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Cardiovascular Maternal Morbidity and Mortality In the United States – What is the Cardiovascular State of Health for Pregnant Women and What is the Role of the Cardiologist?

Introduction

Despite advances in health care in the United States (US) maternal morbidity and morbidity remains significantly higher in the US relative to other developed nations with a reported maternal mortality of 14 per 100,000 live births in 20151.  Unfortunately, maternal morbidity and mortality rate has steadily increased over the last 2 decades2. The Centers for Disease Control (CDC) implemented the Pregnancy Mortality Surveillance System. The CDC defines a pregnancy-related death as the death of a woman while pregnant or within 1 year of the end of a pregnancy – regardless of the outcome, duration or site of the pregnancy–from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes2.  Although the maternal morbidity and mortality rate declined in the 20th century, recent statistics have shown that this rate has increased more than 2 fold as the number of reported pregnancy-related deaths in the United States steadily increased from 7.2 deaths per 100,000 live births in 1987 to 17.2 deaths per 100,000 live births in 2015. More recent date has suggested that this rate is even higher at 26.4 per 100,000 live births3. Cardiovascular disease (CVD) accounts for approximately a third of pregnancy related deaths and is the leading cause of maternal morbidity and mortality2.  According to the American College of Obstetrics and Gynecology (ACOG) acquired heart disease is thought to be the cause for the rising cardiovascular mortality in women with an increasing number of mothers entering  pregnancy with a greater burden of common risk factors for CVD such as age, obesity, diabetes and hypertension2,3.

 

Disparities in Outcomes

There are also significant racial and ethnic disparities seen in maternal morbidity and mortality rates in the US with Black women having  a greater than 3 fold higher rate compared to White, non-Hispanic women (42.8 per 100,000 vs. 13 per 100,000 live births)2. The lowest maternal morbidity and mortality rate is seen in Hispanic women with a rate of 11.4 per 100000 live births. This rate progressively increases with White Non Hispanic women having a rate of 13.0 per 100,000 live births followed by 14.2 per 100,000 in Asians/Pacific Islander, 32.5 in American Indian Alaskan Native, and is highest in Black Non-Hispanic Women of 42.5 per 100,000 live births2 Figure 1.

The cause of this disparity is multifold and may also be related to a higher prevalence of CVD risk factors such as obesity and hypertension in Black non-Hispanic women4. There may also be limited access to adequate postpartum care in this patient population. There has been some action taken by ACOG with regards to providing recommendations for addressing these disparities5,6. However, there is a lot of work left to be done in resolving these inequities in maternal healthcare.

 

Role of the Cardiologist

It is vital that mothers who are at increased risk for CVD or have established CVD be referred to a Cardiologist for cardiovascular assessment and management in the early postpartum period. Therefore, raising the awareness amongst the Obstetrics and Gynecology community of this necessity of cardiovascular care in these women is important. Additionally, for us in the Cardiology community it is important to recognize these female patients when they present to us for the first time for care. Their presentation may be in the antepartum or postpartum period. In the antepartum period it is vital for us to be able to differentiate pathologic cardiovascular signs and symptoms from the physiologic cardiovascular changes related to pregnancy. It is also important that if these women present to us in the antepartum or postpartum period that they have an adequate assessment of their cardiovascular risk. Key historical features to obtain includes a thorough obstetrics history as there are several pieces of the obstetric history that may indicate a higher cardiovascular risk such as preterm deliveries, pre-eclampsia and frequent first trimester miscarriages. A systematic review and meta-analysis published in Circulation in 2018 by Grandi S, et al analyzed 84 studies that included more than 28 million women and had indicated that women with placental abruption and stillbirth in addition to hypertensive disorders of pregnancy, gestational diabetes mellitus, and preterm birth are at increased risk of future cardiovascular disease7  Figure 2. In addition to an obstetrics history, a family history of heart disease particularly premature heart disease is also important. These women should also be assessed for common CVD risk factors such as obesity, hyperlipidemia, diabetes, hypertension, smoking and a sedentary lifestyle. These risk factors should be appropriately and intensively managed through a combination of therapeutic lifestyle changes and medications where appropriate.

In the prepartum period women intending to become pregnant should also be screened  with regards to their CVD risk assessment and these risk factors should be appropriately managed to improve their overall CVD health prior to becoming pregnant. This is especially so as pregnancy could be viewed as nature’s stress test and the more cardiovascularly healthy women are when they conceive the more likely they will have better cardiovascular outcomes in the postpartum period.

In unique cases of women with Congenital Heart disease, it is imperative that these patients are seen by an Adult Cardiologist with expertise in Adult Congenital heart disease before considering pregnancy as there may be cases where women with certain Adult Congenital heart diseases or pathology such as Eisenmenger’s syndrome should be advised to avoid pregnancy. Additionally, there may be cases where therapies or procedures may have to be considered prior to becoming pregnant such as women with Marfan’s syndrome with significant aortic root dilation.

 

Solutions to the Problem

The rise in maternal morbidity and mortality in the US has been attributed to acquired CVD1 and is therefore preventable. In order to address this problem the following should be considered:

  1. Recognition and management of CVD risk factors in the prenatal Period
  2. Appropriate cardiovascular assessment in the prenatal period for women with congenital heart disease to determine if pregnancy is contraindicated and if not contraindicated to determine suitable follow up of these women in the ante and postpartum period. Appropriate delivery plan should be outlined in an appropriate tertiary high Obstetrics risk center with appropriate cardiovascular and neonatal services available.
  3. Adequate cardiovascular follow up during the pregnancy and postpartum period for women with an intermediate as well as a high CVD risk.
  4. A multidisciplinary Pregnancy Heart Team approach is important for women with intermediate and high CVD risk in the antepartum and postpartum period.
  5. Early postpartum period cardiovascular assessment is important in the first 1-2 weeks post delivery for women with high CVD risk features such as women with placental abruption and stillbirth in addition to hypertensive disorders of pregnancy, gestational diabetes mellitus, and preterm births.
  6. Women with high CVD risk should have long term cardiovascular care not only in the first year postpartum but these women will likely require long term cardiovascular follow up even beyond a year to improve their lifelong cardiovascular risk.
  7. Removal of barriers to access to appropriate prenatal, antepartum and postpartum cardiovascular care is important for all women regardless of race or ethnicity.
  8. Raising awareness of the elevated maternal morbidity and mortality risk predominantly due to CVD is important in both the Cardiovascular and Obstetric Gynecology medical community so that as providers we can deliver the best possible care to these patients to improve their outcomes.

 

Future Directions

With the increasing maternal morbidity and mortality in the US that has been attributed to CVD there is a role for increased collaboration between the Cardiologist and the Obstetrician with regards to a Pregnancy Heart Team. The role of this team is vital in improving CVD outcomes in the antepartum and postpartum period for these women. Hopefully the research collaborative called the Heart Outcomes in Pregnancy: Expectations (HOPE) for Mom and Baby Registry which aims to address key clinical questions surrounding the preconception period, antenatal care, delivery planning and outcomes, and long-term postpartum care and outcomes of women will help to address the knowledge gaps and disparities in the care of women with heart disease in pregnancy8.

There is also a need for greater risk prediction tools with regards to assessing CVD risk in the prenatal, antenatal and postnatal period. The recently concluded Cardiac Disease in Pregnancy (CARPEG II) study indicated that there were 10 predictors that could be utilized to assess maternal CVD risk9. These 10 predictors include:

  1. 5 general predictors;
    1. Prior cardiac events or arrhythmias (3 points)
    2. Poor functional class or cyanosis (3 points)
    3. High-risk valve disease/left ventricular outflow tract obstruction (3 points)
    4. Systemic ventricular dysfunction (2 points)
    5. No prior cardiac interventions (1 point)
  2. 4 lesion-specific predictors:
    1. Mechanical valves (2 points)
    2. High-risk aortopathies (2 points)
    3. Pulmonary hypertension (2 points)
    4. Coronary artery disease (2 points)
  3. 1 delivery of care predictor (late pregnancy assessment) (1 point)

Patients with a higher CARPREG II score had a higher incidence of adverse cardiac events in pregnancy.

It is hopeful that these new initiatives will assist providers in improving their ability to appropriately risk stratify women in the prenatal, antepartum and postpartum period with regards to CVD risk. Additionally, it is hoped that  these initiatives will also improve care of these women through improved collaboration between the cardiologist and the obstetrician.

 

 

References:

  1. World Bank Statistics -2018 https://data.worldbank.org/indicator/SH.STA.MMRT?locations=FI-VE&year_high_desc=false Accessed July 28, 2019
  2. Centers for Disease Control Pregnancy Mortality Surveillance System. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-mortality-surveillance-system.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Freproductivehealth%2Fmaternalinfanthealth%2Fpmss.html Accessed July 28, 2019.
  3. American College of Obstetrics and Gynecologist (ACOG) Releases Comprehensive Guidance on How to Treat the Leading Cause of U.S. Maternal Deaths: Heart Disease in Pregnancy News Releases 2019. https://www.google.com/url?q=https://www.acog.org/About-ACOG/News-Room/News-Releases/2019/ACOG-Releases-Comprehensive-Guidance-on-How-to-Treat-Heart-Disease-in-Pregnancy?IsMobileSet%3Dfalse&sa=D&ust=1564343293391000&usg=AFQjCNGL5pYJww-2z_FrcgJuZhx4vTeRGA Accessed July 28, 2019.
  4. Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association. Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Das SR, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Jordan LC, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, O’Flaherty M, Pandey A, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Spartano NL, Stokes A, Tirschwell DL, Tsao CW, Turakhia MP, VanWagner LB, Wilkins JT, Wong SS, Virani SS; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee.Circulation. 2019 Mar 5;139(10):e56-e528. doi: 10.1161/CIR.0000000000000659
  5. American College of Obstetrics and Gynecology (ACOG) Committee Opinion No. 729: Importance of Social Determinants of Health and Cultural Awareness in the Delivery of Reproductive Health Care.Committee on Health Care for Underserved Women.Obstet Gynecol. 2018 Jan;131(1):e43-e48. doi: 10.1097/AOG.0000000000002459. Review.
  6. American College of Obstetrics and Gynecology (ACOG) Committee Opinion No. 649: Racial and Ethnic Disparities in Obstetrics and Gynecology.Obstet Gynecol. 2015 Dec;126(6):e130-4. doi: 10.1097/AOG.0000000000001213
  7. Grandi SM, Filion KB, Yoon S, Ayele HT, Doyle CM, Hutcheon JA, Smith GN, Gore GC, Ray JG, Nerenberg K, Platt RW. Cardiovascular Disease-Related Morbidity and Mortality in Women With a History of Pregnancy Complications. Circulation. 2019 Feb 19;139(8):1069-1079.
  8. Grodzinsky A, Florio K, Spertus JA, Daming T, Schmidt L, Lee J,
    Rader V, Nelson L, Gray R, White D, Swearingen K, Magalski
    A.Maternal Mortality in the United States and the HOPE Registry.
    Curr Treat Options Cardiovasc Med. 2019 Jul 25;21(9):42.
  9. . Silversides CK, Grewal J, Mason J, Sermer M, Kiess M, Rychel V,
    Wald RM, Colman JM, Siu SC. Pregnancy Outcomes in Women With
    Heart Disease: The CARPREG II Study J Am Coll Cardiol. 2018 May
    29;71(21):2419-2430

 

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Live Streaming, Cardiovascular Disease, and Violence: What I Learned at Scientific Sessions 2018

Take a trip back down memory lane to your glory days as a happy and shiny nine-year-old. If your childhood was as amazing as I remember mine to be, then you spent your days running outside with friends, making mud pies, and then fabricating methods by which you could trick your little sister into eating said mud pies. Now even though life is all spick-and-span for you at that age, imagine that you have a close friend whose parents are experiencing some domestic problems – so bad in fact, that it results in the mother attempting to commit suicide by ramming the car, full speed, into a cement block with your friend and his/her two other siblings inside. In your present day and age, can you even begin to fathom the degree of trauma that this past event brought to your friend? Now, would you believe me if I say that if undealt with, your friend may not only experience mental health issues but also cardiometabolic problems? While this may not be your first thought, it is now becoming more widely known that violence (or stress) is an independent risk factor for adverse cardiovascular health. This story may seem just a tad over the top; however, this was the topic of discussion for the session titled Unpacking the Cardiovascular Biology of Violence at Scientific Sessions 2018 and was the eye-opening account given by physician Marjorie Fujara from Chicago during her presentation.

As a new graduate student, this was my first time experiencing Scientific Sessions and I was completely taken aback by the various works discussed. Presentations that I was luckily able to witness via Live Streaming. Yes, you read correctly, LIVE STREAMING. Complete transparency here, I definitely opened my iPad with the preconceived notion that I would not be as engaged watching from my tiny screen in comparison to what I would experience being presented live and in-person. However, from the comforts of my own home, I found myself unreservedly hooked on the late-breaking science from researchers across the country. From the new Physical Activity Guidelines, to the nature versus nurture of cardiovascular disease, it was without a doubt an exciting weekend for science!

Considering the variety of disciplines at the conference, there were a number of ways to personally connect to the science presented. For example, my lab studies the effects of early life stress (or adverse childhood experiences) on the development of obesity and its related diseases later in life. As a result, the cardiovascular biology of violence talks were the ones that resonated with me the most because of its applications to my own research and personal interests.

During the discussion on the connections between heart health and trauma exposure, one panelist considered the case of primordial violence on developmental programming. Key points stemmed around the idea that excessive punishment led to increased levels of circulating cortisol. This then results in damage to the hippocampus (memory and learning), amygdala (emotions), and frontal cortex (reasoning). This data has led to the implementation of “No Hit Zones” in various hospitals. At the genetics level, however, what makes the people who experience increased levels of violence different from the rest of the population? When considering the epigenetics of the situation, violence in one’s life results in alterations in DNA methylation patterns (either hypo- or hyper-) and eventually leads to a higher cardio-metabolic risk. During the discussion, it was mentioned that for a child, just hearing about violence in one’s own community resulted in a difficulty concentrating for periods ranging from two days to an entire month. You can easily begin to wonder, “What does this mean for children living in areas with high homicide rates?” Overall, people exposed to trauma, and are not properly dealing with it, are predisposing themselves to diastolic elevations much earlier in life consequenting in early onset of cardiovascular disease.

The question is now, “What interventional methods can we use to better help people who are experiencing cardiac alterations due to increased stress exposure?” One solution discussed is the Bright Star Community Outreach program. Bright Star is a nonprofit aimed at using science and research to aid members of the south side Chicago community in recovering from the trauma of violence. By confronting the trauma, instead of bottling it away, they hope to help people to end the cycle and limit violence-induced early cardiovascular insults.

As the reader, and possibly someone who was unable to attend (or live stream) AHA Scientific Sessions 2018, what else do you think can be done clinically to better serve this group in terms of cardiovascular health? Do you think they will need different pharmacological interventions compared to the “traditional” hypertensive patient, for example?

 

Disclaimer

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

 

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The Evolution of Cardiac Care- “Moving the Needle from Predominantly Treatment to Additional Prevention of Cardiovascular Disease”

Cardiovascular disease (CVD) remains the number one cause of mortality for both men and women in the United States1. Although CVD related mortality is decreasing with advanced diagnostic testing and therapies of CVD, the prevalence of this disease remains high including in the younger aged population younger than 55 years of age1. This suggests that as providers we have done a successful job at treating CVD however there remains a lot of work to be done with regards to preventing this disease.

 

Moving the Needle

The prevention of CVD disease requires effort not just at the individual provider- patient level, but requires effort at the professional organization/societal and legislative level. The focus of the recent 2018 American Heart Association Scientific Meeting on several areas of Preventive Cardiology  such as the recently released 2018 Cholesterol Practice Guidelines as well as the recently released Department of Health and Human Services Physical Activity Guidelines for Americans indicates that there is some momentum and interest in moving the focus of health care from solely treating CVD to also preventing CVD in addition to treatment. The 2018 Cholesterol management guideline document has indicated that assessment of CVD risk begins as early as 20-39 years of age and this provides an opportunity to counsel these patients on heart healthy lifestyle modification to improve their cholesterol profile and therefore decrease their CVD risk2. The cholesterol guidelines also focus on the fact that the lower the cholesterol level the lower the CVD risk2.

It has been shown that most individuals in the United States do not report enough physical activity to meet the American Heart Association physical activity guidelines1. The recently released Department of Health and Human Services Physical Activity Guidelines for Americans also indicates that there is also legislative support for increasing physical activity in an effort to improve the cardiovascular health of Americans3.

The Million Hearts 2022  national initiative that is co-led by the Centers for Disease Control and Prevention and the Centers for Medicare & Medicaid Services is also another effort in the prevention of CVD. The goal of this initiative is to prevent 1 million heart attacks and strokes in 5 years through focused partner actions on several priorities selected for their impact on heart disease, stroke, and related conditions.

These initiatives indicate that there is an effort to move the needle of healthcare to preventative medicine. This plays an important role in decreasing CVD prevalence and will therefore lead to improved CVD outcomes for the United States population.

 

Impact on our Patients

A heart healthy diet and a physically active lifestyle has been shown to decrease the risk of developing CVD disease1. Counselling patients on a heart healthy lifestyle positively impacts our patients as it raises their awareness of the impact of lifestyle on overall cardiovascular health and also encourages them to adopt a heart healthy lifestyle.

 

More Work to be Done

Adequate training in Preventive Cardiology for fellows has been lacking as many of our trainees are not being taught the required amount of preventive cardiology during their General Cardiology fellowship training4. A survey in 2012 indicated that only a quarter of the surveyed General Cardiology fellowship training programs met the Core Cardiology Training Symposium (COCATS) guidelines recommendation of a dedicated 1 month rotation in preventive cardiology. In view of this, many Cardiologists in practice do not include nutritional and physical activity assessment as a part of their clinical evaluation. As a result, counselling on a heart healthy lifestyle as a part of preventive cardiology is not practiced by many Cardiologists. This void in training and experience in preventive cardiology provides an opportunity for us to assess and improve our own practice in this area as Cardiologists and also provides an opportunity to develop formal training in Preventive Cardiology for our cardiology fellows.

 

Despite the fact that CVD disease related mortality is decreasing in the United States, the prevalence remains high1. This indicates that providers within the Cardiovascular community have done a great job in treating CVD disease but there is still a need to improve our practice with regards to preventing CVD. The movement by the American Heart Association,  Centers for Disease Control and Prevention and the Centers for Medicare & Medicaid Services in focusing on areas of lifestyle medicine and preventive cardiology indicates that there is an effort to shift the needle from not just treating CVD disease but also preventing this disease. This movement therefore provides an opportunity for the Cardiovascular community to improve our practice in this area and to equip our cardiology fellows with adequate training in Preventive Cardiology to become better practitioners in this area in their future role as Cardiologists.

 

References:

  1. Benjamin EJ, Virani SS, Callaway CW, sChamberlain AM, Chang AR, et al. Heart Disease and Stroke Statistics—2018 Update: A Report From the American Heart Association
  2. 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
  3. The Physical Activity Guidelines for Americans: THe HHS Roadmap for an Active Healthy Nation. Second Edition. ADM Brett P. Giroir, MD
  4. Pack QR,Keteyian SJ, McBride PE, Weaver WD, Kim HE. Current status of preventive cardiology training among United States cardiology fellowships and comparison to training guidelines. Am J Cardiol 2012;110:124-8.

 

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What Do The New Lipid Guidelines Mean For Patients?

One of the highly anticipated stories for Scientific Sessions 2018 was the new lipid guidelines. Following the reactions on Twitter during the session, I read a lot of opinions on CAC scoring and the pros and cons of its use to further stratify those at intermediate risk. Also trending – when to target LDL-C, now that thresholds are back on the table. These are the kinds of topics that typically get a lot of attention: which drugs, which targets, which tests? Conveniently, tests and prescriptions are also reasonably easy for clinicians to implement in practice.

In addition to my work as a nurse scientist, I’m a primary care provider who works with undeserved, often uninsured patients. CAC scores are, frankly, not highly relevant to my practice (at least until you can get them for $4 at Walmart). There were, however, two aspects of the new guidelines that caught my attention as a clinician serving this population. First, that it’s officially OK to measure non-fasting lipid levels. Second, that a clinician-patient discussion is recommended before initiating statin therapy for primary prevention. While these topics may seem entirely separate,  both are highly relevant to patient experiences of care. Primary prevention of ASCVD (or any condition) hinges on clinician-patient interaction because by definition, these patients are not yet sick. They have to buy in, and they do so (or not) based on their experiences with us as their care providers. Which dose of which medication to prescribe is irrelevant if a patient does not wish to take it.

The implications of non-fasting labs for patients are not hard to grasp, but this change will particularly impact patients who face barriers to care including transportation issues and the inability to take time off work. It’s a more impactful change that seems to remove a barrier to high-quality care, and I’m glad to see it.

The risk discussion, though not new, is more complex. Per the guidelines, it should include “a review of major risk factors (cigarette smoking, elevated blood pressure, LDL-C, hemoglobin A1C, and calculated 10-year risk of ASCVD); the presence of risk-enhancing factors; the potential benefits of lifestyle and statin therapies; the potential for adverse effects and drug–drug interactions; consideration of costs of statin therapy; and patient preferences and values”. Did you get all that? Now, imagine that you don’t have any medical or scientific background. You’ve been sitting in the waiting room for an hour, you skipped breakfast because you were getting fasting labs, and you are feeling a little nervous. Your doctor is talking fast because she’s running behind. Does this sound familiar? Is the review of major risk factors going well? Is it conducive to shared decision-making and buy-in?

My point isn’t that we can’t or shouldn’t have the conversation about risk, but that we need to find effective ways to have this conversation even though we face constraints on our time. A conversation, according to Merriam-Webster online, is an “oral exchange of sentiments, observations, opinions, or ideas”. Key word: exchange. The literature shows us different ways to communicate risk to patients, although we don’t have consistent data on what works and what doesn’t, and for whom. Yet even if we identify methods for us to best communicate the information, we still need to receive information from the patient and incorporate that into our ultimate shared decision. This is not easy. It will require a broader kind of work to improve. To effectively implement these guidelines will require work to understand how patients understand and how clinicians spend limited time. These guidelines use science to guide us in what to do– now we need science to help us learn how to do it.

Image: text from “Top 10 Take-Home Messages to Reduce Risk of Atherosclerotic Cardiovascular Disease Through Cholesterol Management” displayed by frequency via WordItOut (worditout.com)

 

Source: Grundy SM, et al. 2018 Cholesterol Clinical Practice Guidelines: Executive Summary
https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000624

 

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Joint Hypertension 2018 Scientific Sessions – You Should Have Been There

hypertension 2018

Just as promised, the Joint Hypertension 2018 Scientific Sessions (Hypertension18) was indeed among the most impactful meetings one could have attended. Council on Hypertension Scientific Sessions Planning Committee Vice Chair Dr. Karen Griffin, FAHA was accurate in her statement that it would be “the premier scientific meeting.” There were experts from all parts of the world covering more cardiovascular topics that I think my fingers could not keep up with in note taking, and each session was more informative than the next with up-to-date information on hypertension.

During the President’s Welcome Address, Dr. Ivor Benjamin, FAHA foreshadowed what was to be expected during the meeting. He gave general overviews of the hypertension guidelines, what the changes mean to clinicians and researchers, as well as the role AHA will play in helping drive those changes forward. His welcome was a great introduction to the ‘Recent Advances in Hypertension’ Session chaired by Drs. Joey Granger from the University of Mississippi Medical Center and John Bisognano from University of Rochester Medical Center. This session covered the new guidelines, implementation, and basic research advances of clinical hypertension moving forward by Drs Basile, Egan, Oparil, and Ellison. The whirlwind of information was just the icebreaker! During the refreshment break and exhibits, I met a number of “Rockstars” including clinicians and researchers from University of Alabama Birmingham, Drs. David and Jennifer Pollock and AHA Early Career blogger Tanja Dudenbostel. Additionally, this was the only time I spent visiting with vendors. Among them, Hulu explained the importance of calibrating automatic blood pressure machines. Historically blood pressure was taken with a manual sphygmomanometer and a technician listening for ausculatory sounds via a stethoscope, but now it is all automated. Generally one machine is used for all patients. This technology forces us to question the accuracy of the readings of the machines. Are they calibrated? Should the BP be taken radially or at the wrist? Should the machine be changed throughout the day? There was Aegis representatives sharing information about products to assist medical professionals determine patient compliance to therapy and toxicology testing equipment. During these conversations, it was surprising to discover some of the rationales behind why people would opt to not take medicine as prescribed.

With my research being focused on oxidative stress-induced vascular injury and since I have become increasingly more interested in health and wellness, I took particular interest in the session focused on “Lifestyle Modifications and Impact on BP” chaired by the Associate Editor of Hypertension, David Harrison, MD, FACC, FAHA, “Recent Advances Obesity and Cardiovascular Disease” chaired by the consulting Editor of Hypertension Suzann Oparil, MD, FAHA, and “Obesity, Diabetes, and Metabolic Syndrome” chaired by Drs. Kamal Rahmouni and Carmen De Miguel. During these sessions, it was not surprising that regular exercise reduced vascular stiffness, but what was noteworthy was that weight training contributes to atherosclerosis. Additionally, the sympathetic nervous system seems to be important in glomerular filtration. Dr. Elizabeth Lambert delivered an intriguing talk about how diet and exercise can significantly decrease metabolic syndrome in middle aged obese individuals, which is consistent with a recent study (Hypertension18 Meeting Report P388) that suggests lifestyle changes can reduce hypertension in both men and women. Further, the study suggests that following the DASH diet, exercising, and weight management over a course of 16 weeks were contributing factors in reducing BP in test subjects. We all know anti-hypertensives work in reducing BP. Lifestyle changes should be the first line of defense in evading hypertension and getting it under control at the onset, according to the American Heart Association/American College of Cardiology  Hypertension Guidelines. We have all heard that we have to get out there and get moving. Choosing the right exercise is just as important as exercising, according to Dr. Tanaka.

I recently wrote a blog discussing metabolic syndrome and therein indicated there is not a direct correlation between obesity and diet. During this conference, Dr. John Hall lectured on the recent advances in CVD and obesity. He suggested that epigenetic transmission of obesity in humans (and others) is associated with increased adiposity and insulin resistance, depletion of nuclear protein, influence chromatin conformation, and altered germ cell methylation and gamete micro RNA.

The new concurrent session Clinical Practice Clinical Science and Primary Care tracks did not go unnoticed. Although I did not get to attend many of these sessions, I did pass them to see that they were well attended. I did attend some of the lunch meetings and they were very insightful. Please refer to my Twitter to see my detailed notes. As mentioned in my pre-conference blog, with all the sessions that were available one should not have had an issue meeting the goals outlined in the program by coordinators (infra vide). Several sessions that met the interest of all researchers/clinicians, early career, and everyone in between. Not a person that attended Hypertension18 could say they could not find a learning opportunity at the Joint Hypertension 2018 Scientific Sessions! Even if one was merely a passerby, there was a session relevant to them. For example, I was on my way to get coffee when I encountered Drs. Yagna Jarajapu from North Dakota State University and Daniel Batlle from University of Chicago discussing research concerning STZ diabetic Foxn1 mice that were ischemic for several days. Subsequently, Eric Metterhausen shared his mission of services (MOS, for you military people) with me as we conversed about field medicine with the United States Public Health Services (USPHS). I did know our US Armed Forces had research officers and divisions of research, but the amount of detail that Major Metterhausen described was a beast that I had not known. Conversations such as these lead to increased mentoring relationship, as well as potential collaborations in research and grant proposals. We all go to conferences to learn, to purchase new research equipment, and to present our data, but we also should not forget to network and build relationships.

Conference Learning Objectives:

  • Discuss changes to the AHA/ACC guidelines for the management of hypertension and their clinical implications.
  • Describe opportunities to improve blood pressure measurement in the clinical setting to provide more accurate results.
  • Identify immune and inflammatory mechanisms that contribute to the development of hypertension and hypertension-related end-organ damage and discuss the research and clinical implications.
  • Educate participants about medical approaches for the management of comorbid obesity in patients with hypertension.

 

  • Describe participants on the impact of value-based reimbursement on hypertension management and identify opportunities to improve its management.

 

See you all in Chicago at Scientific Sessions 2018!!!

  • Leave a comment and follow me on Twitter @AnberithaT and @AHAMeetings if you have questions or are interested in something else specifically.

 

Anberitha Matthews, PhD is a Postdoctoral Fellow at the University of Tennessee Health Science Center in Memphis TN. She is living a dream by researching vascular injury as it pertains to oxidative stress, volunteers with the Mississippi State University Alumni Association, serves as Chapter President and does consulting work with regard to scientific editing.

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Growing My Network at BCVS18

Basic Cardiovascular Science 2018 (BCVS18) Scientific Sessions was held in San Antonio this year. I had no initial intention on attending BCVS18, but there was an email notification urging members to participate in a tweeting competition. A Researcher from University of Tennessee Health Science Center challenged me to participate in the competition to try to win one of the two prizes, which ultimately led to my attending the session to assist with social media coverage of the programs. Although I took part in the tweet storm, I was not in the running for the prize. We thought it best to leave those for another researcher.

As with most meetings, this gave me the opportunity to reconnect with people that I had previously met as well as receive career guidance. This meeting was different for me in the respect that, in addition to diving into the science aspect, I actively sought out vendors from organizations of interest to me as a means of gaining insight into transitioning from academic research to industry. This is often an underexplored opportunity at meetings. As a scientist, I spend most of my time going to scientific sessions and poster sessions, and only visit the vendors that I need to meet with to purchase equipment/products or get information about equipment/products that are currently in use in the lab. BCVS is a smaller meeting with fewer vendors allowing more opportunity to go to sessions, as well as spend time gathering career information. I met with people from three noteworthy organizations.

  1. Kara Keehan, Executive Editor for AJP-Heart and Circulatory Physiology took several moments to share with me ways to interact more openly as an introvert. Often times introverted people are perceived as being standoffish or anti-social, but in reality, may just be uncomfortable in social or unfamiliar settings. Kara shared with me some strategies to mingle in social and professional settings to increase my ability to network. For example, walk up to someone and start talking about the last session or Twitter. Additionally, she gave me some insight into the role of an editor and the requirements.
  2. I have become increasingly more interesting in Medical Science Liaison (MSL) positions. Having the ability to be connected to the science and share the information in a way that will help people life a healthier life has resonated with me on many levels. However, understanding how to translate an academic research background into one that will be appealing to recruiters in the industry has proven to be difficult. George Ruth III, Sale Consultant at Pfizer, gave me ample amount of guidance on creating a resume that will catch the eye of the human resource personnel that will be looking to fill those positions. Searching the career website is not always as clear as one would hope, thus George also gave advice on how to identify positions of an MSL with a pharmaceutical company.
  3. Chandler Dental Center came to BCVS to share information about “Oral Systemic Health Services” for patients struggling with inflammatory diseases such as cardiovascular disease. His booth had information about The Heart Gene and articles to support studies that suggest a link between dental health and vascular health. In our one-on-one dialog, he suggested that 78% of people suffering from myocardial infarctions had bacteria in their thrombus that were specific to the mouth. As a dentist, he can take saliva samples and test for the bacterial strain for early detection and treatment, leading to subsequent offset of CVD symptoms. This conversation reiterated the point that physicians rely on scientist to assist in conducting studies that are otherwise not feasible. Thus, Bryce (dentist) works in concert with Bradley Bale (clinical assistant professor) School of Medicine, Texas Tech Health Sciences Center to conduct the cardio-dental research.

When going to a conference, one should take advantage of the total experience. Do not get caught up in only one portion of the meeting. Yes, the science is important, but networking and looking out for the next career step is equally as important. Was it Darwin that said, “Chance favors a prepared mind?”

 

Leave a comment or tweet @AnberithaT and @AHAMeetings if you have questions or are interested in a specific topic. Also, follow me and @American_Heart for more #HeartSmart information.

 

Anberitha Matthews, PhD is a Postdoctoral Fellow at the University of Tennessee Health Science Center in Memphis TN. She is living a dream by researching vascular injury as it pertains to oxidative stress, volunteers with the Mississippi State University Alumni Association, serves as Chapter President and does consulting work with regard to scientific editing.

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Pharmacological Smoking Cessation Aides And Cardiovascular Safety

Pharmacological smoking cessation therapies have had their challenges. For example, varenicline previously had a US Food and Drug Administration black box warning regarding neuropsychiatric risks.

The EAGLES study, published 2016, was an industry sponsored, randomized, placebo-controlled trial of nicotine, varenicline, and bupropion that sought to address the neuropsychiatric risk profile of these medications.1 They randomized participants with and without known psychiatric comorbidities to these medications and found that these agents were not associated with an increased risk of neuropsychiatric adverse events. Further, the study found varenicline to be more effective than nicotine, bupropion, and placebo for smoking cessation.

The FDA black box warning for varenicline was removed. However, concerns regarding the cardiovascular safety persisted. Apart from abundant observational data on this topic, there have been several randomized trials as well. For example, in 2015, a randomized clinical trial of varenicline versus placebo for patients hospitalized with acute coronary syndrome demonstrated efficacy for cessation and did not raise a safety signal.2

Further, a secondary analysis of the EAGLES study regarding cardiovascular safety was recently published.3 They compared rates of major adverse cardiovascular events, and changes in blood pressure and heart rate, among participants randomized to placebo, varenicline, bupropion, and nicotine replacement. They found very low rates of major cardiovascular events and did not find differences between drugs. Of course, these were not patients with recent or significant cardiovascular comorbidities, so the results do not generalize beyond the general population of smokers.

There is thus mounting evidence for both the psychiatric and cardiovascular safety of pharmacological smoking cessation therapies. While it can be argued that an adequately powered safety trial in patients in acute and/or significant cardiovascular disease has yet to be performed, it may nonetheless be time to create gold standard cessation programs for patients with cardiovascular disease. It may be premature, however, to do the same for patients with cerebrovascular disease – more evidence may be needed.

References:

  1. Anthenelli RM, Benowitz NL, West R, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet. 2016:387;2507-2520.
  2. Eisenberg MJ, Windle SB, Roy N, et al. Varenicline for Smoking Cessation in Hospitalized Patients With Acute Coronary Syndrome. Circulation. 2015:137; https://doi.org/10.1161/CIRCULATIONAHA.115.019634.
  3. Benowitz NL, Pipe A, West R, et al. Cardiovascular Safety of Varenicline, Bupropion, and Nicotine Patch in SmokersA Randomized Clinical Trial. JAMA Internal Medicine. 2018; doi:10.1001/jamainternmed.2018.0397.

Neal Parikh Headshot

Neal S. Parikh, MD, earned his MD from Weill Cornell Medical College and completed residency training in neurology at the same institution. He is now an NIH T32 neuro-epidemiology and vascular neurology fellow at New York-Presbyterian Hospital/Columbia University Medical Center. He tweets @NealSParikhMD and contributes to Blogging Stroke as a blogger.

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On My Way To NoLa – AHA EPI | Lifestyle Specialty Conference

The AHA EPI | Lifestyle Specialty Conference will be smaller and more specific than any conference that I have attended. My conference experience has consisted of, for the most part, international meetings that are held in large venues such as Experimental Biology (EB) in the San Diego Conference Center. This center boast 525,701 gross ft2 on the ground level and 90,000 ft2 of column-free space in the Sails Pavilion on Upper Level. EB uses this vast conference space to house over 14,000 researchers, 400 oral sessions that are hosted by 6 societies and 35 guest societies. To attend an event of this size can prove to be too exhaustive to experience everything that is being offered. I have opted to attend the AHA EPI | Lifestyles specialty conference because it is smaller and focused on Health Promotion: Risk Prediction to Risk Prevention.

Since Bailey DeBarmore went into great detail outlining the schedule for the meeting, I will not expound on that any further. Although I have more of a molecular biology/biomedical background that focus on oxidative stress in the microvasculature, I was surprised to see this meeting offered topics that would enhance not only my knowledge of health promotion, but also contribute to my scientific research. The section Hypertension: Guidelines and Prevention, Rapid Fire Oral Presentations consist of several researchers/clinicians that will present their work in 10 minute burst, giving the vibe of “speed dating”. This is an interesting way to present topics, but it is also challenging! From my experience, there is so much to say and so little time to say it. Which, is true. The topics are so specific, one is required to have background knowledge of the topic to understand the speakers’ findings. It is also a good way for the listener to gain a vast amount of information in a short time.

Additionally, I am excited about several of the sessions that will be held at AHA EPI |Lifestyle Specialty Conference. My career trajectory has taken me through proteomics, genomics, and metabolomics as mechanistic tools to elucidate the onset of inflammation, and subsequently, cardiovascular disease. The intersection between theoretical prediction of a disease to the onset of the disease, and ultimately the prevention of the disease by reducing the risk is the obvious pathway of ameliorating chronic diseases. The topic of interest to me, due to the time constraints, are as follows:

  1. Session 2 – Hypertension Guidelines and Prevention. Now that the new guidelines are beginning to be accepted among the clinical/scientific communities, it will be interesting to learn more about the methods being initiated to accomplish these new levels.
  2. Session 5 – Cardiovascular Biomarkers I expect will introduce more detail about the markers clinicians use for early identification of cardiovascular disease and what can be done to truncate its occurrence.
  3. Session 6 – Hot off the Press – there are several new articles that have been released this year. Among them, Schoenthaler et al addressed social needs of hypertensive patients.
             a. For decades there has been arguments as to whether one should have a low fat or low carbohydrate diet to lose a weight. This study by Gardner et al, will add to what we know about the impact diet have on weight loss in overweight adults using genotype patterns and/or insulin secretions as the associated factors.
             b. The study by Powell-Wiley et al, suggest there is a correlation between crime and physical activity and obesity among African American women. Since we know there are many variables that plays a role in obesity and physical activity, I am interested to learn more about their study and what variables were tested to come to the conclusions that they have drawn.
             c. Fuchs et al explored the use of low-dose diuretics to optimize prehypertensive values as a means of lowering blood pressure.
             d. Banck et al discussed racial disparities among young adulthood modifiable risk factors in the incidence of type 2 diabetes during middle adulthood as a modifiable risk factor.
  4. Session 10 – I have learned about 3 of the omics and the more I learn the more that seem to be identified. The Omics section, I will imagine, will cover the well-known, proteomics, genomics and metabolomics; however, some that are exciting, due to them being novel to me, are the Trans-Omics and Phenomics.
  5. Session 11 – The William B. Kannel MD Memorial Lectureship in Preventative Cardiology
  6. Session 12 – The debate will cover some of the Pros and Cons of medical cost. The main argument when it comes to cardiovascular care is the rising cost of medical treatment. This session will cover some of the cost associated with cardiovascular disease treatment, and I hope, some ways that they can be overcome by prevention.
  7. It is my desire, during this AHA EPI | Lifestyles conference to disseminate information that will assist in empowering clinicians, researchers, and the general population of methods that can be taken to promote health and a healthy lifestyle. Hope to see you there in person or online to share thoughts on the lessons learned during this conference.

Anberitha Matthews, PhD is a Postdoctoral Fellow at the University of Tennessee Health Science Center in Memphis TN. She is living a dream by researching vascular injury as it pertains to oxidative stress, volunteers with the Mississippi State University Alumni Association, serves as Chapter President and does consulting work with regard to scientific editing.

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Cardiology Beyond Single Imaging Modality

Cardiovascular (CV) imaging plays a crucial role in declining mortality and optimal disease management. Knowledge of various imaging modality is vital for understanding and management of patients of various CV diseases. Since the first A-mode echocardiogram, there have been great revolutional changes. However, the imaging principal is exactly the same. Echocardiogram and nuclear modality were the only clinically available imaging for management in patients with different CV diseases. The introduction of cardiac magnetic resonance (CMR), computer tomography (CT), three-dimensional (3D) printing, and strain echocardiography makes things quite different. Multi-modality imaging (MMI) plays a role in all CV diseases that includes ventricular function, coronary artery disease, valvular disease, congenital heart disease, intervention guidance, and vascular diseases.

In less than fifteen years, as a non-invasive imaging option, CMR has grown from a being a mere curiosity to becoming a widely used clinical tool for evaluating CV disease. CMR is now routinely used to study myocardial structure, cardiac function, macro vascular blood flow, myocardial perfusion, and myocardial viability. CMR provides a number of key tools to the clinician to evaluate cardiovascular pathologies. Among available imaging modalities to assess global and regional ventricular function, cine CMR based measurements are considered the ‘gold standard.’ While more involved than echocardiogram, CMR based phase contrast methods are robust in the evaluation of regurgitant volume and valvular function.

CT scan have been able to segment the heart better than Echocardiogram. Computers can combine these pictures to create a 3D model of the whole heart. This imaging test can help doctors detect or evaluate coronary heart disease, calcium buildup in the coronary arteries, problems with the aorta, problems with heart function and valves, and pericardial disease. This test may be also used to monitor the results of coronary artery bypass grafting or to follow up on abnormal findings from earlier chest x-rays. Different CT scanners are used for different purposes. A multidetector CT is a very fast type of CT scanner that can produce high-quality pictures of the beating heart and can detect calcium or blockages in the coronary arteries. An electron beam CT scanner can also show calcium in coronary arteries.

3D printing is a fabrication technique used to transform digital objects into physical models. Also known as additive manufacturing, the technique builds structures of arbitrary geometry by depositing material in successive layers based on a specific digital design. Several different methods exist to accomplish this type of fabrication and many have recently been used to create specific cardiac structural pathologies. While the use of 3D printing technology in cardiovascular medicine is still a relatively new development, advancement within this discipline is occurring at such a rapid rate that a contemporary review is warranted.

With rapid advances in imaging technology, current fellows in training and future consultants will frequently be required to use MMI in patient care. CV imaging is fundamentally about the information in the image, not how it is acquired. MMI has been the area of discussions for more than a decade, and the 2015 Core Cardiology Training Symposium guidelines published in May 2015 have further reinforced its importance. Nearly everyone agrees that MMI training is imperative, and most fellows in cardiology programs who are interested in careers in noninvasive imaging have expressed strong interest in acquiring such expertise and eagerly ask about its formal inception. However, despite all of the interest and goodwill, the practical implementation of MMI training has been slow.

Cardiac MMI is a highly dynamic field of continuing research driven by the constant technological advances and innovation of noninvasive imaging and the increasing clinical interest. Its impact extends beyond its clinical utility onto the organization of diagnostic healthcare structures. Furthermore, there is a belief that too much imaging is being done at significant cost and without strong evidence that this amount of imaging is needed or indeed improves outcomes. As part of U.S. healthcare reform efforts, physicians will be required to document that they are following appropriate use criteria (AUC) for outpatient medical imaging orders by using clinical decision support software documentation. The software must be certified by the Centers for Medicare and Medicaid Services in order to receive full reimbursement for diagnostic imaging services for Medicare and Medicaid patients. This will affect advanced outpatient imaging for CT, MRI and nuclear imaging. These new AUC are intended to provide guidance for clinicians when choosing among available testing modalities for various cardiac diseases.

In the assessment of CV disease, multiple imaging modalities may contribute toward determining the diagnosis, prognosis, and approach to treatment. However, each imaging modality may provide relevant information regarding more than one of these clinical needs. Therefore, to explore fully the potential impact of imaging, the strategy should be individualised according to the specific clinical needs and AUC.

Fawaz Alenezi Headshot
Dr. Fawaz Abdulaziz M Alenezi is a Clinical Imaging Fellow at the Duke University Health Systems. He conducts medical research on the derivation and validation of novel echocardiographic approaches to myocardial deformation and a new echocardiographic technique which assists patients with heart ventricular function.

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Early Career Blog

Being at the American Heart Association makes me realize (again) that I have one of the greatest jobs in the world. There are so many inspiring people and talks and I am happy that I can share some of my experience in the Early Career blogging program.

Leonie in front of heart and torch at Scientific Sessions

The first day of the American Heart was all about the early career scientists. Speakers gave great advice on how to find a mentor, the transition to how to succeed in grants, the transition to faculty, how to respond to a rejection letter and how to get your name out there. Tips that were given you can read on the blogs by Bailey DeBarmore and Fawaz Abdulaziz M Alenezi. The second day of the American Heart were for me the day of awards. In this blog, I would like to acknowledge researchers who achieved awards for mentoring, research achievements or are finalists.
 
Cardiovascular Stroke and Nursing Counsel (CVSN) Kathleen Dracup award
 
This award highlights the importance of early-career mentoring in cardiovascular and stroke nursing to the CVSN. This year the award was given to Dr. Susan J. Pressler. I would like to congratulate her and thank her for being an example with her gifts and generosity in mentoring Early Career scientists.

Dracup Distinguished Lecture Program

Kathleen A. Lembright Award
 
This award recognizes and encourages excellence in cardiovascular research by established nurse scientists. This year winner is Dr. Shirley Moore. She gave a great talk about the responsibility of researchers to report on null trials.

Dr. Shirley Moore speaking at the Lembright Award

null trials slide

Martha N. Hill New investigator Award
 
This award recognizes the outstanding contributions of investigators in understanding, preventing, and treating cardiovascular diseases.

I would like to congratulate the finalists this year: Dr. Margo B Minissian and Dr. Billy Canceres.

Dr. Margo B Minissian conducted research in the association of spontaneous preterm delivery and postpartum vascular function.

Dr. Billy Canceres conducts research in high cardiovascular disease risk in sexual minority women.

Three people at Scientific Sessions
Congratulations to your all!

Leonie Klompstra Headshot

Leonie Klompstra is a Nurse Scientist at the Linköping University in Sweden. Her primary focus is on heart failure and rehabilitations.