Early Career Blogger – Page 3 – The Early Career Voice

Have You Picked Your Mentor’s Brain Lately?

January 6, 2020January 8, 2020 Barinder Hansra, MD

It’s funny how people meet – some are coordinated efforts at work or meetings while others are random. I met one of my mentors – Dr. Jane Freedman – in the outpatient echo lab. We had never met prior to my fellowship but I recognized her name from the echo reports of my patients. After introducing myself to Jane, I fired all sorts of questions her way – mostly about restaurants in Boston we both enjoy, things we do in our free time, how to get involved in the AHA, and how best to read echocardiograms. This sparked not only a great friendship but an even better mentorship.

Jane has become my work-life-balance mentor, advising me on how to be an effective chief fellow, developing my own leadership style, types of jobs to pursue, and balancing personal life with the intense time commitment of medicine. I soon realized in order for me to be a good mentee, I had to support my mentor when I could. This included, attending her talk at the AHA not out of a feeling of obligation but out of a genuine desire to support my mentor. Over time, our mentor-mentee relationship has taken on more academic facets – largely, honing in the on the type of job I would want in the future. Jane has pushed me to clarify the type of job I want to pursue and more importantly, what are the reasons for wanting it.

mentor Over the course of my training, I realized that not all of my colleagues have mentors to turn to for these critical career conversations. It made wonder how mentors can help fellows in training, and more importantly, what are the key elements to a successful mentor-mentee relationship. To understand what made our mentor-mentee relationship successful, I asked Jane at a recent dinner at one of the many great restaurants we wanted to try.

In her experience, a successful mentor-mentee relationship comes down to be receptive as a mentor and mentee. You have to have the self-awareness of the relationship to provide support for those seeking it. In addition, the relationship has to be symbiotic. The mentor has to give advice to the mentee based on the level he or she is at. For example, the chair of cardiology may not be a good mentor to a first-year fellow if he or she is not able to give the appropriate support needed for the fellow at that specific stage of training. Conversely, the mentee needs to work hard towards the goals and expectations he or she has set for this to be a successful relationship. This made me think: how do we go about even choosing the ‘right’ mentor??

Jane highlighted that everyone needs more than one mentor. For example, an academic mentor to help me pursue research opportunities, a clinical mentor who helps cultivate knowledge in my area of interest, and even a work-life mentor that I can turn to when this demanding job seems undoable. Every mentor offers something unique to the relationship and more importantly, not one mentor will be able to give you everything you need. Jane stressed that she never stopped at one mentor but sought those that will help her become successful in all aspects of her life and career.

Jane explained that while she was training she reflected on what would improve her work-life balance. There were only so many things she could accomplish in a day and had to recognize where she needed help. For example, with the various apps to help improve efficacy, I could order groceries to be delivered to our home. The time saved at the grocery story can be spent with my significant other or at the gym. Something Jane stressed – which I took to heart – was to never feel guilty for not being able to do it all. People who go into health care are incredibly driven but we all have our limits. It’s important to recognize these limits to prevent burnout, enjoy our work, and continue to work on achieving a balanced life.

A piece of advice Jane gave me is to make sure I pick a career path that will make me happy, not the one I think I should take. With the extensive amount of board certifications in cardiology, fellows feel pressured to take them even if they do not want to. Again, this comes back to a point Jane highlighted earlier – we need self-awareness to be successful.

As dinner started to wind down, I was able to reflect on how I was performing as a mentee and what steps I can take in the future to make our relationship more successful. Checking in with my mentors always brings about new found motivation and energy to continue to strive for success.

What do Immunology and Impostor Syndrome Have In Common?

January 3, 2020January 3, 2020 Nosheen Reza, MD

As an Advanced Heart Failure and Transplant Cardiology Fellow this year, transplantation immunology is an important part of my curriculum. While I try to stay up-to-date on the latest advances in care in heart failure, cardiogenic shock, and mechanical circulatory support, I recently took a deeper dive into the fascinating history of organ transplantation and immunology – which brought me to Sir Peter B. Medawar, widely regarded as the “father of transplantation”.

Sir Peter Brian Medawar: https://www.thefamouspeople.com/profiles/peter-medawar-7366.php

Medawar was a Brazilian-born British zoologist who received (with Sir Frank Macfarlane Burnet) the Nobel Prize for Physiology or Medicine in 1960 for developing and proving the theory of acquired immunological tolerance. His early training and studies in England were focused in zoology and comparative anatomy, and his initial research was on connective tissue cells and tissue culture.

He became interested in skin grafting during World War II after witnessing military pilots sustaining severe burns in plane crashes and moved to Glasgow to continue this work for the Medical Research Council. Over the 1940s-early 1950s, he performed and published a series of experiments on the behaviors of skin autografts and allografts in burn victims. He demonstrated that skin allografts (i.e. homografts), although initially successful, were rejected within two weeks. In his experiments, when a second allograft from the same donor was attempted, the allograft was rejected much more quickly. Thus, he established the idea that allograft reactions were immunological. In the conclusion of their paper The Fate of Skin Homografts in Man, Gibson and Medwar state that “The time relations of the process, the absence of a local cellular reaction, and the accelerated regression of the second set of homografts suggest that the destruction of the foreign epidermis was brought about by a mechanism of active immunization.”

He furthered the ideas of genetically determined immunologic systems and immunologic tolerance through additional studies in different model organisms, including cattle and mice. In 1951, he tested the effects of cortisone on survival of skin homografts in rabbits and found that the daily subcutaneous administration of 10 mg cortisone acetate to adult rabbits delayed graft healing and vascularization and lengthened the life of skin homografts by 3x-4x!

Figure 3 from Billingham RE, Krohn PL, Medawar PB. Effect of Cortisone or Survival of Skin Homografts in Rabbits. Br Med J. 1951. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2068993/pdf/brmedj03547-0003.pdf

As excited as I was to read about this fascinating history of immunology and transplantation, I was even more interested to find that Medawar was a supporter of women in science (#HeForShe). In 1979, he published a book called Advice to a Young Scientist, a book he says is “the kind of book I myself should have liked to have read when I began research…” In the eight short pages of his book’s fifth chapter entitled “Sexism and Racism in Science”, he addresses the concepts of impostor syndrome, gender equality in academic medicine, and the frequent invisibility of women in science – all concepts still at the forefront of our current dialogue 40 years later.

Excerpt from Advice to a Young Scientist by Peter B. Medawar

The history of medicine is full of fascinating personalities and stories like this one, and to quote Medawar himself, “I do not know any scientist of any age who does not exult in the opportunity continuously to learn.”

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.

Support Your Colleagues in 2020: The Year of the Nurse

January 2, 2020January 2, 2020 Elizabeth Knight, PhD, DNP

The World Health Organization (WHO) has designated 2020 The International Year of the Nurse and Midwife (coinciding with and honoring the 200th anniversary of Florence Nightingale’s birth.) “International Year of the Nurse and Midwife”

The WHO stresses that “strengthening nursing and midwifery – and ensuring that nurses and midwives are enabled to work to their full potential – is one of the most important things we can do to achieve universal health coverage and improve health globally.” If you work in health care in a clinical, community, education, or research setting, you almost certainly work with nurses. In the U.S. alone, there are over 3 million registered nurses (via Bureau of Labor Statistics).

Do you know what roles nurses serve in in your community, and what their scopes of practice are? In many areas, nurses are not permitted to practice to the full scope of their education and training (which may include bachelors, masters, and/or doctoral degrees) due to both legal and institutional restrictions. This means we’re leaving much needed, highly skilled work on the table. Why, and how can we fix this?

The December 2019 issue of the Lancet includes an editorial about the value and potential of nursing. The authors note that “…for all its importance, nursing remains underappreciated. Perhaps the biggest barrier that continues to stifle the profession concerns gender and stereotypes. Most nurses are women, and nursing is still viewed by many as women’s work and as a soft science, rather than as the highly skilled profession it really is.” Though most readers likely feel they do not value women less than men, the institutions we work within demonstrably do. What are the gender and educational preparation of the president of the university, the CEO of the health system, the PI of the big grant? How many full professors in your department are women? What salaries do nurses make, what salaries do women make, and how do they stack up against others in an organization? If your organization is typical, you might be surprised at the disparities. AHA pledged to have no all-male panels (#nomanels!) at Scientific Sessions this past November— is that true of other events you’ve attended?

Understandably, some nurses have met the WHO’s announcement with skepticism. We’ve heard calls for recognizing and honoring nurses before, without much substantive change following. Can this time be different? I believe we can work to address the undervaluing of nursing as a profession and women as professionals, which is hindering improvement in global health. Institutions can support nursing— and I don’t mean with a pizza party during nurses’ week (although I do love pizza, so please don’t stop doing this). I mean with safe staffing, respect, leadership roles and adequate compensation. With decision-making power. With professional autonomy. This is easier said than done.

Providing this support means developing a better understanding of the breadth and depth of nursing expertise. As early career professionals, we are poised to set priorities for the coming decades of healthcare, research, and education. When it comes supporting nurses and nursing, ask yourself if you are truly walking the walk, and look for ways to do more.

Here are some ways to increase your awareness of the actual and potential impact of nursing:

Read the Journal of Cardiovascular Nursing or other nursing research journals. Learn what kinds of research nurses are doing and how it might impact your work.
Invite nurses to present at grand rounds. Their clinical expertise is often vast.
Invite nurses to be part of your research team— not only as staff to do your data collection, but as co-investigators. Doctorally-prepared nurses work as researchers, teachers, and advanced practice clinicians, and they are likely to have invaluable insights into aspects of science and health that others may not have.
Look at your citations when you write: are you including diversity, including professional role, gender, race, and nationality?
For nurses and those interested in nursing, have you affiliated with the Council on Cardiovascular and Stroke Nursing? Get involved, fill out a science volunteer form (committee assignments are made in April), and get in touch with the leadership.
Consider joining other professional organizations and getting involved with political causes— scope of practice and reimbursement issues are often hashed out by legislators, and voices supporting nursing are sorely needed. This includes from physicians!

What will you do to support nursing this year?

Has the image of nursing changed since these historical photos were taken? (Photos via Unsplash.com)

What Are Your Thoughts on Work-Life Balance/Imbalance in Science and Medicine?

January 2, 2020January 2, 2020 Sasha Prisco, MD, PhD

My blog post this month is meant to be a starting point for discussion. There are a plethora of articles and blog posts on work-life balance/imbalance in medicine and science (and many other professions). Some articles and blog posts even discuss that it is not possible to have work-life balance in medicine/science/academia^1-3. As the winter holiday season comes to an end and a new year and decade starts, I find myself reassessing my personal and professional goals and resolutions for this upcoming year and decade. On my list is “continuing to work on work-life balance.” My blog is meant to stimulate discussion and solicit advice from those of you in science and medicine on potential tips to improve work-life balance. Figuring out how to balance the personal and professional aspects of our lives throughout a long and arduous career can be a formidable process.

Some people have voiced concerns about the recommendations often told to trainees and early career physicians/scientists to maintain work-life balance and wellness in order to prevent burnout: get adequate sleep, eat well, exercise, meditate, pet dogs, wake up earlier to plan your day, travel, read nonmedical/nonscience books, continue your hobbies, find good mentors, and spend time with family and friends all while providing good clinical care and/or doing good research. How are there enough hours in a day to do all of this?

An article in The Atlantic published last year entitled “Give Up on Work-Life Balance”⁴ discusses a recommendation from Brad Stulberg, author of The Passion Paradox, of not thinking of work-life balance as dividing hours within a day for personal and work activities. Alternatively, consider balance in terms of “seasons.” For example, one “season” could be a few years where the majority of the time is focused on one’s training/career and another “season”, possibly during a time when one has young children, where focus is on spending time with family. One of my mentors who has young children says that when he goes home, he prioritizes spending time with family and tries not to do any work until he and his wife go to bed. Some people have noted that they dislike the term work-life balance since it implies that there is a scale where one side is competing against the other. Instead, “integrating” work and personal lives is encouraged. Unfortunately, careers in science and/or medicine do not always allow for easy integration of work and personal lives, but system changes can occur to allow for better integration of work and personal life. For example, I applaud the efforts of one of my co-AHA early career bloggers, Dr. Nosheen Reza (@noshreza), in assisting with establishing a culture and creating tangible changes to support breastfeeding cardiology fellows⁵. Another AHA early career blogger, Dr. Renee Bullock-Palmer (@RBP0612) wrote a blog post last year discussing tips for integrating motherhood and a career as a female cardiologist (https://earlycareervoice.professional.heart.org/balancing-versus-integration-of-motherhood-and-your-career-as-a-female-cardiologist/).

Many established researchers and clinicians have recently told me that they regret not spending more time with their families. This same sentiment has been echoed by many clinicians/researchers on Twitter over the holiday season. While it is not always possible to spend every holiday with loved ones, especially while in training, allotting some protected time to spend with loved ones is important for maintaining wellness.

Establishing work-life balance is a constant evolving process dependent on the stage of our careers and personal lives and is a very individualized process. As mentioned before, I hope that we can have a further discussion on work-life balance and that you will share some tips on ways to improve work-life balance. I wish all of you a happy, healthy, and productive new year!

Lazzari, Elisa. To be a top performer you need to be happy – something academics tend to forget. Naturejobs Blog. 13 Jun 2016. http://blogs.nature.com/naturejobs/2016/06/13/can-scientists-really-have-worklife-balance/.
Powell, K. Young, talented and fed-up: scientists tell their stories. Nature538, 446–449 (2016).
Is Work-Life Balance for Physicians a Unicorn? com. 3 Jan 2018. https://www.kevinmd.com/blog/2018/01/work-life-balance-physicians-unicorn.html
Khazan, Olga. Give Up on Work-Life Balance. The Atlantic. Atlantic Media Company. 30 May 2019. https://www.theatlantic.com/health/archive/2019/05/work-life-balance/590662/.
Kay J, Reza N and Silvestry FE. Establishing and Expecting a Culture of Support for Breastfeeding Cardiology Fellows. JACC: Case Reports. 2019;1:680-683.

Can artificial intelligence save our lives?

January 2, 2020January 2, 2020 Noora Alhajri, MD, MPH

The role of artificial intelligence (AI) in our life is advancing rapidly and is making strides in 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 controversy 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 chest strap monitor was the most accurate in tracking the heart rate across different types and intensities of exercises⁴.

The 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, in 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 unnecessarily test 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.

References:

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
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
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
Wrist-Worn Heart Rate Monitors Less Accurate Than Standard Chest Strap. Medical Design Technology. http://search.proquest.com/docview/1875621494/. Published March 9, 2017.
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

How to Celebrate the Year of the Nurse

January 2, 2020January 2, 2020 Allison Webel, PhD

Full disclosure. I am nurse. A proud nurse. I am a nurse because the strongest, kindest, and most adventurous women I knew when I was growing up were nurses. And throughout the course of my nursing career, I have been repeatedly reminded that nurses are privileged to experience some of the most distressing times in a person’s life alongside them – and to expertly help them through it.

My love for my chosen profession is one of the reasons I celebrate the World Health Organization declaring 2020 The Year of the Nurse and Midwife. This official recognition of the pivotal role that nurses, around the globe, have in creating healthier lives for all people regardless of their age, sex, or social status. As countries and health care rapidly evolved during the 20^th-21^st centuries, fewer people died from maternal and child illness and infectious diseases and today cardiovascular disease is one of the biggest killers of adults around the globe. The type of cardiovascular disease varies in different global settings- we see more ischemic heart disease in more developed countries and more hypertensive heart disease and cardiomyopathies in low income countries. Yet, despite the differing types of cardiovascular disease, in every corner of the globe nurses are helping people prevent, manage, and recover from cardiovascular disease.

There are more than 12 million cardiovascular nurses around the globe making them the largest discipline promoting cardiovascular health. Decades of evidence demonstrate that nurses have a critical role in promoting high-quality, cost effective care to improve cardiovascular health. As Leonie Rose Bovino, PhD, APRN, FAHA – Nurse Practitioner at Yale New Haven Hospital Outpatient Cardiology – states “Much of the premature cardiovascular morality is due to modifiable factors and nurses excel at building a rapport and establishing shared decision-making with patients about their health. This allows them to have an integral, immense and important role in decreasing CVD mortality.”

Francis Njoroge and his team at the Cardiac Care Unit at Moi Teaching & Referral Hospital in Eldoret, Kenya.

Nurses and nurse practitioners use this rapport to manage hypertension and high cholesterol; provide smoking cessation, diabetes and nutrition counselling; facilitate patients completing cardiac rehabilitation; and help manage the distressing symptoms of heart failure. And when nothing more can be done, nurses are there to help patients die with the comfort and dignity they deserve—holding hands, crying with family, and comforting those who don’t know what tomorrow will bring.

Francis Njoroge (pictured left) is the Nursing Officer-in-Charge at the Cardiac Care Unit at the Moi Teaching & Referral Hospital in Eldoret, Kenya. He provides care to patients with rheumatic heart disease, infective endocarditis, and heart failure. He helps them understand how to prevent complications from these conditions, conducts home visits after their discharge, and counsels both patients and their family members about their “ongoing disease process, adherence to medication, dietary habits and lifestyle modification”. Like Dr. Rose Bovino, Francis’ role as a nurse and a leader is big and diverse, and sometimes complicated by familiar challenges – patients being unable to buy necessary medicines, high acuity patients, not enough time with patients, and too few hospital beds. But despite these challenges, Francis and Dr. Rose Bovino chose their profession because they wanted a challenging career – one that would allow them to make a difference in people’s daily lives and, themselves, to be changed by the patients and their own stories. Asked what he wants young people to know about nursing, Francis states, “Nursing is a career that helps a person save lives, brings happiness to individuals and their families, and comfort to those in need. Despite being a challenging job, it’s very interesting and makes a difference in people’s lives. I would encourage young people to join us, and join nurses everywhere, in making a difference in their own communities”.

Many of the readers of this blog will be nurses, and many will not. But no matter what your profession is, chances are you know a nurse. So this year, ask the nurses you know about their stories. Why did they choose nursing? Why do they continue to be a nurse? What would make it easier for them to provide the best quality nursing care possible? Listen to them. Let their stories change how you think about your own health, or your work, or your relationships. Let them inspire you to be stronger, kinder, bolder, and seek out adventure in your right. Because when we recognize the pivotal role that nurses have in our community, we recognize the best of all of us. And I hope that recognition lasts long after the Year of Nurse and Midwife concludes.

The 21-year-old man who survived an acute myocardial infarction

December 23, 2019January 2, 2020 Noora Alhajri, MD, MPH

One of the most important things we can do as health-care providers, parents, teachers, caregivers and peers is to successfully recognize and improve the health issues and health outcomes of the teens and young adults. In this blog I’ll share the story of a young man who was seen by my husband in the ED and sparked my interest as a scientist to study the prevalence and clinical profile of myocardial infarction (MI) in young adults in my community.

I encourage you to share this blog with the young adults in your life, as well as parents and caregivers who have teenagers:

Three nights ago as my husband was preparing to sign off his shift in the ED, a 21 years-old man was brought in by the ambulance with a 30-minute history of severe central, crushing pain radiating down to his left arm. The pain was associated with nausea, vomiting, sweating and breathlessness. It was his first time to ever experience a central crushing pain. The man had a history of membranoproliferative glomerulonephritis and was on immunosuppressive therapy. He was also diagnosed with secondary hypertension and was on enalapril and nifedipine. Thankfully, he was in safe hands, the ED team were able to recognize his symptoms and a diagnosis of acute myocardial infarction was made. But, can you imagine how emotionally and physically upsetting this was to himself and his family.

Overview

Coronary artery disease (CAD) is the leading cause of morbidity and mortality worldwide. Myocardial Infarction (MI) is a lethal manifestation of CAD and can present as sudden death. Although it mainly occurs in patients older than 45 years, young men and women can suffer from myocardial infarction1. Unfortunately, when it happens to young adults, the disease can carry significant psychological impact, financial constraints and morbidity to the patients and their family. The protection being offered by young age is gradually being taken away with the high prevalence of CAD risk factors in these young adults such as obesity, lack of physical activity and smoking. Several studies have described the clinical profile and outcome of young patients with MI and its incidence ranged between 2%-10%. Overall, young patients are more likely to be male, with a history of smoking and hyperlipidemia, however, they were less likely to have other comorbidities and less extensive CAD on coronary angiogram².

Causes of myocardial infarction in young adults

The causes of myocardial infarction in young adults can be broadly divided into two groups, those with angiographically normal coronary arteries and those with coronary artery disease of varying etiology.

Angiographically “normal” coronary arteries

Hypercoagulable state:
- Nephrotic Syndrome
  - Proteinuria associated with the nephrotic syndrome results in the loss of low molecular weight proteins which alters the concentration and activity of coagulation factors. As a result, factors IX, XI and XII are decreased due to urinary excretion. While the liver tries to compensate for the hypoalbuminaemic state, there is an increased synthesis of factor II, VII, VIII, X, XIII and fibrinogen resulting in raised blood levels³.
- Antiphospholipid syndrome (Hughes syndrome)
  - Arterial and venous thrombosis is a prominent feature of this syndrome together with antiphospholipid antibodies and miscarriage in pregnancy. The mechanism of thrombosis with this syndrome is complex and not well understood. However, it is plausible that anti-phospholipid antibodies predispose to premature atherosclerosis which increases the risk of infarction with his syndrome⁴.
- Coronary artery spasm
  - Coronary artery spasm (CAS) is probably the predominant mechanism for myocardial infarction with the use of cocaine. Cocaine has been associated with angina, myocardial infarction, tachyarrhythmia’s and bradyarrhythmias, sudden cardiac death and myocardial contraction bands, which can possibly act as a substrate for arrhythmias. The cardiac effects of cocaine are mediated through four main pathways
    1. Endothelial dysfunction which predisposes to vasoconstriction and thrombosis.
    2. Promotion of atherosclerosis
    3. Increased myocardial oxygen demand due to an acute rise in systemic blood pressure and heart rate.
    4. Coronary vasoconstriction caused by its α1- adrenergic properties and calcium dependent direct vasoconstriction⁵.
- Coronary embolization
  - Coronary artery embolism is a rare cause of acute myocardial infarction (AMI) and the precise diagnosis remains challenging for the interventional cardiologist. The true prevalence of this nonatherosclerotic entity remains vague because of its difficult diagnosis in the acute setting.
- Myocardial bridging
  - This is a congenital anomaly in which the coronary artery is embedded within the subepicardial myocardium or has a band of myocardium overlying it. This can impede blood flow during systole that can persist during diastole resulting in myocardial ischemia³.

Angiographically abnormal coronary arteries

We know that even angiographically “normal” looking coronary arteries can still have significant atherosclerotic plaque, and not surprisingly, can still result in myocardial infarction. Therefore, the definition of normality is arbitrary and not definite.

Accelerated atherosclerosis
- The true prevalence of advanced coronary atheroma in young adults is not well studies. An autopsy study of 760 victims of accidents, suicide and homicides aged 15-34 years found advanced coronary atheroma in 2% of males aged 15-19 years and none in women. This reveals that being male solemnly is a risk factor for atherosclerosis. Additionally, in the 30-34 age group, about 20% of men and 8% of women had advanced coronary atheroma. It is known that genetic mutation in the low density lipoprotein receptor produces familial hypercholesterolemia, an autosomal dominant disorder characterized by premature atherosclerosis and high serum cholesterol. Various other lipid fractions and hyperhomocysteinaemia are implicated in premature atherosclerosis and MI³.
Aneurysm and anomalous origin of arteries dissection
- Coronary artery aneurysm are congenital or acquired secondary to Kawasaki’s disease in childhood. They have been linked to myocardial infarction in young adults, although the actual mechanism is not well understood.
Spontaneous dissection
- Spontaneous dissection is a condition with great prevalence in women, especially in the peripartum or early postpartum period. However, it is a rare cause of MI⁶.

REFERENCES:

Wong CP, Loh SY, Loh KK, Ong PJ, Foo D, Ho HH. Acute myocardial infarction: Clinical features and outcomes in young adults in Singapore. World J Cardiol. 2012;4(6):206–210. doi:10.4330/wjc.v4.i6.206
Sinha SK, Krishna V, Thakur R, et al. Acute myocardial infarction in very young adults: A clinical presentation, risk factors, hospital outcome index, and their angiographic characteristics in North India-AMIYA Study. ARYA Atheroscler. 2017;13(2):79–87.
Osula S, Bell GM, Hornung RS. Acute myocardial infarction in young adults: causes and management. Postgrad Med J. 2002;78(915):27–30. doi:10.1136/pmj.78.915.27
Turrent-Carriles A, Herrera-Félix JP, Amigo MC. Renal Involvement in Antiphospholipid Syndrome. Front Immunol. 2018;9:1008. Published 2018 May 17. doi:10.3389/fimmu.2018.01008
Hung MJ, Hu P, Hung MY. Coronary artery spasm: review and update. Int J Med Sci. 2014;11(11):1161–1171. Published 2014 Aug 28. doi:10.7150/ijms.9623
Adlam D, Alfonso F, Maas A, Vrints C; Writing Committee. European Society of Cardiology, acute cardiovascular care association, SCAD study group: a position paper on spontaneous coronary artery dissection. Eur Heart J. 2018;39(36):3353–3368. doi:10.1093/eurheartj/ehy080

The American Heart Association Annual Scientific 2019 Meeting- “An Engaging and Enlightening experience”

December 17, 2019December 17, 2019 Renee Bullock-Palmer, MD

The recent American Heart Association Annual Scientific meeting held in Philadelphia, Pennsylvania was filled with many sessions centered around the area of Cardiac Imaging with emerging areas in Nuclear Cardiac imaging,Echocardiography, Cardiac CT as well as Cardiac MRI. There was also the long awaited results of the ISCHEMIA trial. In addition, the Women in Cardiology (WIC) Committee had several sessions related to professional development including several networking opportunities with the WIC networking luncheon as well as a networking WIC dinner that was sponsored by the University of Pennsylvania. In this blog I will discuss several of these highlights.

Heart Disease in Women- Focus on Cardiac Imaging

Drs. Viviany Taqueti and Parham Eshtehardi moderated an excellent session on the multimodality assessment of microvascular coronary artery disease (CAD) in women.

Invasive Assessment of Microvascular Coronary Artery Disease:

During this session Dr. Carl Pepine discussed invasive assessment of microvascular disease in women. He discussed the use of coronary TIMI frame count (cTFC) to predict adverse events in women with symptoms/signs of ischemia with no obstructive coronary artery disease (INOCA). He discussed the results of a pilot study from the National Heart, Lung and Blood institute ( NHLBI) sponsored Women’s Ischemia Syndrome Evaluation (WISE) which showed that in women with INOCA, resting cTFC provided independent prediction of hospitalization for angina¹. He also discussed the pros and cons of the three invasive methods for the assessment of coronary microvascular function: Thermodilution (IMR), Doppler wire (hMR) and Continuous Thermodilution (MVR). IMR being most user friendly of the 3 methods and has also been a method that has been validated against clinical outcomes. IMR is also feasible in every coronary anatomy. However, IMR is adenosine dependent. hMR and MVR both have reasonable reproducibility. hMR has also been validated against clinical outcomes while MVR provides a direct assessment on coronary blood flow and is adenosine free. However, IMR and hMR are dependent on the use of adenosine². The indications for invasive coronary function testing (CFT) include (a) Evidence of ischemia with persistent chest pain and no obstructive coronary artery disease (CAD) (b) Chest pain refractory to medical management and (c) Preference for definitive diagnosis. Invasive CFT has excellent safety data with <0.6-0.7% serious adverse event rate (coronary dissection, myocardial infarction)^3-5. Invasive diagnosis of coronary microvascular disease in women was associated with worse angina and hospitalization free survival compared to women without evidence of microvascular CAD⁶.

Role of Positron Emission Tomography (PET) assessment of Microvascular CAD (CMD) in Women:

Dr. Sharmila Dorbala gave an excellent talk on the use of Cardiac PET to assess the presence of CMD with myocardial blood flow and coronary flow reserve assessment with robust evidence data with over 35 years of research data involving over 20,000 patients. The presence of severely impaired coronary flow reserve (<2.0) is associated with excess cardiovascular risk in women relative to men referred for coronary angiography⁷. She had also discussed the evidence showing that CMD diagnosed with PET was associated with an increased risk of heart failure with preserved ejection fraction (HFpEF). The future of myocardial blood flow assessment with Cadmium Zinc Telluride (CZT) SPECT cameras was also discussed. The key points for the diagnosis of CMD with nuclear perfusion imaging are the following:

Nuclear stress imaging is required to assess stress myocardial blood flow (MBF) and to assess myocardial flow reserve: stress MBF/rest MBF
The stress agent used for assessment of MBF is typically done with vasodilatory agents such as regadenoson, adenosine or dipyridamole. Cold pressor test is usually done in research labs to assess endothelial dysfunction. Exercise MBF is not very feasible.
Epicardial CAD has to be excluded
CMD is typically defined as MBF <2.

Quantitative Blood Flow assessment with Cardiac MRI (CMR):

Dr. Chiara Bucciarelli-Ducci gave a very informative talk on the use of CMR to assess myocardial blood flow. The general principles of quantification of blood flow requires knowledge of the amount of contrast agent in the myocardium and knowledge of the amount of contrast agent in the blood pool (arterial input function). The challenge in this assessment is the lack of linearity between signal and contrast concentration. The main sources of non-linearity and bias includes spatial signal variations (sensitivity profile of the surface coils), imperfect saturation of magnetization during contrast bolus passage, T2* decay and signal loss by contrast concentration in the blood pool and non-linear signal response (inherent to saturation recovery). Novel CMR techniques such as perfusion mapping and extracellular volume (ECV) assessment were also discussed. The assessment of cardiac perfusion imaging with inline quantitative flow mapping was also discussed, including the fact that this is a fully automated workflow without any user interaction.

Artificial Intelligence in Cardiac Imaging with Cardiac CT and Cardiac PET imaging

There was a very innovative session that discussed the use of machine learning and deep learning in FFR Cardiac CT (FFRct) to improve diagnostic accuracy. Cardiac CTA has been shown to be an established diagnostic tool in clinical practice with FFRct offering functional information for intermediate and severe lesions. FFRct has also showed good correlation with invasive FFR. Machine Learning improves FFR-ct algorithms with improved accuracy, decreased analysis stime, potential to increase the availability of this FFRct technology and potential cost reduction. Deep Learning (DL) in automatic calcium scoring on cardiac CT using paired convolutional neural networks was also discussed. Assessment of ischemic myocardium with Cardiac CTA with DL was also discussed with the use of tissue segmentation and tissue characterization. The use of DL in cardiac PET was also discussed with regards to its utility in cardiovascular event prediction.

The ISCHEMIA trial

The long awaited ISCHEMIA trial results were released at the AHA 2019 and my take home points were outlined in my last blog, https://earlycareervoice.professional.heart.org/my-top-10-take-home-points-from-the-ischemia-trial/

ischemia trial

The ISCHEMIA trial is the largest trial studying an invasive versus conservative strategy for patients with stable ischemic heart disease⁸. The overall conclusions of the ISCHEMIA trial were:an initial invasive strategy compared with an initial conservative strategy did not demonstrate a reduced risk over a median follow up period of 3.3 years with regards to the primary endpoint of cardiovascular death, myocardial infarction, hospitalization for unstable angina and heart failure as well as with regards to the secondary endpoints of cardiovascular death or myocardial infarction. The probability of at least a 10% benefit of an invasive strategy on all cause mortality was < 10, based on pre-specified Bayesian analysis. The ISCHEMIA trial concluded that patients with stable CAD and moderate to severe ischemia had significant durable improvements in angina control and quality of life with an invasive strategy if they had angina occurring daily/weekly or monthly. Shared decision-making should be done to ensure alignment of treatment with patients’ goals and preferences for patients with angina. However, in patients without angina, an invasive strategy led to minimal symptom improvement or quality of life benefits as compared with a conservative strategy. An early invasive strategy was not associated with a significant reduction in clinical events.

Imaging of Valvular Heart Disease

There was also an enlightening session on the role of cardiac imaging in the assessment of tricuspid valvular heart disease with a focus on severe secondary tricuspid regurgitation as well as congenital Ebstein’s anomaly of the tricuspid valve. The preoperative risk factors for significant post op tricuspid regurgitation that were noted were (a) preoperative tricuspid regurgitation of 2+ or more (b) atrial fibrillation and (c) huge left atrium⁹. Mitral valve surgery as well as double valve surgery including the aortic and mitral valve were associated factors for the development of late significant tricuspid regurgitation after left sided valve surgery¹⁰. Mild to moderate progressive functional tricuspid regurgitation with tricuspid valve annular dilation of >40 mm or > 21 mm/m2 by 2D echocardiography has a class IIa indication for tricuspid valve repair at time of left sided valve surgery. In addition any symptomatic severe functional tricuspid regurgitation at the time of left sided valve surgery has a class I indication for tricuspid valve repair or replacement¹¹.

Ebstein’s anomaly involving the tricuspid valve accounts for <1% of congenital heart disease. The tricuspid valve malformation is often complex and typically involves the tricuspid valve leaflets, the chordal apparatus and the myocardium of the right ventricle. The severity of tricuspid valve leaflet displacement on echocardiography has been identified as an independent predictor of cardiac mortality in patients with Ebstein’s anomaly¹².

Primary tricuspid regurgitation may also result from lesions of the tricuspid valve apparatus itself such as in endocarditis, congenital disease or from mechanical trauma to the leaflets, annulus and/or chordae. Echocardiography remains the primary imaging modality to diagnose the etiology and severity of tricuspid valve disease. Features on echocardiography that may indicate significant tricuspid regurgitation includes tricuspid valve annular dilation of >40 mm or > 21 mm/m2, tethering distance >0.76 cm, tethering area >1.63 cm2 and right ventricular end systolic area of > 20 cm2¹³. However, CMR and Cardiac CT are useful in some cases. CMR is considered the gold standard for the quantification of tricuspid regurgitation, quantification of right ventricular volumes, evaluation of right ventricular function, assessment of fibrosis and occasionally assessment of the etiology. Limitations for CMR includes presence of cardiac devices, arrhythmias, claustrophobia and renal failure (gadolinium). In special situations tricuspid regurgitation can be complex. 3D echocardiography provides useful information and it is sometimes necessary to assess tricuspid regurgitation with multimodality imaging as Cardiac CT can provide information about the anatomical regurgitant orifice area. Additionally, CMR and Cardiac CT can provide information about the dimensions of the tricuspid valve annular diameter, right heart volumes and function as well as vascular assessment¹³. In the presence of significant tricuspid regurgitation, tricuspid valve repair should be performed whenever possible.

Multimodality imaging of Aortic Diseases

There was also an excellent session dedicated to the multi modality imaging with CT and MRI of acute and chronic aortic diseases such as aortic intramural hematoma, aortic aneurysms, aortic dissection and endovascular repair of the aorta (TEVAR) planning for aortic repair. 4D flow MRI was also discussed with regards to TEVAR planning.

With regards to aortic aneurysms, type B aortic dissection should be considered a chronic disease with complex pathophysiology with up to 75% of patients developing an aortic aneurysm¹⁴. Hemodynamic forces are believed to play a central role in this pathophysiology.

In the presence of type B intramural hematoma, tiny intimal disruptions/fenestrations (TID) does not confer poor prognosis as the risk of aorta related events are similar when compared to patient without TID. 14% of these patients progress to focal intimal disruption in a recent meta analysis¹⁵. Focal intimal disruptions and ulcer like projections may cause large communications in intramural aortic hematoma with >3mm connection with the aortic lumen and are typically absent on the initial study. Limited intimal tears of the aorta although rare are an unquestionable cause of acute aortic syndromes and is considered a variant of aortic dissection. It is predominantly seen in type A intramural hematoma with an aneurysmal aorta and patients are older than patients with classic aortic dissection. Limited intimal tears can be seen on state of the art CT angiography and 3D volume rendering can make lesions more conspicuous.

Quality Cardiac Imaging

The last day of AHA 2019 was kicked off with an inspiring and informative session that discussed Quality in Cardiac Imaging that was led by several leaders in the field which included Dr. Pamela Douglas and Dr. Leslee Shaw. Dr. Ritu Sachdeva discussed strategies to maximize imaging information and outcomes by facilitating implementation by removing barriers and incentivizing schemes. She also discussed designing strategies to keep up with the pace of technology through improving quality, promoting innovation and research and focusing on adequate training in cardiac imaging. It was also mentioned that achieving excellence in imaging has to include collaboration between providers, professional societies, patients, payers and industry. The focus should move from “Volume Driven Healthcare” to “Value Driven Healthcare”.

The future of Cardiac Imaging in a value based healthcare system has to include definitions of the cardiovascular imager of the future, ensure robust innovation and research and maximizing imaging information and improving outcomes. This was outlined in the “Future of Cardiac Imaging Think Tank” article by Dr. Pamela Douglas¹⁶.

AHA Presidential Address

The AHA Opening session was a very energetic, encouraging and enlightening session. This session was opened by wonderful performances by Broadway’s Hamilton cast of actors. The Presidential address by Dr. Robert Harrington (Figure 1) was encouraging as he spoke on the importance of increasing diversity in the cardiology workforce as well as improving gender equality in the cardiology field.

Figure 1 President of the American Heart Association, Dr. Robert Harrington at the American Heart Association 2019 Annual Scientific Session Presidential Address

AHA Women in Cardiology (WIC) Committee Events

Professional Development: There were many Women in Cardiology Professional Development sessions that covered a wide range of topics such as “Volunteerism to Advance Your Career” with Drs. Stacy Rosen and Michelle Albert, “Negotiations” with Drs. Sandra Lewis and Linda GIllam, “Time Management” with Drs. Toniya Singh and Gina Lundberg, “Self-Advocacy” with Drs. Elaine Tseng and Linda Shore, “Sponsor vs. Mentor” with Dr. Emelia Benjamin and “Around the World with Go Red for Women”. These sessions were held in the Women in Science and Medicine Lounge in the expo hall and were very engaging and well attended sessions.

Networking Activities

WIC Networking Luncheon:

The AHA Women in Cardiology networking luncheon was an excellent session that provided an opportunity to network with other colleagues and AHA leadership. This session also hosted an excellent panel of speakers led by Dr. Laxmi Mehta who spoke on the topic of “Physician Burnout” and how to address this issue in Medicine. The other panel of speakers included Dr. Minnow Walsh who discussed the “Increased demand of the aging population and decreased supply of clinicians causing burnout – what can be done?”, Dr. Athena Poppas discussed “What can Cardiology leaders and Chiefs of Cardiology do to help decrease the stress from the clinical workload and increase career satisfaction?”, Dr. Sandy Lewis discussed “Legislative advocacy to decrease physician burnout – what can organizations do?” and Dr. Sherry Ann Brown discussed “What can cardiologists do to decrease their stress levels?” and she also discussed “What can fellowship program directors do to help fellows decrease burnout?” The attendees at the luncheon also added their own experiences relevant to this topic and also shared words of wisdom and advice.

The All Council Reception and Clinical Cardiology Council Dinner:

The All Council reception was very well attended with standing room only. It was also very lively with performance by the members from the Mummers Philadelphia group. This reception led into the Clinical Cardiology Council Dinner and during the dinner there were several awards given as well as recognition of the new Fellows of the American Heart Association. Dr. Sharon Reimold was the recipient of the AHA Women in Cardiology Mentoring Award.

The AHA WIC Networking dinner hosted by University of Pennsylvania:

The AHA Women in Cardiology committee was very grateful to the University of Pennsylvania led by Dr. Monika Sanghavi who hosted a wonderful dinner that provided an opportunity for Women in Cardiology fellows in training (FIT) to network with several Women in Cardiology leaders in the field. We appreciated pearls of wisdom from leaders such as Dr. Nanette Wenger, Dr. Sharonne Hayes, Dr. Minnow Walsh, Dr. Andrea Russo, Dr. Martha Gulati and Dr. Annabelle Volgmann. This was the second annual WIC event at the AHA Scientific meeting and we are hoping to continue this at future AHA Scientific meetings as these events have been very well received by our Women in Cardiology FITs.

AHA 2019 was an educational, engaging and exciting meeting where new scientific data relevant to Cardiology practice was presented. The event also offered many opportunities for networking with many leaders in the field. I look forward to the American Heart Association Scientific meeting in November 2020 in the beautiful city of Dallas, Texas.

References:

Petersen JW, Johnson BD, Kip KE, Anderson RD, Handberg EM, et al. (2014) TIMI Frame Count and Adverse Events in Women with No Obstructive Coronary Disease: A Pilot Study from the NHLBI-Sponsored Women’s Ischemia Syndrome Evaluation (WISE). PLoS ONE 9(5): e96630. doi:10.1371/journal.pone. 0096630
Banning AP, De Maria GL.Measuring coronary microvascular function: is it finally ready for prime time? Eur Heart J. 2019 Jul 21;40(28):2360-2362. doi: 10.1093/eurheartj/ehz426. No abstract available. PMID: 31236565
Wei J, Mehta PK, Johnson BD, Samuels B, Kar S, Anderson RD, Azarbal B, Petersen J, Sharaf B, Handberg E, Shufelt C, Kothawade K, Sopko G, Lerman A, Shaw L, Kelsey SF, Pepine CJ, Merz CN.Safety of coronary reactivity testing in women with no obstructive coronary artery disease: results from the NHLBI-sponsored WISE (Women’s Ischemia Syndrome Evaluation) study. JACC Cardiovasc Interv. 2012 Jun;5(6):646-53. doi: 10.1016/j.jcin.2012.01.023.PMID: 22721660
Reriani M, Sara JD, Flammer AJ, Gulati R, Li J, Rihal C, Lennon R, Lerman LO, Lerman A.Coronary endothelial function testing provides superior discrimination compared with standard clinical risk scoring in prediction of cardiovascular events. Coron Artery Dis. 2016 May;27(3):213-20. doi: 10.1097/MCA.0000000000000347. PMID: 26882018
Ong P, Athanasiadis A, Borgulya G, Vokshi I, Bastiaenen R, Kubik S, Hill S, Schäufele T, Mahrholdt H, Kaski JC, Sechtem U. Clinical usefulness, angiographic characteristics, and safety evaluation of intracoronary acetylcholine provocation testing among 921 consecutive white patients with unobstructed coronary arteries. Circulation. 2014 Apr 29;129(17):1723-30. doi: 10.1161/CIRCULATIONAHA.113.004096. Epub 2014 Feb 26. PMID: 24573349
AlBadri A, Bairey Merz CN, Johnson BD, Wei J, Mehta PK, Cook-Wiens G, Reis SE, Kelsey SF, Bittner V, Sopko G, Shaw LJ, Pepine CJ, Ahmed B. Impact of Abnormal Coronary Reactivity on Long-Term Clinical Outcomes in Women. J Am Coll Cardiol. 2019 Feb 19;73(6):684-693. doi: 10.1016/j.jacc.2018.11.040. PMID: 30765035
Taqueti VR, Shaw LJ, Cook NR, Murthy VL, Shah NR, Foster CR, Hainer J, Blankstein R, Dorbala S, Di Carli MF. Excess Cardiovascular Risk in Women Relative to Men Referred for Coronary Angiography Is Associated With Severely Impaired Coronary Flow Reserve, Not Obstructive Disease.’Circulation. 2017 Feb 7;135(6):566-577. Doi: 10.1161/CIRCULATIONAHA.116.023266. Epub 2016 Nov 14.PMID: 27881570
https://www.google.com/url?q=http://www.ischemiatrial.org/&sa=D&ust=1576542824370000&usg=AFQjCNH06i1Ohvx0btiCyHrVJARGarMYOA
Matsuyama K, Matsumoto M, Sugita T, Nishizawa J, Tokuda Y, Matsuo T. Predictors of residual tricuspid regurgitation after mitral valve surgery. Ann Thorac Surg. 2003 Jun;75(6):1826-8. PMID: 12822623
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Factors associated with development of late significant tricuspid regurgitation after successful left-sided valve surgery. Heart. 2009 Jun;95(11):931-6. doi: 10.1136/hrt.2008.152793. Epub 2009 Mar 24. PMID: 19321491
Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM 3rd, Thomas JD; ACC/AHA Task Force Members.2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Circulation. 2014 Jun 10;129(23):e521-643. doi: 10.1161/CIR.0000000000000031. Epub 2014 Mar 3.
Tobler D, et al. Tricuspid Valve Abnormalities. Congenital Heart Diseases in Adults Imaging and Diagnosis. Springer er. 2019
Hahn RT, Thomas JD, Khalique OK, Cavalcante JL, Praz F, Zoghbi WA. Imaging Assessment of Tricuspid Regurgitation Severity. JACC Cardiovasc Imaging. 2019 Mar;12(3):469-490. doi: 10.1016/j.jcmg.2018.07.033. Review. PMID: 30846122
Fattori R, Montgomery D, Lovato L, Kische S, Di Eusanio M, Ince H, Eagle KA, Isselbacher EM, Nienaber CA. Survival after endovascular therapy in patients with type B aortic dissection: a report from the International Registry of Acute Aortic Dissection (IRAD). JACC Cardiovasc Interv. 2013 Aug;6(8):876-82. doi: 10.1016/j.jcin.2013.05.003. PMID: 23968705
Moral S, Cuéllar H, Avegliano G, Ballesteros E, Salcedo MT, Ferreira-González I, García-Dorado D, Evangelista A. Clinical Implications of Focal Intimal Disruption in Patients With Type B Intramural Hematoma. J Am Coll Cardiol. 2017 Jan 3;69(1):28-39. doi: 10.1016/j.jacc.2016.10.045. PMID: 28057247
Douglas PS, Cerqueira MD, Berman DS, Chinnaiyan K, Cohen MS, Lundbye JB, Patel RA, Sengupta PP, Soman P, Weissman NJ, Wong TC; ACC Cardiovascular Imaging Council. The Future of Cardiac Imaging: a Report of a Think Tank Convened by the American College of Cardiology. JACC Cardiovasc Imaging. 2016 Oct;9(10):1211-1223. Doi: 10.1016/j.jcmg.2016.02.027. Review. PMID: 27712724

AHA19 Reflection

December 16, 2019December 16, 2019 Adham Karim, MD

“Half of what we will teach you in medical school is right, and half of it is wrong – the problem is we don’t know which is which.” This quote, or some variation of it, is relayed by many educators at medical schools across the globe. At AHA19, these words rang in my ears as my head was spinning from attending lecture after lecture being given by experts in the field of cardiology. What I found to be most educational (and hilarious), were the debates on controversial topics.

The debates I attended ranged from the age-old IABP vs impella in cardiogenic shock patients, to thought-provoking jabs at conventional practice, such as whether or not sodium restriction is necessary in acute decompensations of heart failure. However, I’m not here to convince you that one form of mechanical circulatory support is superior to another, or that perhaps some of the things we put a lot of stake in (hello salt restriction), might not be true in all cases.

With each debate, when a physician explained their reasoning for being Pro-X or Anti-Y, I couldn’t stop nodding in agreement. Gaining insight into their reasoning was thought provoking in and of itself! I found myself agreeing, disagreeing, and scratching my head at different concepts. It helped me discover gaps within my own knowledge, and pushed me to review the primary literature in a way that no amount of pimping on the wards ever could.

One of my favorite debates was watching Dr. Gregg Stone debate with Dr. Obadia on the merits of mitral valve clipping for secondary mitral regurgitation (the lead investigators of 2 separate trials that basically showed totally different results). Neither physician said the other was wrong! In fact, they both more or less agreed with one another, and helped highlight key differences that a discerning physician should look for when faced with such discrepancies.

And the lectures that weren’t meant to be debates ended up sparking hot debates anyways! I’m looking at you #ISCHEMIA trial. The #Cardiotwitter explosion that began that ensued has been so eye-opening to me as a trainee. Not only did it help highlight some details of landmark trials I might have missed, but it gave me a great window into the line of thought of many skilled clinicians.

Coming through college, medical school, and residency, I’ve been exposed to many different styles of teaching, and I’ve seen conventional medical education evolve from a bunch of disjointed sciences taught in school to a formal systems-based curriculum. Social media has changed the landscape of many fields, and medical education is not immune to its effects. FOAMed (Free open access medical education) and social media have become staples in how some trainees learn, and we must embrace that. The way that the AHA sought to integrate this into their programming was a great experience that truly helped to cement new knowledge for me, and ultimately improve my patients’ care. And as I’ve come to learn, when it comes to these debates, it’s not about who is right or wrong, it’s about how much you can learn form hearing both perspectives.

The Electrocardiogram In The Age of Artificial Intelligence: Decoding Hidden Secrets With Deep Learning

December 9, 2019December 9, 2019 Sumeet Pawar, MD

The electrocardiogram (ECG) is arguably the cardiologist’s best friend. Willem Einthoven’s invention created one of the most widely used diagnostic tests in clinical practice. The ECG is an easily available, patient-friendly, noninvasive, inexpensive, and reproducible technique, without peer for the diagnosis of myocardial ischemia, cardiac arrhythmias, structural changes of the myocardium, drug effects, and electrolyte and metabolic disturbances.¹ In addition to this, the ECG can provide information about the extent and severity of ischemia in acute coronary syndromes, assist in the localization of the site or pathway for tachycardias, identify heart failure patients who would benefit from cardiac resynchronization and identify familial diseases with risk of sudden cardiac death.

The ECG detects pathological changes prior to the development of structural changes in the heart. For instance, a strain pattern, defined as a down-sloping convex ST segment with inverted asymmetrical T-wave opposite the QRS axis in lead V5 or V6, is predictive of future risk of HF and death in hypertensive patients.² In fact, the 12 lead surface ECG is but one format to represent the electrical activity of the heart. Small changes in the morphology of the surface ECG, not visible to the human eye may reflect significant shifts in electrochemical messaging. Techniques such as signal averaged ECG, vectorcardiography aim to overcome these limitations and have been around for several decades.³ However, sophisticated and more advanced applications of the ECG have not found their way into the routine practice of clinical cardiology. Most of these are limited by low sensitivity which prohibits widespread application.

With advances in computational techniques and availability of big data collected from a variety of sources, there have been advances in unpacking the information encoded in several biologic signals. Deep learning is a type of machine learning technique with a diverse set of validated applications such as facial and speech recognition. Using deep learning to analyze retinal fundus images, Google has developed an algorithm that makes a diagnosis of diabetic retinopathy with a high degree of accuracy comparable to ophthalmologists.⁴ Furthermore, this algorithm detects cardiovascular events and even identifies gender from retinal images alone.⁵ This work represents a new way of scientific discovery, an alternative to the traditional hypothesis driven research approach. A data-driven approach can help generate newer hypothesis-guided experiments.

Deep learning for the analysis of ECG signals is an area of active research. Hannun and colleagues have shown comparable accuracy and even higher sensitivity for classifying arrhythmias using a deep neural network model versus board certified cardiologists.⁶ Work presented at scientific sessions 2019 from the University of Dusseldorf by Makimoto and colleagues showed that a convolutional neural network (CNN) was able to diagnose myocardial infarctions (MI) with more accuracy than cardiologists.⁷ The accuracy of MI recognition in ECGs by CNN was 84±2%, which was significantly higher than by cardiologists (64±7%, p<0.001). Designing clinical workflows where deep learning models provide rapid, expert level over read of ECGs, complemented by human oversight can have significant clinical impact.

The ECG signal represents the various electrical, chemical and mechanical events during the cardiac cycle. Deep learning algorithms have been able to decode these signals to make predictions about LVEF and diastolic dysfunction based on ECG data alone. Sengupta and colleagues used continuous wavelet transformation for post-processing the ECG signals and correlated several derived features for predicting abnormal myocardial relaxation as defined by abnormal tissue doppler.⁸ The area under the curve for their machine learning model for prediction of abnormal myocardial mechanical relaxation was 91% [CI: 0.86-0.95]. Attia and colleagues from Mayo Clinic presented their work at scientific sessions 2019 on predicting LVEF using single lead ECG signals acquired by an ECG-enabled stethoscope.⁹ A neural network previously used on 12-lead ECG for predicting EF was trained on single lead ECG data and was able to predict low EF with an area under the curve of 0.88 [CI:0.80-0.94] for EF<=35% and 0.81 [CI:0.72-0.88] for EF<50%

These findings and many others are constantly expanding the utility of the ECG in clinical practice wherein, the ECG provides more nuanced and finer details such as ejection fraction and predicts future outcomes with high accuracy. This represents significant progress from the days of the string galvanometer of Einthoven. Modern cardiovascular medicine is faced with many challenges related to prevention, diagnosis and treatment of disease, compounded by rising healthcare costs. The inexpensive and reliable best friend of the cardiologist – the ECG – can reveal its secrets to tackle these problems. The words of Einthoven remind us that there remains much to be done for decoding these secrets, “An instrument takes its true value not so much from the work it possibly might do but from the work it really does.”¹⁰ Future research is needed to validate the promise of these exciting new findings.

References:

Wellens HJ, Gorgels AP. The electrocardiogram 102 years after einthoven. Circulation. 2004;109:562-564
Okin PM, Devereux RB, Nieminen MS, Jern S, Oikarinen L, Viitasalo M, Toivonen L, Kjeldsen SE, Dahlof B, Investigators LS. Electrocardiographic strain pattern and prediction of new-onset congestive heart failure in hypertensive patients: The losartan intervention for endpoint reduction in hypertension (life) study. Circulation. 2006;113:67-73
Gatzoulis KA, Arsenos P, Trachanas K, Dilaveris P, Antoniou C, Tsiachris D, Sideris S, Kolettis TM, Tousoulis D. Signal-averaged electrocardiography: Past, present, and future. J Arrhythm. 2018;34:222-229
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Poplin R, Varadarajan AV, Blumer K, Liu Y, McConnell MV, Corrado GS, Peng L, Webster DR. Prediction of cardiovascular risk factors from retinal fundus photographs via deep learning. Nat Biomed Eng. 2018;2:158-164
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Makimoto H, Hoeckmann M, Gerguri S, Clasen L, Schmidt J, Assadi-Schmidt A, Bejinariu A, Mueller P, Gloeckner D, Angendohr S, Brinkmeyer C, Kelm M. Abstract 13914: Artificial intelligence finds myocardial infaction in ecg more accurately than cardiologists. Circulation. 2019;140:A13914-A13914
Sengupta PP, Kulkarni H, Narula J. Prediction of abnormal myocardial relaxation from signal processed surface ecg. J Am Coll Cardiol. 2018;71:1650-1660
Attia ZI, Dugan J, Maidens J, Rideout A, Lopez-Jimenez F, Noseworthy PA, Asirvatham S, Pellikka PA, Ladewig DJ, Satam G, Pham S, Venkatraman S, Friedman P, Kapa S. Abstract 13447: Prospective analysis of utility of signals from an ecg-enabled stethoscope to automatically detect a low ejection fraction using neural network techniques trained from the standard 12-lead ecg. Circulation. 2019;140:A13447-A13447
Rosen MR. The electrocardiogram 100 years later: Electrical insights into molecular messages. Circulation. 2002;106:2173-2179