Early Career Blogger – Page 5 – The Early Career Voice

Environmental and Neighborhood Influences on Health at #AHA19

November 29, 2019November 29, 2019 William Aitken, MD

Where we live and work shapes us in many ways. Whether growing up in an urban, suburban, or rural community, our neighborhoods can have an outsized impact our hobbies, lifestyle, and health. It was inspiring to see so many investigators presenting findings on this topic today at the American Heart Association (AHA) 2019 Scientific Sessions during the “Environmental and Neighborhood Influences on Health” poster session.

W. Wyatt Wilson and colleagues at the University of Chicago presented “Spatiotemporal Association Between Violent Crime And Ambulatory Elevations In Systolic Blood Pressure”, an innovative analysis of 133,024 geo-coded violent crimes reported by the City of Chicago and home addresses of patients with blood pressure readings from 232,488 unique outpatient appointments. They found that longer duration of exposure to violent crime within 500 meters of patients’ home addresses was associated with increased systolic blood pressure (approximately 0.27 mmHg per crime) [Figure 1]¹. These results echo findings from the Jackson Heart Study published earlier this year by Tanya M. Spruill and colleagues on chronic stress and incident hypertension among black adults². This analysis followed 1,829 adults without hypertension over a median of 7 years and recorded their blood pressure and self-reported stress. After multi-variable adjustment, they found moderate or high perceived stress was associated with higher risk of developing hypertension. The chronic health effects of stress resulting from living in a neighborhood with violent crime is a newly identified and very significant externality of these crimes.

Figure 1:

Daniel W. Riggs and colleagues at the University of Louisville presented findings on the interaction between neighborhood greenness, air pollution, and arterial stiffness³. This cross-sectional study of 63 adults measured: neighborhood greenness (satellite-derived normalized difference vegetation [NDVI] index), air pollution (particulate matter [PM] 2.5 levels and ozone levels), and arterial stiffness (augmentation pressure, pulse pressure, and aortic systolic pressure in mmHg). They found among participants living in low greenness areas that air pollution was positively correlated with arterial stiffness. Further, Zachary Rhinehart and colleagues at the University of Pittsburgh presented their poster “Association of Particulate Matter and Incident Stroke in Atrial Fibrillation” which was a retrospective study of 31,414 patients at their academic medical center⁴. They found that among patients diagnosed with atrial fibrillation, living in neighborhoods with high levels of air pollution (highest quartile compared to lowest quartile) was associated with an increased risk of stroke (HR 1.50; CI 1.30 – 1.72) [Figure 2]. Given such consistent findings between air pollution and cardiovascular disease, I wonder if built environment interventions such as increased vegetation might help mediate neighborhood factors that contribute to cardiovascular disease long-term.

Figure 2:

Attending scientific sessions this year was a phenomenal experience. I came away with new insights for clinic from the late breaking trial sessions, met some incredibly smart and gifted people, and as evidenced by this specific session came away with a renewed enthusiasm to research some questions I was left with. Looking forward to #AHA20!

References:

W. Wilson et. al. Spatiotemporal Association Between Violent Crime And Ambulatory Elevations In Systolic Blood Pressure. Poster Presentation, American Heart Association 2019 Scientific Sessions, Philadelphia, PA, November 18, 2019 https://www.ahajournals.org/doi/10.1161/circ.140.suppl_1.17139
J Am Heart Assoc. 2019;8:e012139. DOI: 10.1161/JAHA.119.012139.
W. Riggs et. al. Effect Modification of Neighborhood Greenness on the Relationship Between Ambient Air Pollution and Arterial Stiffness. Poster Presentation, American Heart Association 2019 Scientific Sessions, Philadelphia, PA, November 18, 2019 https://www.ahajournals.org/doi/10.1161/circ.140.suppl_1.15881
Rhinehart et. al. Association of Particulate Matter and Incident Stroke in Atrial Fibrillation. Poster Presentation, American Heart Association 2019 Scientific Sessions, Philadelphia, PA, November 18, 2019 https://www.ahajournals.org/doi/10.1161/circ.140.suppl_1.16440

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.

Climate Change & Cardiovascular Health: New Perspectives

November 29, 2019November 29, 2019 Elizabeth Knight, PhD, DNP

I have always advocated making time to attend a talk that’s outside of your area of focus when attending a big conference. It’s a powerful way to experience new perspectives. On Monday, the last day of Sessions, there was a panel held in Main Event I— the grand stage, where the presidential session and the big-news late breakers are held— about climate change. That definitely qualifies as outside of my area. Climate change, at a cardiovascular health conference? Yes, the panelists argued, climate change is a dire threat to cardiovascular health, and we need our scientists and clinicians to address it.

Dr. John Balbus suggested several avenues through which climate impacts health, including air pollution, thermal stress and migration and conflict. These problems create cumulative physiological stress, which is a major driver of cardiovascular disease. Direct evidence of health impact can be seen. For example, during severe wildfires in California, Dr. John Balmes noted, not only did lung-related illness increase, but so did myocardial infarction.

Photo: Marcus Kauffman via Unsplash

AHA took a great step towards raising the profile of the climate problem by hosting this panel, and by doing it as a Main Event. I was dismayed, though, to see the room mostly empty. Why does this issue not have traction? Is it “too big”— leaving folks feeling like they can’t make an impact, or any impact would be too distant to feel? Is it a question of importance vs. urgency— we see people dying vaping-related lung injuries right now, and we are facing the specter of climate-related illness less immediately? Is it that the clear lines of causation between human activity, climate change, and health problems aren’t yet clearly visible to all? I don’t know, but it is up to us as the next generation of health and science professionals to insist.

So here we are, as early career scientists and clinicians. We know there’s a problem, and we know it’s a big one. But what can we do, as busy, ambitious, career-focused young(ish) people, working in universities and healthcare organizations? Get ready to channel your inner Greta Thunberg and speak truth to power!

During the climate panel at sessions, Dr. Caren Solomon presented a framework for action with six ideas. Here’s how we can apply them to professional meetings and conferences, and maybe this will help you think about how to apply them at your home institution, as well.

Personal Behaviors: Traveling to a meeting is resource-intensive. For the trip to Philly this year, I tried to mitigate my impact by using public transit instead of taxis or Lyft, bringing a reusable mug/water bottle, skipping daily linen changes and housekeeping at my hotel, turning down the lights and heat when I left the room, forgoing items like bags, straws, and lids that I didn’t need, and eating plant-based (that’s a topic for another post!). These changes aren’t hard, but they do require paying attention. What else could you change to reduce your impact?
Institutional Decarbonization- Hosting organizations could focus on providing sustainable food and food packaging, reducing waste (think of all the printed papers and giveaways that wind up in the trash), or purchasing carbon offsets for meeting travel (organizations like Terrapass make this easy).
Education: The public views physicians and nurses as trusted sources. When we are knowledgable, the potential impact is high. Professional organizations like AHA can therefore facilitate the flow of information. AHA is on the right track, including a climate panel at scientific sessions. Maybe next year, we can work to increase exposure around this issue and boost uptake: promote the issue in conference materials, schedule it at a high-visibility time, and minimize conflicting sessions.
Advocacy: AHA recently joined a consortium of medical organizations focused on education and advocacy around climate issues https://medsocietiesforclimatehealth.org/ and @DocsForClimate). This is a great step! This group provides organization and resources to help health professionals educate local lawmakers, the press, and community groups. I’d like to see organizations do more to take up the link between climate and cardiovascular health directly, consistently, and visibly. That’s a great way to be a relentless force for a world of longer, healthier lives.
Nonprofits and public institutions generally have their financial information available, including financial relationships with companies and other organizations. Advocating for divestment can make some waves in an organization because it’s so closely tied to the bottom line, and it often requires a very compelling case to make change. Financial relationships can conceal conflicts between an organization’s stated values and its actions effectively— and it often takes guts to challenge the apparatus. But you have guts, right?
Protest & Non-violent direct action. We can be visible, as scientists, clinicians, and members of our professional organizations (including AHA). Speak out in public, wear your lab coat or your “Go Red” gear. Write letters to the editor. Attend a demonstration. We can leverage the respect our society affords us as health experts to encourage societal change.

Need for COURAGE to evaluate for ISCHEMIA?

November 29, 2019November 29, 2019 Saurav Chatterjee, MD

The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial¹ has been a landmark in clinical decision-making for patients with stable ischemic heart disease – leading to a paradigm shift in clinical care by establishing that revascularization/percutaneous coronary intervention(PCI) in patients with stable ischemia did not reduce subsequent mortality or myocardial infarction(MI) outcomes over ‘optimal’ medical therapy. There was a reduction of ischemia-driven revascularization with invasive management-which has been attributed as a ‘soft end-point’. However, there have been criticisms of the trial – one of which has been that patients had not been selected based on a significant extent or severity of ischemia. This has been fueled by a subsequent analysis from the courage trial investigators which revealed mortality/MI outcomes benefit with revascularization in patients with moderate to severe ischemia². This has led the national institutes of health(NIH) to evaluate the hypothesis of upfront revascularization with the eponymous International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) trial³-the baseline characteristics of the participants having been published recently. So, there was tremendous excitement and interest for the presentation of the ISCHEMIA trial at the annual scientific sessions of the American Heart Association (AHA) in Philadelphia in November, 2019-which I was fortunate to be able to attend in person with assistance from the AHA Early Career Blogger program.

The results⁴ validated the earlier COURAGE trial results with no significant differences overall with invasive vs conservative management strategies with cardiovascular mortality, overall myocardial infarction rates, unstable angina, heart failure, and resuscitated cardiac arrest as well as the composite, primary end-point. The presentation of the primary trial itself referred to the outstanding questions after the COURAGE trial results-namely:

Do higher risk patients based on substantial ischemia benefit?
Does elimination of referral bias by randomizing before cardiac catheterization cause outcomes to differ by planned strategy of management?
Does use of newer stents and FFR as needed impact outcomes?

The mode revascularization appeared to reflect contemporary practices with 98% of patients receiving PCI being treated with drug-eluting stents and 93% of bypass surgery candidates receiving a arterial graft. The trial did show a higher risk of all cause MI (procedural+non-procedural) at 6 months with invasive management which was reversed to a significant extent by 4 years of follow-up. Additionally, patient with significant angina at baseline had improvement of their quality of life and angina symptoms with revascularization. The above findings with MI were in contradiction to the COURAGE results-which however did show improvement in angina symptoms with revascularization.

These findings made me wonder if the ISCHEMIA trial had significant differences amongst the participants compared to the COURAGE trial-other than those mandated by trial protocol? I reviewed the baseline characteristics of the participants from the index publication of the COURAGE trial for both the PCI and the OMT groups. These were then compared and contrasted against the baseline characteristics identified for the ISCHEMIA trial population³.

The baseline characteristics of the ISCHEMIA trial population appeared to mirror the baseline characteristics in the two arms of the COURAGE trial published over a decade ago with some notable differences – Table 1. ISCHEMIA enrolled more than double the number of participants of the COURAGE trial, and consequently has greater statistical power in evaluating clinically meaningful end points. In terms of demographics, ISCHEMIA has enrolled significantly higher numbers of females and those of non-white ethnicity. ISCHEMIA also appears to have enrolled a significantly higher proportion of patients with hypertension and diabetes, but a lower proportion of patients with prior myocardial infarction. There also appears to be a greater number of patients with multi-vessel coronary disease and proximal left anterior descending disease in ISCHEMIA. There is a stark contrast in the location of recruiting sites – COURAGE was entirely US and Canada-based, whereas ISCHEMIA has only enrolled 16.5% of patients in the US and Canada. Participants of the ISCHEMIA trial also appear to have a better lipid profile and lower prevalence of active smoking. In terms of the medical treatment-more patients appear to be on statins in ISCHEMIA while surprisingly the proportion of other guideline-directed medications for treating coronary artery disease like aspirin, ACE inhibitor, beta blockers and antianginals appear to be lower. And eventually, only 41% of the trial participants were considered at ‘high level’ of medical optimization⁴.

The differences in the baseline characteristics between COURAGE and ISCHEMIA may have important implications. ISCHEMIA appears to have recruited a higher risk population including more women that will evaluate clinical benefits with strategy of upfront revascularization. Less than a fifth of the population being recruited from US Canada raises the question of the applicability of the results to the general US population. It is also of interest that a lower proportion of patients were on guideline directed medical therapy excepting for statins, when contrasted against a population of a similar US-based trial published over a decade ago. In summary, ISCHEMIA has important differences in the population recruited in comparison to the COURAGE trial – and these may need to be taken into account for interpretation of the final results, when published.

table 1

References:

Boden WE, O’Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, Knudtson M, Dada M, Casperson P, Harris CL, Chaitman BR, Shaw L, Gosselin G, Nawaz S, 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 Med. 2007 Apr 12;356(15):1503-16.
Shaw LJ, Berman DS, Maron DJ, Mancini GB, Hayes SW, Hartigan PM, Weintraub WS, O’Rourke RA, Dada M, Spertus JA, Chaitman BR, Friedman J, Slomka P, Heller GV, Germano G, Gosselin G, Berger P, Kostuk WJ, Schwartz RG, Knudtson M, Veledar E, Bates ER, McCallister B, Teo KK, Boden WE; COURAGE Investigators. Optimal medical therapy with or without percutaneous coronary intervention to reduce ischemic burden: results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial nuclear substudy. Circulation. 2008 Mar 11;117(10):1283-91.
Hochman JS, Reynolds HR, Bangalore S, et al; for the ISCHEMIA Research Group. Baseline characteristics of participants in the IISCHEMIA randomized clinical trial [published February 27, 2019]. JAMA Cardiol. doi:10.1001/jamacardio.2019.0014.
https://www.ischemiatrial.org/system/files/attachments/ISCHEMIA%20MAIN%2011.20.19%20with%20background.pdf . Last accessed 11/28/2019

My TOP 5 Moments of #AHA19 Scientific Sessions

November 29, 2019November 29, 2019 Michel Ibrahim, MD

Another successful scientific session in the books and I am already looking forward to the next one #AHA20, on to Dallas. But first, from the City of brotherly love, these are some of the highlights.

Let the countdown begin.

5) Late breaking clinical trials

There is usually a lot of noise around these sessions. People eager to learn about the new trials that may or may not affect their clinical practice, inspire new research ideas and question prior data. In Philadelphia, it was about time the long awaiting ISCHEMIA trial results go public. Practice changing or not? It’s coming out party was nail-biting and met all the expectations whether you think it will change your practice in the future or not. To quote Dr. Alice Jacobs in the New York Times, ISCHEMIA “certainly will challenge our clinical thinking”. Bottom line, my take home point from the session is simply to “Get with the Guidelines”. Adherence to GDMT is critical and presents a challenge for the best of us. Only time will tell the impact of the long-awaited ISCHEMIA results.

4) Presidential session

This year’s presidential session was mesmerizing, a bit longer understandingly so. A lot of highlights within my top 4^th moment. Started with a piece from Broadway’s hit musical “HAMILTON”. If you wanted to be in the room where it (#AHA19) happened, Pennsylvania Convention Center was the place to be. From Dr. Harrington’s incredible speech highlighting the incredible of work of the AHA in advancing clinical research and education, he reminded us “Evidence Matters”

What came after was stand up ovation worthy. Several students from the city of Philadelphia walked on stage to share their stories and stand up against Vaping. This is also a reminder to all of us to stand up for our patients not only in clinics and hospitals but where ever we can make a significant contribution to their health and well-being.

Finally, the presidential sessions weren’t without emotions. From Dr. Harrington’s emotional speech about his life story to CEO Nancy Brown’s remembering Bernard Tyson: “Through his words, actions and the way he made people feel, he left the world of health care – and the world at large – better than he found it”. This truly is exemplary of great leadership.

3) Vaping

Again, AHA not only talks the talk but also walks the walk. The American Heart Association is truly invested in fighting for the young and against the vaping epidemic on a multi-level nationwide platform. The future is bright and #AHA knows it as it is highlighted with their #QuitLying initiative that empowers kids in their schools and communities to call out different vaping companies on their lies.

#QuitLying

2) Cardiomyopathy

[The “PechaKucha Potpourri”: The Key Things You Need to Know about Interesting Cardiomyopathies] session moderated by Dr. Sandra Chaparro was one of my favorites and highlighted key points regarding less common cardiomyopathies. Information covered was very concise and it was provided by the experts in their respective fields such as Sarcoidosis, Chagas Disease, Check Point inhibitors and Myocarditis, Hypertrophic Cardiomyopathy, Stress Cardiomyopathy, Recovered Cardiomyopathy and Peripartum Cardiomyopathy. #AHA20 needs to bring back “PechaKucha Potpourri’’.

1) Early Career Blogger
This was the first time, I attended AHA as an Early Career Blogger. This was truly a different perspective where I had a lot of fun enjoying the different sessions, twitting the different topics of interests, meeting new people and representing the #AHA19.

Attending AHA19 Online From Anaheim, CA

November 26, 2019November 26, 2019 Anberitha Matthews, PhD

I have gone back and forth with attending the American Heart Association (AHA) Scientific Sessions online in 2017 (AHA17), to onsite (AHA18), and this year (AHA19) I attended online again. There was absolutely no comparison between attending AHA18 to the online versions! I was the first to say that going to conference is overwhelming because there is so much to see and so many people to meet. I have since come to appreciate the benefits to attending meetings onsite. Generally, I stay within my session [Atherosclerosis, Thrombosis, Vascular Biology (ATVB) or Hypertension (HTN)]. Attending online gives some limitations, such as being at home, work, or traveling, there is a time restraint as well as multiple distractions. I experienced them all! I was traveling to a conference that conflicted with AHA19, thus the distractions of traveling and keeping up with my meeting responsibilities was a lot to juggle. Once I was home, there was everything that goes along with getting settled back into the routine of things that gave me a distraction. This year was a beast of responsibilities, but before I discourage you from attending a meeting online, let me share some benefits and things that I enjoyed about having the flexibility of being online rather than onsite.

With all the distractions I experienced viewing AHA19 online, the main benefit was that I was able to watch sessions at my own pace as well as read the transcripts while the speaker was talking. In previous years I did not use that function; this year, I used it for almost all sessions, and it was wonderful. To be able to take screenshots of the talk and look things up later was the best tool in my toolbox. Additionally, there was a textbox that allowed viewers to ask questions to the speaker without standing in long lines and potentially not getting a response. That has happened to me more times than not because, as chance would have it, the best speakers and researchers show up to AHA meetings. These are the opportunities to get the best guidance regarding research methodology, mentoring, clinical expertise, and networking with some of the best in every discipline from around the globe.

I had the privilege of sitting in on several topics that sparked my interest. For example:

Update in Clinical Lipidology – Aspirin: Who Needs it Anymore? Discussing what markers should be considered with prescribing aspirin; role of and how to interpret the stenosis score; and considerations of patients with diabetes, family history of nonclassified plaque
Clinical Trials—ASPREE (JJ Mcneil, NEJM 2018; MATCH); ISAR REACT 5 Trial; and GLOBAL LEADERS)

Share some of your favorite parts of AHA19 with me in the comments or follow me on Twitter (@AnberithaT); also @ahameetings and @ATVBCouncil. Let’s keep this conversation going. Did you attend online or onsite?

Mechanical Circulatory Support in Acute Myocardial Infarction and Cardiogenic Shock

November 25, 2019November 26, 2019 Lina Ya'qoub, MD

Mechanical circulatory support (MCS) use in cardiogenic shock (CS) in the setting of acute myocardial infarction (AMI) is one of the most controversial topics in cardiology. Despite advances in many aspects in our cardiovascular field, mortality from CS remains unacceptably high. At the most recent AHA meeting, two studies suggested the use of intra-aortic balloon pumps (IABP) in CS might result in better outcomes compared to use of the percutaneous MCS device, Impella. I wanted to share my thoughts and ideas on this topic in light on these studies.

Major Randomized Clinical Trials on MCS

There is limited evidence in the literature supporting the use of MCS in AMI-CS^1-3. There are two main randomized clinical trials in MCS devices: IABP-SHOCK II and IMPRESS trials. IABP-SHOCK II trial compared IABP with medical treatment in 600 patients with AMI-CS, and showed no difference in survival between the two groups². The IMPRESS trial compared Impella CP versus IABP in 48 patients with CS-AMI and again did not show a difference in survival between these groups³.

Summary of recently-released studies at AHA19

A study by Amin et al, which included 48,306 patients undergoing percutaneous coronary intervention (PCI) with MCS from the Premier Healthcare Database, found wide variations in the use and clinical outcomes of Impella (mortality, stroke, bleeding, acute kidney injury) across hospitals. They also found that Impella had higher odds of adverse events and higher costs compared to IABP after adjusting for hospital, patients and time period⁴.

A separate study by Dhruva et al, which included 28,304 matched patients with AMI-CS undergoing PCI from NCDR Cath-PCI registry, found that 8,471 patients (29.9%) had IABP only, and 1,768 patients (6.2%) had Impella only. In-hospital outcomes were compared; in-hospital mortality was 34.1% with IABP compared to 45% with Impella use, and in-hospital bleeding rates were also lower in IABP group with 16% versus 31.3% in the Impella group⁵.

Discussion

In light of the results of these two observational real-world studies, I think we should take these results with a grain of salt. As we know, observational data has its own limitations, including confounding bias. Patients with AMI-CS may differ significantly based on their co-morbidity profile and angiographic complexity, which could potentially influence device selection; as we expect that patients who are sicker will usually get Impella as it provides more hemodynamic support compared to IABP, making comparison between these two devices inaccurate.

Both studies have shown an increase in the use of Impella over the past years, which is an opportunity to study these devices with larger numbers in different clinical settings. Registries across the nation are being established to build databases to compare these devices. Stronger evidence and more robust data with potential randomized clinical trials are much needed to help us know how to best manage this complex patient population and select which MCS device is optimal for each of our patient populations.

I would like to say special thank you to Dr Khaldia Khaled, my friend and colleague at Louisiana State University, for helping me write this blog and for her continued support.

References

1- Schrage B et al: Impella Support for Acute Myocardial Infarction Complicated by Cardiogenic Shock. Circulation. 2019 Mar 5;139(10):1249-1258.

2- Thiele et al: Intraaortic Balloon Support for Myocardial Infarction with Cardiogenic Shock. N Engl J Med 2012; 367:1287-1296. DOI: 10.1056/NEJMoa1208410

3- Ouweneel DM et al: Experience from a randomized controlled trial with Impella 2.5 versus IABP in STEMI patients with cardiogenic pre-shock. Lessons learned from the IMPRESS in STEMI trial. Int J Cardiol. 2016 Jan 1;202:894-6. doi: 10.1016/j.ijcard.2015.10.063. Epub 2015 Oct 9.

4- Amin et al: The Evolving Landscape of Impella® Use in the United States Among Patients Undergoing Percutaneous Coronary Intervention with Mechanical Circulatory Support.

Circulation. 2019 Nov 17. doi: 10.1161/CIRCULATIONAHA.119.044007.

5- https://www.tctmd.com/news/more-adverse-events-higher-costs-impella-new-observational-studies

AHA19 Was the Juice I Didn’t Realize I Needed

November 25, 2019November 26, 2019 Nasrien E. Ibrahim, MD

I left Scientific Sessions 2019 (AHA19) feeling so refreshed, empowered, motivated, and ready to rock it when I got home to Boston. I’ve been told this a lot, but I really felt it this time – that conferences serve more than just to educate and provide a venue for networking; they rejuvenate you. We all exist in our silos within our various institutions, but when we’re at AHA’s scientific conferences, we’re surrounded by people from all over the world, sharing science, friendship, and most important, hope for the future of medicine. AHA19 was particularly diverse in my eyes, I saw more people of color than I have seen at any scientific session, both attending and sharing their science.

When I’m at my institution, I sometimes forget about the world outside of it. You get caught up in the things going on at your institution and the work your research team is doing. You forget that there’s an entire world out there doing brilliant work too and that we’re all in this together – to better medicine and to open doors for the generations we will be passing the baton to. Attending conferences is one of the best ways to exit that bubble.

During the AHA President’s address, when several students from all over Philadelphia were on the stage sharing their stories as part of their ant-vaping campaign – #QuitLying Big Vape – I was assured that the future of medicine is so, so, so bright. The diversity of the students on that stage made me so proud and made me even more determined to work so hard in order to have the ability to create opportunities for the underrepresented women and men who will be our next generation’s healthcare leaders. It’s moments like these that you remember your life’s purpose.

My life’s purpose in medicine is 2-fold. 1) To make sure underserved, underrepresented, and disadvantaged patients receive world-class healthcare. Meaning, if you’re a Google executive or a school environmental services employee- you have the exact same access to healthcare, including organ transplantation. And 2) To make it to the top so that I can create opportunities for historically underrepresented women and men in medicine too. Get to the table and bring all of my friends, and by friends, I mean the women and men missed for opportunities because of the color of their skin, their religious preference or lack thereof, their sexual orientation, the way they wear their hair, their socioeconomic status, their disabilities, or any number of superficial factors that contribute to inequities in medicine.

When you identify your life’s purpose and keep it at the center of every decision you make, I can’t imagine not succeeding. We’ve been given a gift – we are scientists, academics, teachers, advocates, activists, and most important, we are healers. It’s our responsibility to pay that gift forward. Especially to those who don’t have a voice and haven’t made it through those doors yet.

I came home from AHA19 ready to crush more goals and added new ones to my list. AHA19 was literally the juice I didn’t realize I needed. I’m looking forward to AHA20 already.

How to Ensure Accurate Public Communication and Information Sharing

November 25, 2019November 26, 2019 Mo Al-Khalaf, PhD

Public communication and knowledge dissemination are often thought of as straight cut, on/off types of action, especially in medicine and the broader health sciences. However it is also very evident in our present day that miscommunication and inaccurate knowledge sharing exists, and has increasingly harmful consequences on the global population. Examples of this are plenty, such as the anti-vaccination movement, the numerous debates about food health categorization, novel diet constructions, and many others.

This year in Philadelphia, where the annual AHA meeting (#AHA19) was hosted, many relevant hot topics in medicine and healthcare were spotlighted, as is usually the case in these types of marquee events. The sense coming out of the meeting was that two major issues of discussion will have to be reckoned with:

The strong AHA call to action against the E-cigarette proliferating market, specifically in the way it targets youth and minority groups;
The global trial called ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches), with its top-line statement that there was no difference between interventionist and conservative therapies for patients diagnosed with stable ischemic heart disease.

Debates quickly flared, and the messages became misunderstood and controversial. These provide a real life test once again, on how we must optimize public communication and knowledge dissemination.

At #AHA19, the start of the #QuitLying campaign against the forces driving the steep increase in youth consumption of nicotine-containing vaping products, has garnered welcome applause and support by numerous school boards, concerned parents, and health conscious youths, former users of e-cigarettes or not. These groups are well aware of the high prevalence of use (more than 1 in 4 adolescents self report¹as e-cigarette users within the past 30 days, in 2019). Everyone is genuinely concerned about the ramifications if nothing is done. This is why the AHA has stepped up with the #QuitLying initiative to combat against the big industry players that drive the majority of the proliferation of these products within youth culture.

However when the message and information being distributed is counteracted by other sources that aim to mislead and obscure facts, public communication and knowledge sharing becomes much more convoluted and disrupted. Everyone has the right to voice their opinion, that’s not in question, and there is no way to avoid lies and deceptive facts from being shared. But there are new tools to clarify, and focus-deliver facts and evidence-based information to the public that deserves the highest quality data and analysis available to it.

The ISCHEMIA trial debate is another #AHA19 event that requires some clarification and focused-delivery of facts to the public. Some specific details of the trial are nicely outlined by my colleagues Dr. Renee Bullock-Palmer² and Dr. Adham Karim³, and the primary medical publications from the NIH database are available⁴ for review by whomever is interested in the full datasets from the sources. The issues I’m addressing here are not with the trial itself, but the resulting real world consequences that form after the debate from ISCHEMIA gets filtered thru multiple gateways, many well-meaning reporters, and some opinion dispensers that lean one way or another regarding the results of the trial.

ischemia trial

When public communication and knowledge dissemination is unidirectional and gated, patients can become misinformed and fueled with distrust towards the working relationships they have with their healthcare providers (doctors, nurses, surgeons, medical professionals and hospitals). This can lead to compromised decision making, and potentially harmful health outcomes. Optimizing communication and focused-delivery of evidence-based information are essential goals in our present day world, especially between the medical research and healthcare field, and the general public being served.

For many decades, from the initial beginnings of professional journalism and news reporting, up to the start of the new millennium, the available and universally accepted method of public communication and knowledge dissemination was a unidirectional pathway: researchers that perform primary data generation and analysis → reporting and communication by well established, reliable and accountable organizations → the public learning of new information that relates to their health and well-being. That being said, presently communication methods are not confined to the same gated, unidirectional path necessarily. The value of professionals in news reporting and communication is still high, and their existence is an asset and a necessity, especially in situations where communication has to be as widespread as possible in as short a time as is necessary. However, we need to encourage, promote, and build pathways that facilitate communication between the primary sources of data, and the general public, so that accuracy and integrity of the information is maintained, and trust is strengthened between all.

Everyone gains when public communication and knowledge dissemination is accurately spread, and trust is established and elevated when stakeholders are not walled off, so that they can be reachable and communicated with. Social media platforms, professional avenues to connect researchers to the public (like this one! The Early Career Voice) are pathways that can and should be used and widely encouraged, mainly as an effort to create a new model of communication that will reduce inaccuracy of information, increase the sense of trust between the public and those who serve it, and help us all lead a healthier life.

References:

Miech, Richard, et al. “Trends in adolescent vaping, 2017–2019.” New England Journal of Medicine15 (2019): 1490-1491.
Bullock-Palmer, Renee, MD, “My Top 10 Take Home Points from The ISCHEMIA Trial”, The Early Career Voice, November 18, 2019; (Page Link Here)
Karim, Adham, MD, “A Few Things the Critical Care Cardiologist Might Have Missed While Talking About the #ISCHEMIA Trial”, The Early Career Voice, November 18, 2019; (Page Link Here)
ClinicalTrials identifier: NCT01471522; NIH U.S. National Library of Medicine; (Link)

Recent Development and Advances in Basic Cardiovascular Science Research at AHA19

November 22, 2019November 26, 2019 David Paik, PhD

This year’s #AHA19 meeting, despite its abbreviated 3-day format, delivered a fantastic lineup of basic science research sessions, comprising of presentations from trainees to early career and senior investigators. Here I review some of the major topics in basic science cardiovascular research highlighted at #AHA19! This is by no means a comprehensive list of all exciting new developments in basic science, but what caught my attention the most.

Single-cell sequencing

Advances in single-cell RNA sequencing (scRNA-seq) technologies in the past 3-4 years have had a transformative effect on biomedical research, enabling the profiling and analysis of the transcriptomes of single cells at unprecedented resolution and throughput. scRNA-seq has allowed identification of novel or rare cell types, analysis of single-cell trajectory construction and stem or progenitor cell differentiation, and comparison of healthy and disease-related tissues at single-cell resolution. These applications have likewise been critical in advances in cardiovascular research, as evidenced by the generation of cell atlases of mammalian heart and blood vessels, elucidation of cardiovascular development and stem or progenitor cell differentiation mechanisms, and comparison of healthy and disease conditions for the development of novel therapeutic solutions.

#AHA19 highlighted the use of scRNA-seq in a truly wide gamut of applications, from cardiac development to cardiovascular tissue atlas to understanding disease mechanisms at the single-cell level. On Saturday Dr. Eric Olson opened his “Science Catalyst Keynote” by discussing scRNA-seq data of neonatal mouse cardiac regeneration, where his team identified intercellular crosstalk among various cell types and revealed the role of cardiac macrophage-specific Ccl24 in cardiomyocyte proliferation. In “Arrhythmia Research Summit: New Arrhythmia Concepts” session, Nathan Tucker from Massachusetts General Hospital showed his single-nuclei RNA-seq data of the four chambers of the human heart. During the “Abstract Rapid Fire Oral” sessions in Zone 1, Yifei Miao at Stanford University showed scRNA-seq data of human cardiac tissue with hypoplastic left heart syndrome.

On Sunday, during the “Mom, Where Do Baby Cardiac Myocytes Come From?” session, Fabienne Lescroart at Universite Libre de Bruxelles and Enzo Porrello at the University of Queensland displayed the use of scRNA-seq and lineage-tracing models to better understand cardiomyocyte division and proliferation during cardiac development in various model organisms. During the “Main Session”, Kory Lavine at Washington University School of Medicine discussed his scRNA-seq data that elucidated the cellular and molecular events of cardiovascular inflammation. Furthermore, the newly added “Single-Cell RNA Sequencing Bootcamp”, led by Jennie Lin and Nathan Tucker, was a major success with an enormous number of attendees. It was clear that such bootcamp events should be employed at other AHA subspecialty conferences, perhaps with a larger room and a longer session period to accommodate the full coverage of essential topics in the ever-evolving single-cell sequencing technology today. In the “Frontiers in Cardiovascular Target Discovery”, I myself shared unpublished data from our laboratory at Stanford Cardiovascular Institute in identifying organ-specific transcriptomic features of endothelial cells from the Tabula Muris dataset.

On Monday, the increasing use of single-cell sequencing in clinical and preclinical studies was evident. Anne Cornelissen from CVPath Institute discussed single-cell heterogeneity of endothelial cells post balloon angioplasty and stent implantation, and Man Rao from Fuwai Hospital in Bejiing, China showed scRNA-seq data in dissecting the cell type-specific molecular changes in heart failure.

Consequently, single-cell sequencing, in particularly those enabled by the microdroplet-based method, has become an essential tool in understanding cardiovascular biology. In addition to the heavy use of scRNA-seq, single-cell ATAC-seq is poised to become an important tool in deciphering the chromatin accessibility at the single-cell level, and spatial transcriptomic techniques for tissue- and location-specific investigation of gene expression.

A number of limitations of the technology does indeed exist, and I will discuss these in a later post. Stay tuned!

Omics

The “Omics Approaches in Cardiovascular Medicine” session on Sunday highlighted the role of multi-omics tools in basic and clinical cardiovascular research. Moderated by Sarah Franklin and Maggie Lam, the full spectrum of omics were discussed by the leaders in the field, including but not limited to: proteomics, metabolomics, epigenomics, “N of 1” personal omics, and machine learning.

With the continued efforts of the Trans-Omics for Precision Medicine (TOPMed) Initiative by the NIH NHLBI now entering Year 6, comprehensive integration and development of multi-omics tools will certainly be critical not only for advancing basic science but also in precision cardiovascular medicine.

Cardio-Oncology

Another big topic of the #AHA19 sessions was the rapidly rising field of cardio-oncology. What is cardio-oncology? I will have a blog post later dedicated to this subject. #AHA19 did a wonderful job of organizing a number of superb talks and poster presentations, from both the bench and the bedside. Some of the notable sessions included: “Cardio-Oncology or Onco-Cardiology: Cardiac and Cancer Treatment in the Balance”, “Novel Concepts in Cardio-Oncology”, and “Cardio-Oncology Debates” held on Monday.

In summary, the #AHA19, to me, was one of the most EXCITING sessions in recent years, which showcased the emergence and applications of new technologies used to address the new and old questions in cardiovascular research. The conference displayed innovative and insightful research from all over the world and from scientists in all career stages and diversity backgrounds, which may not have been the case for a few of the past sessions and thus should be highly lauded. Personally, I did wish that the conference was a bit longer (e.g. 3.5-day or 4-day instead of 3), as I found numerous interesting talks occurring concurrently. In particular, a majority of basic science talks were jam-packed into Sunday, calling for #AHA20’s extra efforts to spread the BCVS talks out across the three days of the sessions.

In any case, #AHA19 in my opinion was an IMMENSE success. Philadelphia was a wonderful (first-time!) venue for the sessions. All credit goes to the organizers of #AHA19, Dr. Bob Harrington, and the BCVS Council led by this year’s Chair Dr. Joseph Wu and Vice Chair Dr. Elizabeth McNally. I cannot wait to come back for #AHA20!

Late Breaking Science DAPA-HF: SGLT-2 inhibitors might influence Cardiovascular outcomes—- Benefits extend above and beyond HbA1c.

November 22, 2019November 26, 2019 Noora Alhajri, MD, MPH

The DAPA-HF trial was definitely the highlight of the scientific sessions at the AHA19 conference. I’m fascinated by the interesting outcomes and keen to learn more about the effect of SGLT-2 inhibitors on heart failure (HF) patients with preserved ejection fraction (HFpEF). In the next few lines, I’m going to briefly discuss the significant findings of DAPA-HF that were presented at AHA19, and will sooner nor later change the guidelines for management of patients with HFrEF.

Sodium-glucose cotransporter-2 inhibitor (SGLT-2 inhibitor) are relatively new class of drugs that act on inhibiting glucose reabsorption from proximal tubules, and thus decrease serum blood glucose concentrations.¹ They are commonly prescribed to treat T2DM patients who have poor glycemic control. However, new data are emerging in large support of the beneficial effects of SGLT-2 inhibitors not just on diabetics but also on non-diabetic HF patients. The data is big and clear as presented by Dr. John McMurray at AHA19 and it is expected to list SGLT-2 inhibitors such as dapagliflozin (Farxiga) as guideline directed medical therapeutics (GDMT) in 2021 for HF patients.

In the DAPA-HF, McMurray and colleagues enrolled 4,744 patients with heart failure characterized by reduced ejection fraction (defined as left ventricle ejection fraction of 40% or less) from 20 different countries. There were 2,139 patients diagnosed with diabetes who were more likely to have HF etiology of ischemia when compared to non-diabetic patients with HF. The study population consisted of high risk middle aged patients with a mean LV ejection fraction of 31%. The primary end point was a composite outcome consisted of cardiovascular death, HF hospitalization and urgent HF hospital visits over an average of 18 months. As for diabetics in the DAPA-HF trial there was a 25% reduction of CV events (HR 0.75, 95% CI 0.63-0.90) when comparing dapagliflozin against placebo. While, there was a 27% reduction among those who did not have diabetes (HR 0.73, 95% CI 0.59-0.91).²

“The relative and absolute risk reduction in death and hospitalization were substantial, clinically important and consistent across the age spectrum and baseline health status in both patients with or without diabetes”, McMurray noted.

The mechanism by which dapagliflozin provides the cardiovascular benefits that has been documented in the DAPA- HF trial remains to be unclear. It is plausible that SGLT-2 inhibition modifies many CV risk factors such as BP, visceral adiposity, arterial stiffness, hyperinsulinemia, albuminuria, circulating uric acid levels and oxidative stress. These factors are involved in several pathways related to the cardiorenal outcome, where SGLT-2 inhibitors regulate the glucose and sodium excretion and therefore modify the factors in these pathways.

Below is an illustration that explains the proposed pathways involved in cardioprotective role of SGLT-2 inhibitors³

dapahf

In conclusion, dapagliflozin offers new approaches to the treatment of HF with reduced ejection fraction (HFrEF) in patients with or without diabetes. Data from the DAPA-HF trail provides robust support for the initiation of SGLT-2 inhibitors in patients who either have an established CVD or at risk of developing CVD, and HF in particular, or at risk for renal decline and progression into chronic kidney disease (CKD).

References:

Mcmurray, John J. V., Demets, David L., Inzucchi, Silvio E., et al. A trial to evaluate the effect of the sodium–glucose co‐transporter 2 inhibitor dapagliflozin on morbidity and mortality in patients with heart failure and reduced left ventricular ejection fraction (DAPA‐HF. European Journal of Heart Failure. 2019;21(5):665-675. doi:10.1002/ejhf.1432
Packer, Milton. Lessons learned from the DAPA-HF trial concerning the mechanisms of benefit of SGLT2 inhibitors on heart failure events in the context of other large-scale trials nearing completion. Cardiovascular diabetology. 2019;18(1):129. doi:10.1186/s12933-019-0938-6
Ali, Amar, Bain, Steve, Hicks, Debbie, et al. SGLT2 Inhibitors: Cardiovascular Benefits Beyond HbA1c-Translating Evidence into Practice. Diabetes therapy : research, treatment and education of diabetes and related disorders. 2019;10(5):1595-1622. doi:10.1007/s13300-019-0657-8