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Wellness Amid a Pandemic

I think about wellness often and the unique aspects of being a physician that make preserving our wellbeing even more important. Of course, this COVID-19 pandemic has tested all of us and the things we turn to for wellness and our escape from medicine, may not be available to us right now. After work dinner and drinks, early morning group fitness classes, and young professional networking events have been replaced by Netlfix© and dine-in, home workouts, and Zoom “wine” downs. We all had to dig down deep inside to find new venues for wellness and if we were lucky, our institutions provided resources to help us during this crazy time. What this pandemic taught me was that there are things I still needed to work on to build my resilience even further- and I am totally okay with that. Working on ourselves to better ourselves should be a continuous goal- everyone has room for improvement.

As a single woman living in the city, my nights and weekends were always filled with social events. I felt very isolated and realized how much of my free time was being occupied by my friends and the events I attended as part of my wellness routines. I miss my morning classes at bootcamp and will never complain again when my alarm wakes me up at 4:25am to get to class- whenever that may be. Some of the things that have helped me are FaceTime and Houseparty dates with friends and family, walking outside on the few sunny days Boston has graced us with, trying to eat healthy when I can, in-home workouts which I am not a fan of to be completely honest, but most important, was being vulnerable with friends, family, colleagues, and even patients who asked how I was doing during our virtual visits. I met with a Wellness Coach provided through my institution and the lightbulb moment for me was when he reminded me to be kind to myself. I remember seeing posts all over social media about how we should be building businesses, getting in shape, writing grants, or checking off any other number of “goals” because we have “so much time” and feeling bad, but I got over that. In the middle of this crisis, all our lives have been disrupted, some much more so than others, and we are all doing the absolute best we can. I remind myself to be grateful and I started writing specific things down that I am grateful for each day.

May is Mental Health Awareness Month and as physicians, we shy away from talking about such things. It may be that we are supposed to be superheroes who are invincible, or it may be that if we did seek help and received a diagnosis we would have to declare it on some medical state licensing applications, or we may just be afraid. Mental health is one of the many aspects of overall wellbeing and there are many ways to reach out for help for those who need it. COVID-19 has had many casualties and we must guard our mental health during this pandemic. Find what works for you and do it. Reach out when you need to and remember that it is totally okay to not be okay. Protect your mind, body, and soul as these are key aspects of our overall wellbeing. I feel optimistic about our future. When we come out on the other side of this let us take all the lessons we learned and remember to never take things such as human contact for granted again.

Stay safe and stay healthy.

“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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Conferences in the Time of COVID

As with pretty much everything else, conference season is going to look a lot different from last year due to COVID-19. Conferences have already switched gears to go completely virtual to meet this challenge but still give scientists the opportunity to share their work with the world. Initially, I was a little bummed about the need to switch meetings to a virtual format — but I then realized that there are also some really great advantages to this situation.

As a new mother, I had already resigned myself that I wouldn’t really be able to participate much in conferences this year, but now that has completely changed. I’m actually going to attend three meetings, including the AHA BCVS conference in July, which I am really excited about. While it would be great to see everyone in person and I know that it won’t completely be the same without the social interactions many of us look forward to, the virtual format provides science opportunities to many that otherwise would have missed out. It’s important in this strange time to celebrate the positives. To get more insight on how to make the best of a virtual meeting, check out fellow blogger Shayan Mohammadmoradi’s latest piece — it’s filled with great tips!

In addition to conferences going virtual, seminars at universities and professional organizations have done the same thing. Once it was apparent that COVID-19 was changing the face of the world, The International Society for Heart Research quickly organized a virtual seminar series that has been keeping researchers from all over the world updated on the latest science. Check out the schedule here to attend any meeting you want via zoom from your home!

If you are planning a meeting, going completely virtual may seem like a daunting task, but since so many have started to work out the kinks to the online format, it’s becoming easier to find resources to help you make the event a success. Additionally, before COVID-19 took hold, many scientists were already pushing the community to move to a virtual system to combat climate change, so this switch may have been inevitable. Online meetings can be just as enriching as the in-person events that we are used to — we just have to keep an open mind.

“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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Fifth Year at Vascular Discovery: How an Early Career Navigates Through a Virtual Event

It is not news anymore that after World Health Organization (WHO) classified novel coronavirus disease (COVID-19) as a pandemic, the real-life impact of the “new normal” started to show itself. We started to see the impact by pausing the research and of course, cancelation of all scientific events. As scientists shifted their focus toward the data analysis, manuscript preparation, grants or any other means of remote work, the American Heart Association also shifted its focus to keep events happening, virtually. This new mode of attending a conference has many perks including petting your dog when the field’s connoisseur is giving a talk, drinking coffee from your favorite mug, or keeping the PJs on. However, there is a trade-off. Navigating through a professional event such as #VascularDisovery20 is challenging by itself, let alone going after it when you are not physically present. The following tips will help you to turn this year into a great opportunity.

1: Networking with Peers and Mentors: Online Presence

Now that there is no opportunity to join a table for lunch, mingle during the dinner event or grab a coffee with your colleagues from other countries, increase your online presence by interacting with attendees on Twitter. Use the chat mode during virtual sessions to ask questions or chat with others. If you have a burning question about a talk, either tweet at the presenter or email them. This is a great practice for increasing your “professional” online activity.

2: Utilize the Home Stay

Now that you have a desk in front of you instead of sitting on conference room chairs (which are really uncomfortable from time to time), take notes with ease, have your screen open with relevant papers to the talk, take high-quality images from the slides you find important and download the available contents in advance from the #HeartHub. In addition, you can now have a comprehensive look at your favorite posters and get connected with the presenters.

3: Plan Ahead

Although you may think that you can easily jump to the laptop and login to the talk that is “live”, the reality may be different. There are still concurrent sessions that you need to choose which one you attend. Also, there is always a possibility of a technical problem, so make sure that everything is set and you know exactly which talk you are going after. Also, pay attention to the time-zone listed in the schedule.

4: Hangouts at Conference Evenings: Say Hello to Face Time or Zoom

It is an unwritten tradition that many attendees get together after a long day of scientific endeavors to sit down, chit chat and grab a drink. Use the ATVB Journal virtual happy hour with EIC Dr. Alan Daugherty as an example. If you would like to hang out with the “conference buddies”, reach out to them, set up a private virtual meeting and catch up. This is a great practice to break those shyness barriers, especially if you are at the early career stage.

It is obvious that nothing compares to be physically present among your peers, colleagues and mentors. However, during these uncertain times, we can still manage to make the most out of the opportunities we are offered. As scientists, we are always learning to overcome new challenges and come up with new solutions, therefore, navigating through a virtual event not only is a fun challenge but also is a great learning experience with many opportunities.

“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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In defense of peer review

The generation of knowledge, through rigorous, established systematic methods has informed much of our progress in the past few centuries. Science guides all aspects of healthcare today including how we develop the new medications, therapeutic procedures, and non-pharmacological interventions that have improved the quality and duration of human life. Many of the crucial gates in the scientific journey- funding, ethical approval, and dissemination- are guarded by the process of peer review; a process that is increasing under attack in our current hyper-reactive, digital, media cycle.

Peer review is the critical appraisal of a scientific work by those who have requisite knowledge to evaluate one or more aspects of the work. It is a panel of experts in the related field who understand the importance and novelty of the questions under consideration and the rigor and trustworthiness of the methods proposed or employed to answer that question.

Peer review takes time. Time to find agreeable reviewers with the right expertise, time to review and think about the science, and time to determine how to weigh those critiques against the community’s need for information. From the early days of the novel coronavirus pandemic, this balance of time needed for peer review and unquenchable public thirst for rigorous information has been dominating the conversations at leading medical and scientific journals around the world. To better understand how these decisions are made and what we as clinicians, scientists, and health care consumers need to consider when reading and sharing emerging science, I spoke with Dr. Joseph Hill, the Editor in Chief of Circulation one of 12 AHA Journals.

Even though peer review is an established practice, it is important to start by questioning why we should even do it. Unquestionably, the value of thoughtful peer review is that it enhances the quality of the science. “We [the AHA journals)\] handle approximately 20,000 manuscripts a year and with extraordinarily rare exceptions, the paper always gets better with peer review”.

Having now published many of my own scientific manuscripts, I know the pain of peer review well. “They” missed that detail on line 176. “They” clearly lack the expertise to evaluate my work. “They” kept this manuscript for 8 months before sending their disposition! However, I also know that some of the best revisions to my papers have come from generous peer reviewers. Reviewers who volunteered to spend their time reading my papers and think deeply about my findings in the context of larger literature. While painful, the constant assessment and evaluation of our science is critical to improving the quality and impact of our work.

Prior to the coronavirus outbreak, up to 10 experts, including peer reviewers, statisticians, and editors, would review a manuscript for Circulation. But the need for up-to-date information about the epidemiology, pathophysiology, and treatment of COVID-19 challenged Circulation’s editorial team to move fast. While recognizing that it’s “hard to do good science in a war zone”, the quality of published science cannot be compromised in times of crisis. Dr. Hill continues, “We are walking a fine line between trying to get the information out as quickly as possible but we recognize that [in clinical science] we could make it worse and could do harm. So we have to maintain our high standards but function at a high velocity.”

High velocity seems an understatement. After an initial call for high-quality COVID-19 related papers, the editorial team has done over 300 fast track reviews, contributed to a curated coronavirus and cardiovascular disease collection, and conducted 17 interviews with experts working on the front line around the world. All in the past month. This work is exhausting but done with great energy by a team inspired to advance “cardiovascular science for the good of humanity, especially during these times of urgent challenge, anxiety, and forthright resolve.”

Peer review is the best process we have for evaluating science; but peer review is done by peers- busy, human, distractible peers- who will make mistakes. This is why many reputable journals require an editorial screen and at least two peer reviews before it can make a decision on a manuscript. Scientific volunteers do this work. Which brings us to what you, as an early career professional can do. Peer review relies on us—all of us—to sign up to review, accept the invitation to review, and spend the time carefully doing the review. You may wonder if you have the expertise to peer review for Circulation or another AHA Journal; you likely do and you should. Dr. Hill remarked that “some of the best reviews I’ve seen are from early-career scientists”.  If you are interested in helping to contribute to peer review and the sharing of good cardiovascular science, considering signing up to be a journal reviewer in your AHA Science Volunteer Form or emailing Dr. Hill your interest in reviewing for Circulation.

 

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

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The Health Costs of Hunger

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References:

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

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

 

 

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To Stent or not to Stent?

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

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

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

A few big wins for the ISCHEMIA trial:

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

 

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

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

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

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

 

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

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

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

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

 

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

 

References:

https://www.ischemiatrial.org/

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

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

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

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Can artificial intelligence save our lives?

The role of artificial intelligence (AI) in our life is advancing rapidly and is making strides in the early detection of diseases. The consumer market is composed of wearable health devices that enables continuous ambulatory monitoring of vital signs during daily life (at rest or physical activity), or in a clinical environment with the advantage of minimizing interference with normal human activities1. These devices can record a wide spectrum of vital signs, including: heart rate and rhythm, blood pressure, respiratory rate, blood oxygen saturation, blood glucose, skin perspiration, body temperature, in addition to motion evaluation. However, there is a lot of controversies whether these health devices are reliable and secure tools for early detection of arrhythmia in the general population2.

Atrial fibrillation (afib) is the most common arrhythmia currently affecting over 5 million individuals in the US and it’s expected to reach almost 15 million people by 2050. Afib is associated with an increased risk of stroke, heart failure, mortality, and represents a growing economic burden3. Afib represents a diagnostic challenge, it is often asymptomatic and is often diagnosed when a stroke occurs. Afib represents also a long term challenge and often involves hospitalization for cardioversion, cardiac ablation, trans-esophageal echo, anti-arrhythmic treatment, and permanent pacemaker placement. However, if afib is detected, the risk of stroke can be reduced by 75% with proper medical management and treatment3.

Physicians need fast and accurate technologies to detect cardiac events and assess the efficacy of treatment. A reliable, convenient and cost-effective tool for non-invasive afib detection is desirable. Several studies assessed the efficacy and feasibility of wearable technologies in detecting arrhythmias. The Cleveland Clinic conducted a clinical research where 50 healthy volunteers were enrolled. They tested 5 different wearable heart rate monitors including: (Apple Watch, Garmin Forerunner, TomTom Spark Cardio, and a chest monitor) across different types and intensities of exercises (treadmill, stationary bike and elliptical). The study found that the chest strap monitor was the most accurate in tracking the heart rate across different types and intensities of exercises4.

Apple and Stanford’s Apple Heart Study enrolled more than 419,297 Apple Watch and iPhone owners. Among these users, 2,161 (roughly 0.5%) received a notification of an irregular pulse. Of those who received the notifications, only about 450 participants scheduled a telemedicine consultation and returned a BioTelemetry ECG monitoring patch. When the Apple Watch notification and ECG patch were compared simultaneously, researchers found 71% positive predictive value, and about 84% of the cases were experiencing Afib at the time of the alert. Additionally, 34% of participants whose initial notification prompted an ECG patch delivery were later diagnosed with Afib. This finding shows that Apple watch detected afib in about one-third of the cases which is “good” for a screening tool considering the “intermittent nature of afib and that it may not occur for a whole week” says Dr. Christopher Granger, a professor of medicine at Duke University who participated on the steering committee for the Apple Heart study5.

These studies are observational studies and are not outcome-driven. They are not randomized and are not placebo-controlled. There are potentials for false negatives, where the Apple watch fails to detect the afib and false-positive where it detects arrhythmia that does not exist. Unfortunately, patients who are false negative don’t consult the physician about their symptoms of palpitations and shortness of breath since it provides false security. While patients with false-positive are sent unnecessarily to the clinic that could lead to further unnecessary tests and anxiety for the patient.

Is the Apple Watch ready to be used as a default screening tool to monitor the heart rate and rhythm in the general population and by physicians with patients with or at high risk for Afib is still unclear and warrant further studies. In conclusion, physicians should be cautious when using data from consumer devices to treat and diagnose patients.

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

References:

  1. Cheung, Christopher C., Krahn, Andrew D., Andrade, Jason G. The Emerging Role of Wearable Technologies in Detection of Arrhythmia. Canadian Journal of Cardiology. 2018;34(8):1083-1087. doi:10.1016/j.cjca.2018.05.003
  2. Dias D, Paulo Silva Cunha J. Wearable Health Devices-Vital Sign Monitoring, Systems and Technologies. Sensors (Basel). 2018;18(8):2414. Published 2018 Jul 25. doi:10.3390/s18082414
  3. Chugh, S., Sumeet, Havmoeller, J., Rasmus, Narayanan, F., Kumar, et al. Worldwide Epidemiology of Atrial Fibrillation: A Global Burden of Disease 2010 Study. Circulation. 2014;129(8):837-847. doi:10.1161/CIRCULATIONAHA.113.005119
  4. Wrist-Worn Heart Rate Monitors Less Accurate Than Standard Chest Strap. Medical Design Technology. http://search.proquest.com/docview/1875621494/. Published March 9, 2017.
  5. Turakhia, Mintu P., Desai, Manisha, Hedlin, Haley, et al. Rationale and design of a large-scale, app-based study to identify cardiac arrhythmias using a smartwatch: The Apple Heart Study. American Heart Journal. 2019;207:66-75. doi:10.1016/j.ahj.2018.09.002

 

 

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What Does Tobacco 21 Mean for Adolescent Tobacco Use?

We’ve come a long way from the Joe Camel commercials I remember watching as a kid on TV. As a culture, we’ve become a lot less tobacco friendly. Indoor smoking bans, stricter advertising restrictions (meaning no more cartoon characters advertising cigarettes), and other policies have been enacted to curb tobacco use across the country. Despite these changes, teen smoking is still a big problem.

In 2015, the Institute of Medicine reported that raising the legal age for using tobacco products from 18 years to 21 years would significantly decrease, delay, or differ adolescent tobacco use [1]. Just last month Congress decided to test this prediction by passing House Resolution 1865 – Further Consolidated Appropriations Act, 2020 which was subsequently signed into law by President Trump. This spending package includes an amendment to the Federal Food, Drug, and Cosmetic Act, raising the minimum age for purchase of tobacco products to 21 years [2]. This certainly signals a bipartisan effort to curb adolescent tobacco use, but only time will tell the lasting impact of this and other new policies.

Despite laws existing to restrict tobacco sales to adults, there is limited evidence of interventions able to achieve high levels of adherence with these laws [3]. In fact, a majority of smokers endorse first using tobacco products before being of age. While the is ample evidence that exposure to tobacco advertising is related to youth picking up smoking, there are no randomized clinical trials (RCTs) that assess the effectiveness of different advertising restrictions or bans on adolescent tobacco use [4]. What percentage of potential under-age smokers are deterred by age restrictions? What effect would increasing the tobacco tax have on youth sales? What effect could flavor restrictions have on youth smoking? One approach to better understand the health effects of possible tobacco legislation could be to incorporate RCTs into this new law’s implementation.

Last year the Nobel Memorial Prize in Economics was awarded to three researcher who used RCTs to better understand the effects of economic policies on people’s lives [5]. This approach to policy interventions has allowed developmental economists inform legislation aimed at alleviating poverty and its negative externalities. Using these same standards to assess the efficacy of policies aimed at preventing youth tobacco use could have a lasting impact on the health of our nation.

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

References:

  1. Committee on the Public Health Implications of Raising the Minimum Age for Purchasing Tobacco Products; Board on Population Health and Public Health Practice; Institute of Medicine; Bonnie RJ, Stratton K, Kwan LY, editors. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington (DC): National Academies Press (US); 2015 Jul. https://www.ncbi.nlm.nih.gov/pubmed/26269869
  2. R.1865 – Further Consolidated Appropriations Act, 2020 (Subtitle E, Section 603: Minimum age of sale of tobacco products) https://www.congress.gov/bill/116th-congress/house-bill/1865/text#toc-H1CB3CAE840AA412285E15A86531C8446
  3. Stead LF, Lancaster T. Interventions for preventing tobacco sales to minors. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD001497. DOI: 10.1002/14651858.CD001497.pub2. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001497.pub2/information
  4. Lovato C, Watts A, Stead LF. Impact of tobacco advertising and promotion on increasing adolescent smoking behaviours. Cochrane Database of Systematic Reviews 2011, Issue 10. Art. No.: CD003439. DOI: 10.1002/14651858.CD003439.pub2. (Page 1, 12) https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003439.pub2/abstract
  5. The Prize in Economic Sciences 2019. https://www.nobelprize.org/prizes/economic-sciences/2019/press-release/
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Building an academic portfolio during medical training: Part 1 – research outside the box

As a medical trainee in the US, whether you are pursuing an academic career or applying for a fellowship or advanced fellowship, your academic profile is one of the most important currencies you rely on for this endeavor. Academia as a general term refers to 2 main areas: research and education. Many trainees, like myself, start their residency with no or very minimal research experience. It then becomes essential to create a reasonable research portfolio during medical training, which is often not an easy task, especially in clinically demanding specialties. In this series of blogs, I will try to share some ideas and tips that can help you build a competitive research résumé during residency and fellowship. These ideas also apply to medical students, inside or outside the US, who are trying to match their dream US residency program.

The first idea that I would like to talk about is one that I thought was particularly a game changer for me when it comes to research. I like to call this one “research outside the box”, and by the box here, in addition to the abstract meaning of doing things in unorthodox ways, I’m also referring to the literal box that is the walls of your training institution. Residents and fellows are rarely involved in multicenter clinical trials or prospective studies. In fact, the vast majority of research done during medical training is retrospective observational studies. One of the main reasons trainees rely on retrospective studies is the time factor. Prospective studies often take longer to execute, and it becomes difficult to get a tangible product, a conference abstract, or a published manuscript on time for your next fellowship or job application. Therefore, retrospective studies become the more realistic option, and traditionally, these are carried out using institutional databases (i.e. clinical data from patients treated at your own training hospital), which is and will remain one of the most valuable research resources. Then comes the fundamental question – why should I consider doing research in a non-traditional way, or “outside the box”? – For many reasons:

  • Many training hospitals do not have large clinical databases that can produce impactful research projects.
  • You may not find a good research mentor in your training institution.
  • Even with available databases and good research mentors, some retrospective studies may still take long to come to fruition, sometimes longer than you can afford without a back-up plan.
  • Diversifying the ways you do research by pursuing both traditional and non-traditional means, can lead to a marked increase in productivity.
  • Most importantly, collaborating with motivated medical students, residents, and fellows around the country (and sometimes even around the globe), not only enhances your research output but is in itself a great learning and networking opportunity.

The next logical question would be – as a student or a trainee, what type of research can I do outside my institution?

For the same practical reasons that I previously mentioned, I am still referring to retrospective observational research rather than multicenter trials or prospective studies. In that case, to be able to easily collaborate with researchers across different institutions the data has to be publicly available and not protected by privacy laws. There are different types of publicly available data, some are mostly free, such as already published literature, some can be purchased for a fee, such as national and state administrative databases, and others require a research proposal that goes through a grant-like process, such as societal databases. The latter typically requires a higher degree of research expertise and are restricted by application cycles, so I would not recommend them as the first go-to option if you are still taking your very first steps in medical research. Here are some examples of observational research work that can be done collaboratively using these publicly available data sources, without being limited by institutional boundaries:

  • Published medical literature can be used for meta-analyses and systematic reviews. These types of studies commonly address hot topics in medicine or topics with controversy or equipoise. A common scenario where topics are considered “hot” is immediately after the publication of a large clinical trial, particularly if the results are not in line with prior trials on the topic. Meta-analyses are also ideal for examining uncommon side effects or complications of medications or medical procedures.
  • National administrative databases can be used to perform retrospective observational studies, e.g. the National Inpatient Sample (NIS) and the Nationwide Readmissions Database (NRD), which are commonly used in cardiovascular research. They are particularly helpful in researching rare conditions or special populations where getting a large sample size using single-center data is challenging, or to examine trends in diseases or therapies over time. Most of these databases are available for purchase per calendar year (e.g. 2010, 2011, 2012 etc.), meaning that you can buy one or more year worth of data, depending on your budget and your research question.
  • Societal databases can also be used for original outcomes and quality improvement research, e.g. the American Heart Association (AHA) Get With The Guidelines and the American College of Cardiology (ACC) National Cardiovascular Data Registry (NCDR) Although these do not cost money, yet, they mostly require more work including submission of a proposal during an annual or bi-annual application cycle, which is a very competitive process.

These are just examples of what can be done and some common resources that can be used to start with, but in reality, the possibilities and the available resources are endless. Now that we talked about “why” and “what”, the next question is “how” – how to reach potential collaborators? how to build a successful multi-institutional team of young researchers? And what are the challenges to this approach? This will be the topic of my next monthly AHA Early Career Voice blog. So stay tuned..

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.