity” for good health.  It was striking to observe those two trajectories of opposite directions. Like my heart attack patients, when you are faced with a terrible event in life, you can either use it as a wake up call to do better afterwards or fall off a ledge and spiral down. You decide your own fate.

 

2- A supporting family is worth all the medicine of the world.

One patient after another, it became clear to me that the presence of a supporting family member that cares for you during difficult times is worth the most state-of-the-art medicine. It is that person that ensures that your food is low in salt and has no butter, that you do your daily exercise and not miss your medication, that you come to your appointments and ask all the right questions, or that simply hold your hand and tell you it’s going to be okay when things turn sour.

 

3- You’re as old as you think you are.

I met a 90 year-old woman who had a big heart attack and went for the most aggressive therapies. A year later she still shows to my clinic fully groomed and cheerful telling me she picked up dancing and life could not be any better.  I also met a 50 year-old man who after a small heart attack gave up on enjoying life or hoping for better future and couldn’t be convinced otherwise.

 

4- Faith, hope, and courage are your best friends when you’re not in control.

When patients are waiting for a high risk surgery or intervention, they simply are not in control of their fate. I found that those that fared well had three unique characteristics. First, they had faith in themselves, their doctors, or God. Second, they always hoped for the best. Third, they had the courage to face a difficult reality when things don’t go as well.  Whenever you’re not in control, let faith, hope, and courage always be your best friends.

 

5- Write your best story today because you never know when it ends.

While I learned so much from the stories of those patients who made it to my clinic, many did not, and their stories ended in the hospital. As you go through life, live every day to the fullest and write your best story page by page, because you really never know when it ends.

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What Are the 7 Steps to A Heart Healthy Lifestyle

The key ‘take home’ points for patients based on the latest 2019 American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines on Primary Prevention of Cardiovascular disease.

Introduction

Following the theme of Preventive Lifestyle from the 2018 American Heart Association meeting, EPI | Lifestyle 19,  the Cardiology community eagerly awaited the release of the highly anticipated 2019 American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines on Primary Prevention of Cardiovascular disease1. These guidelines were released at the recent ACC annual scientific meeting in New Orleans, Louisiana March 16-18, 2019. There is an increased focus on the importance of lifelong adherence to a heart healthy lifestyle of eating heart healthily and maintaining a physically active lifestyle. There were also new recommendations with regards to use of aspirin for primary prevention. These recommendations have caused some anxiety with regards to use of aspirin, a common drug used by many persons over the last several decades hoping to prevent heart disease. Cardiologists have already received questions from their patients regarding aspirin use and the recently release prevention guidelines. In this blog I will focus on the key take home messages for patients from these prevention guidelines and the seven steps to heart healthy living outlined in the guidelines.

 

Where should I begin?

A heart healthy lifestyle is one that is important to start at any age, and the earlier this is started in life, the better the degree of prevention. Living a heart healthy lifestyle should first begin with an assessment of your cardiovascular (CV) risk which is defined as the probability/chance of an individual having a cardiovascular event, such as a heart attack or stroke, over the next 10 years. CV risk is based on family history of premature heart disease, age, gender, ethnicity, history of tobacco smoking, level of physical activity, diet, the presence of diabetes, hypertension and/or hyperlipidemia.

Your CV risk should be assessed by your physician. Based on your history, physical exam and blood testing, a CV risk profile can be assessed and calculated based on the ACC AHA CV risk calculator. After your risk is calculated, your physician can customize their recommendations based on your CV risk profile. Most times further testing may not be necessary. However, for individuals with an elevated CV risk score further testing may be recommended. These tests may include a Cardiac CT scan without contrast to assess for the presence and degree of calcification of the blood vessels of the heart, which suggests the presence of hardening of the blood vessels known as atherosclerosis. This atherosclerosis indicates a high CV risk as it is a usual precursor for heart attacks and strokes and for patients with this finding further treatment and/or testing may be recommended by your physician.

 

Next steps

There are 7 main take home messages for healthy individuals preventing heart disease, the first three steps are focused on living a healthy lifestyle. The last 4 steps focuses on recommendations related to medical therapy and should be actively discussed with your provider to customize recommendations based on your CV risk profile.

 

Step 1 – Heart Healthy Diet 

A diet that is focused on eating fresh fruits, vegetables, legumes, nuts and whole grains is recommended. Sweetened drinks, processed foods, foods with a high content of sodium, and foods containing trans fats and saturated fats should be avoided.

 

Step 2 – Physically Active Lifestyle 

Maintaining a physically active lifestyle is also recommended with at least 150 minutes a week of moderate intensity exercise such as a brisk walk or 75 minutes a week of high intensity exercise such as playing basketball, rowing, et cetera. Generally, maintaining physical activity should be a daily regimen rather than focused on 1 or 2 days a week which was emphasized in the 2018 updated second edition of the Physical Activity guidelines that were released by the Department of Health and Human services2.

 

Step 3 – Cessation of Tobacco Smoking 

Tobacco smoking is the single most potent reversible risk factor for cardiovascular disease. It is recommended that tobacco smoking is avoided to prevent the development of cardiovascular disease. This recommendation is relevant for all age groups.

 

Step 4 – Maintaining Healthy Cholesterol Levels 

Your cholesterol levels should be checked by your physician on a regular basis as determined by your provider and latest guidelines. Based on your individual CV risk, your physician may opt to start medical therapy to manage your cholesterol or may opt to perform further testing such as a non-contrast Cardiac CT to determine calcifications in the blood vessels of the heart reported as a “CAC score.” This CAC score will assist your physician to determine the need for medical therapy and/or further testing.

 

Step 5 – Maintaining a Healthy Blood Pressure 

Achieving and maintaining a healthy blood pressure of <130/80 is recommended. This may or may not require medical therapy as determined by your physician. A physically active lifestyle, low sodium diet and a diet rich in fruits and vegetables are helpful in maintaining a healthy blood pressure.

 

Step 6 – Maintaining a Healthy Glucose level and Adequate Control of Type 2 Diabetes Mellitus (DM)  

Adequate control of type 2 DM is important to prevent cardiovascular disease. A heart healthy diet as outlined previously in this blog along with one that is low in sugar and processed foods, as well as maintaining a physically active lifestyle, are vital in controlling DM. Additionally for diabetic patients on medications, Metformin is a primary line of treatment while newer drugs such as SGLT-2 inhibitor and GLP-1 receptor agonist are secondary line of treatment options for these patients to prevent the development of CV disease.

 

Step 7 – Aspirin Use

For decades aspirin has been useful in individuals with established CV disease to decrease risk of future cardiac events such as a heart attack. However, there is an increased risk of bleeding associated with aspirin use. For healthy individuals without established CV disease who have a low CV risk profile the increased risk of bleeding with aspirin use outweighs the benefit of cardiovascular disease prevention. For this reason it is recommended that use of aspirin for primary prevention of CV disease should be reserved only for selected patients with a high CV risk profile. Use of aspirin should therefore be discussed with your physician prior to considering starting or stopping an aspirin regimen.

 

Conclusion – Putting it all together!

The 2019 ACC AHA Primary Prevention guideline1 focuses on a heart healthy lifestyle and focuses on a patient centered approach that emphasizes active engagement and discussion between patient and physician to determine the best customized approach and recommendations based on an individual’s CV risk profile.

There are several patient related resources such as:

References:

  1. WRITING COMMITTEE MEMBERS, Arnett DK, Blumenthal RS, Albert MA, Michos ED, Buroker AB, Miedema MD, Goldberger ZD, Muñoz D, Hahn EJ, Smith Jr SC, Himmelfarb CD, Virani SS, Khera A, Williams Sr KA, Lloyd-Jones D, Yeboah J, McEvoy JW, Ziaeian B, ACC/ AHA TASK FORCE MEMBERS, O’Gara PT, Beckman JA, Levine GN, Chair IP, Al-Khatib SM, Hlatky MA, Birtcher KK, Ikonomidis J, Cigarroa JE, Joglar JA, Deswal A, Mauri L, Fleisher LA, Piano MR, Gentile F, Riegel B, Goldberger ZD, Wijeysundera DN, 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease, Journal of the American College of Cardiology (2019), doi: https://doi.org/10.1016/j.jacc.2019.03.010.
  2. The Physical Activity Guidelines for Americans: THe HHS Roadmap for an Active Healthy Nation. Second Edition. ADM Brett P. Giroir, MD

 

 

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Polygenic Scores in Cardiovascular Disease 

For many decades, we knew that cardiovascular disease and several of its risk factors are heritable. This justifies why we often ask our patients about their family history, but is that truly the best measure for someone’s genetic liability to develop a disease?

Diseases such as myocardial infarction, type 2 diabetes, and atrial fibrillation are called complex traits. This is because their genetic liability comes from the summation of weak effects of many single nucleotide variations across the 3 billion nucleotides in our genome. This is different from monogenic diseases such as hypertrophic cardiomyopathy, which is due to a single but highly potent nucleotide variation in the cardiac sarcomere gene.

Owing to multiple large genome-wide association studies, a better understanding of the human genome and advances in statistical genomics methods, this polygenic liability of disease could now be measured in a single individual to predict where he or she falls on the genetic risk spectrum of disease. Over the past year, two high profile papers in Nature Genetics and JACC showed that polygenic scores can accurately predict coronary artery disease, as well as other diseases such as Type 2 Diabetes and Atrial Fibrillation.

A polygenic score is a number that is normally distributed in the population. Where your score is located on that bell-shaped curve determines your risk or protection from disease. While most of us will be in the middle, the unlucky person who happens to be in the upper tail of the distribution will carry several fold increased risk of CAD compared to the rest of us. This could be your 45 year-old patient, non-smoker with an LDL of 120mg/dL and no clinical risk factors who presents with a STEMI. On the other hand, I always wonder whether my 95 year-old grandpa who died of lung cancer with the cigarette in his mouth but a healthy heart actually was on the bottom tail of the CAD polygenic score distribution?

Just like the systolic blood pressure and the LDL cholesterol, polygenic scores are continuous measures of risk that require drawing cut-offs in order to practically classify patients and treat accordingly.  Defining those thresholds and determining how we act on them will be key for the successful implementation of those scores in clinical care. Anytime we draw thresholds to use in screening or treatment, there will be issues of sensitivity, specificity, outcomes, and value. After all, even cutoffs for risk factors that we’ve understood for decades, such as blood pressure and LDL cholesterol, continue to be debated from one guideline update to the other. The power of the polygenic scores is their wide availability and low cost (around $50 once for all diseases) as well as their ability to classify risk at an early stage in life (practically from birth) before clinical risk factors start appearing, which creates an opportunity to target disease early on before it develops.

The journey to clinical implementation of polygenic scores in cardiovascular disease still requires several steps. First, the current predictive ability of those scores declines in populations of non-European ancestry.  Development of scores that carry similar predictive ability across different ethnicities will be crucial to avoid widening healthcare disparities.  Second, prospective trials testing specific thresholds and interventions will be necessary to prove that implementation of those scores can lead to positive outcomes. For example, would targeting lower LDL thresholds in people with high polygenic scores reduce their risk of CAD?  Third, behavioral psychology studies could inform how young and healthy people react to information regarding their score. Ideally, you would want someone with higher score to engage in good lifestyle activities to mitigate his/her risk but also someone with a low score to not get falsely reassured and pick up poor lifestyle choices.  Fourth, clinical trials of existing and new therapies could be better informed with polygenic score stratification to pick up missed opportunities of benefit. One example would be that people at the upper tail of risk could benefit from treatment that when applied to the average population does not show a benefit.

Precision medicine in cardiovascular disease is happening and polygenic scores are one opportunity to prevent disease early on by targeting specific people at risk. Unlike the heritability informed by a positive family history which rarely changes management, the quantitative aspects of polygenic scores and our ability to validate their impact on outcomes prospectively and in different settings will change how we care for patients in the near future.

 

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It’s All In The Family

Our understanding of the genetic basis of adult-onset cardiomyopathy is rapidly evolving. Most of us learned to practice medicine in a paradigm that relied on detailed disease phenotyping, but now we have the ability to incorporate genetic and genomic information into routine clinical care. Even if you cannot remember the last time you thought about genes or pedigrees, here are a few modifications you can make to your practice today that will help you keep up with this exploding field of cardiovascular medicine.

 

1) Take a minimum three-generation family history in all patients with a primary cardiomyopathy.

  • The goals of taking a family history are to learn (1) whether the cardiomyopathy is familial, (2) about disease characteristics among family members, (3) if it is inherited in a specific pattern, and (4) to identify at-risk relatives.
  • Most adult-onset cardiomyopathies are inherited in an autosomal dominant pattern, but other inheritance patterns (e.g. dignetic, multigenic) are possible and need further study.
  • Importantly, an individual can have a genetic form of cardiovascular disease without having affected relatives. Most often, this is due to recessive inheritance, de novo mutations/variants, or reduced penetrance.

 

2) Use focused questions to obtain the family history.

  • The use of vague terms like “heart attack” can lead clinicians away from pursuing an inherited etiology of disease and prevent them detecting other important cardiovascular diagnoses like sudden cardiac death in family members.
  • Ask specific questions regarding heart failure symptoms (e.g. presence or absence of dyspnea at rest or on exertion, paroxysmal nocturnal dyspnea), arrhythmia symptoms (e.g. palpitations, presyncope, syncope with or without exertion), and sudden death (e.g. drowning, single-vehicle accidents) in family members.
  • Knowing about relatives’ cardiovascular procedures like arrhythmia ablation, cardiac surgery, device implantations, or heart transplantation can also be helpful.
  • If a multisystem syndrome like a laminopathy or Fabry disease is suspected, familiarize yourself with the extracardiac manifestations and include pertinent questions in your history.

 

3) Remember that diagnosing an individual with an inherited cardiovascular disease is just the first step in the process.

  • In cardiovascular genetics, a key concept is the transition of practice from individual patient-based care to family-based care. By incorporating the information you generate from your comprehensive multi-generational family history, you also gain insight into disease penetrance, expression, age of onset, and pleiotropy.
  • Generally, cardiomyopathies are considered “medically actionable” because evidence-based treatments to reduce morbidity and mortality exist.
  • Beyond just having effects on medical and device therapies, following this paradigm of family-based care also has implications for reproductive and family planning and lifestyle practices.

 

If you are interested in learning more about this topic, check out the 2018 update to the Heart Failure Society of America Practice Guideline on the Genetic Evaluation of Cardiomyopathy (PMID: 29567486).

 

 

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Why Advocacy is Critical for the Future of Cardiovascular Research & Medicine

As researchers and physicians, many of us got in to our professions to push the scientific enterprise further to ultimately help others. We’ve all trained for an insane amount of years and collectively we work as a unit to uncover the intricacies of the cardiovascular system, develop therapeutics and treat patients. We traditionally think of ourselves as researchers or physicians first, but obviously we are all so much more than our jobs. We are also citizens within a really complex system that has been continually struggling to serve all of its citizens equally. It’s no secret that access to affordable health care is currently not equitable within our society. Similarly, there are also large diversity & inclusivity issues within our training institutions for both researchers and physicians.

However, something we don’t think about enough is that our intensive training and experience within these systems has also prepared us to be effective advocates for these issues. We have the opportunity to promote tangible change and some might argue it’s even our responsibility.

One of the things I really appreciate about being apart of the American Heart Association (AHA) is that this is something the organization doesn’t shy away from. During his presidential address at AHA Scientific Sessions 2018, Dr. Ivor Benjamin gave a heartfelt and determined talk about what the future of the AHA’s advocacy mission looks like. He discussed how supporting local and federal advocacy, early careers and mentoring is key to supporting the future of the AHA – but only 3% of cardiac professionals are African American men and this is something the AHA wants to help change. To help solve the diversity and inclusivity issues within the cardiac field, the AHA is expanding major undergraduate initiatives to fix the leaky pipeline. My favorite part of Dr. Benjamin’s talk was when he urged everyone at AHA18 to get involved in advocacy, not just for our field, but also for our communities. Because this is the key point: in order for our work to have meaning and to be effective, we need to ensure our communities are healthy. We also need to put value to advocacy efforts in our field – this is an essential part of our profession.

Well, this is all great, but how can you get involved? We are all insanely busy; I know adding advocacy efforts can seem daunting. Luckily for all of us, one of the focuses of the AHA for January is Advocacy. Since over 7 million Americans with cardiovascular disease are currently uninsured, advocating for the protection of the Affordable Care Act is something we can all do from our computers right now.

How can you help? (Provided by the AHA newsroom)

https://www.heart.org/en/get-involved/advocate/state-issues

 

Looking for more ways to help on other issues?

  • The AHA has a great advocacy resource page for to get involved with efforts at the federal, state and community levels with issues regarding health care, tobacco prevention, and healthy lifestyles for kids.
  • Sign up here to become part of the AHA’s grassroots network, You’re the Cure, which is focused on advocating for heart-healthy and stroke-smart communities.
  • There are many great non-profits around the country focused on promoting science funding, literacy, inclusion, diversity & advocacy – finding the right one for you is key and many of them have already done the legwork by developing toolkits for you to get started in your community.
  • Interested in STEM outreach as a way to get involved in your community? The great Marian Wright Edelman said, “You can’t be what you can’t see.” Participating in local educational initiatives is one of the best ways to expose kids to what scientists and physicians actually look like (in addition to getting them excited about science). The STEM Ecosystem is a great way to get started; there are local chapters all over the country.

I recently watched the brilliant documentary (I highly recommend it!) about Mr. Rogers, “Won’t You Be My Neighbor”, where I was reminded of his advice many of us take comfort in during intense times.

“When I was a boy and I would see scary things in the news, my mother would say to me, “Look for the helpers. You will always find people who are helping.” – Mr. Rogers

We are the helpers. Its time we use our power to advocate for equity within our field and communities.

 

 

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The Unexpected Benefits of Extending Your Training

During my general cardiology fellowship, I developed a special interest in the care of patients with inherited cardiovascular disease. By virtue of the robust clinical activity of my division’s advanced heart failure and electrophysiology programs, I was exposed to clinical dilemmas like risk stratification in hypertrophic cardiomyopathy, primary prevention of sudden cardiac death in lamin A/C cardiomyopathy, and timing of heart transplantation for Danon disease early in my training. Refreshing my knowledge of clinical genetics alone was overwhelming, and I realized that while the rapid growth in genomic technologies was transforming our understanding of inherited cardiovascular disease, frontline clinicians were lagging behind in applying this knowledge to disease prevention and clinical care. To cultivate my interests further and learn to bridge this gap, I joined my institution’s new National Human Genome Research Institute (NHGRI)-supported postdoctoral training program in genomic medicine, a program created to prepare the next generation of physicians and scientists to implement genomic approaches to improve healthcare.

For M.D./D.O. trainees who have spent six consecutive years entrenched in clinical residency and fellowship programs, the idea of extending training by two years, re-entering the world of formal coursework and letter grades, and learning new skills to perform complex and unfamiliar research is more than enough to deter one from pursuing this career development track. However, participating in this program has afforded me many unexpected benefits outside the bounds of my clinical and research training:

  • Caring for patients with a new type of multidisciplinary team:
    • During my clinical training, my idea of a multidisciplinary care team was mostly grounded in my inpatient experience. While cooperating toward the same goal, physicians, nurses, advanced practice providers, therapists, nutritionists, pharmacists, social and case management workers often performed their roles asynchronously with little collaboration outside of the prescribed morning rounds. In contrast, my experience in our inherited cardiovascular disease clinic introduced me to a new paradigm essential to caring for patients and families with genetic disorders. I have been fortunate to learn about variant adjudication, pre-test and post-test counseling, cascade screening, and much more from our tremendous genetic counselors who are integral in the outpatient evaluations of our probands.
    • Though the initial years of my practice have been focused in adult medicine, I have learned about the importance of tracking variant segregation in families and of comprehensive transitions of care through our joint familial cardiomyopathy and arrhythmia programs, partnerships with our neighboring pediatric hospital.
    • Finally, I have witnessed the potential of real time bedside-to-bench-to-bedside research collaborations as shown by my mentors in their recent report of a clinical incorporation of rapid functional annotation of cardiomyopathy gene variants.1
  • Developing and sharing expertise:
    • In leading my fellowship’s didactic education curriculum as Chief Fellow, I took advantage of opportunities to share my new knowledge and skills with other fellows and residents. For our “fresh case” presentations, I often chose to present perplexing cases of cardiomyopathy to reinforce teaching points regarding the workup of genetic cardiomyopathies and the importance of taking a minimum three-generation family history.
    • After completing the Examination of Special Competence in Adult Echocardiography, I led a fellow teaching conference on echocardiography in hypertrophic cardiomyopathy. I also joined our internal medicine residents for a clinicopathologic conference as an expert discussant, a position usually reserved for faculty but generously offered to me given my interest in cardiovascular genetics and enthusiasm for teaching.
    • Pursuing these opportunities to develop and share my expertise has helped me solidify my own knowledge in the field, develop my oral and written communication skills, and grow as a peer mentor.
  • Meeting physicians and scientists outside of cardiovascular medicine:
    • The world often feels quite small while training within a medical specialty, but through my postdoctoral program, I have been exposed to physicians, scientists, and trainees in many disciplines outside of cardiovascular medicine. I heard diverse perspectives in my bioinformatics, biostatistics, and bioethics courses that have encouraged me develop my own independent opinions about my fields of interest. Multidisciplinary forums like genetics journal clubs, genetic rounds, and campus retreats have helped me contextualize the practice of genomic medicine.

 

 

My time in the postdoctoral program has shown me that these unexpected benefits of training are highly valuable to a trainee’s success. Through the genomic medicine postdoctoral program, the NHGRI “hopes to bring cross-training opportunities to individuals at different career levels and to support the training of investigators working in both basic genome science and genomic medicine” as it recognizes that this “is essential to realizing the full potential of genomics.”2

 

References:

  1. Lv W, Qiao L, Petrenko N, Li W, Owens AT, McDermott-Roe C, Musunuru K. Functional Annotation of TNNT2 Variants of Uncertain Significance With Genome-Edited Cardiomyocytes. Circulation. 2018;138(24):2852-2854.
  2. Green, Eric D. “NHGRI’s Research Training and Career Development: Genome Science to Genomic Medicine.” National Human Genome Research Institute. 3 Sept. 2014. https://www.genome.gov/27557674/may-5-nhgris-research-training-and-career-development-genome-science-to-genomic-medicine/

 

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Diabetes Makes Heart Disease Worse

Global awareness has made us cognizant that people with diabetes are susceptible to various disorders involving eye, kidney or nervous system and blood circulation affecting the limbs in the long run. Along these lines, type 2 diabetic patients are more likely to develop heart disease and have a greater incidence of heart attack. According to American Heart Association (AHA), diabetes is one of the major contributing factors for cardiovascular disease and accounts for at least 68 percent of diabetic population of age 65 or older to die from some form of heart disease.

Diabetic heart disease (DHD) is a broader term used to explain heart problems in patients who have diabetes. DHD may include conditions like coronary heart disease, where plaque accumulating in your arteries reduces the blood flow to the heart eventually leading to heart failure, a condition where your heart cannot pump enough blood to meet your body’s requirements. Another consequence of diabetes can be diabetic cardiomyopathy where the damage is extended to the structure and function of the heart. Patients with diabetic cardiomyopathy are more predisposed to develop irregular heartbeat disorders called arrhythmias.

Arrhythmias are conditions in which there is a problem with the rate or rhythm of your heartbeat. It is observed when the electrical signals to the heart that coordinate heartbeats do not function properly. This leads to increase in heart rate (basal rate of more than 100bpm), a condition called trachycardia or decrease in heart rate (basal rate less than 60bpm), called bradycardia. The detailed illustration of these conditions can be found at AHA website. While these conditions can have serious complications in patients, the condition becomes far worse in patients with DHD.

Under normal conditions, mitochondrias which are the energy sources of the cell, give rise to dangerous chemicals known as reactive oxygen species (ROS), byproducts of aerobic metabolism. Oxidative stress occurs when there is excessive production of ROS and if these chemicals are not removed, they possess damage to proteins, tissues and genetic material of the heart cells. However, mitochondria have antioxidant defense systems which decrease ROS production. Under pathological conditions such as diabetes, glucose fluctuations far exceed the ROS production than the oxidative defense systems are capable of cleaning and thus the problem becomes far more intense.

At this year’s Scientific Sessions, one of my colleagues presented his work establishing an interesting link between oxidative stress and arrhythmias. His project focused on protein which is a key enabler of ROS- mediated cardiac arrhythmias, known as mitochondrial translator protein (TSPO). TSPO is an outer mitochondrial membrane protein, previously described as peripheral benzodiazepine receptor, a secondary binding site for diazepam. It’s primarily associated with cholesterol transport to inside the cell, while the group explains its potential role in mitochondrial instability during arrhythmias by mechanism, where excess ROS generated in diabetic patient positively up-regulates its own levels – a process called ROS induced ROS-release (RIRR). Thus, TSPO can be a potential therapeutic target against arrhythmias in diabetic patients. Preliminary data by the group confirmed the increased levels of TPSO in hearts of diabetic rats, which might be responsible for increased propensity of diabetic hearts to arrhythmic events. While TPSO is probably upregulated as compensatory mechanism during type 2 diabetes, its global gene silencing may interfere with essential homeostatic function including cholesterol import and mitochondrial biogenesis. In relation to that, the group is further looking into avenues for targeted and specific TSPO inhibition in the areas affected after heart attack.

Personally, I am not only proud of his work but also hopeful that research studies like his help us to identify potential targets for curing serious conditions like DHD.

 

References:

Ilkan ZAkar FG. The Mitochondrial Translocator Protein and the Emerging Link Between Oxidative Stress and Arrhythmias in the Diabetic Heart.Front Physiol. 2018;26;9:1518

Ilkan Z, Strauss B, Akar FG. Reversal of TSPO Upregulation in the Diabetic Heart by Chronic TSPO Gene Silencing Causes Metabolic Sink via an Increase in ROMK Expression. Circulation. 2018;138:A16826.