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To Stent or not to Stent?

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

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

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

A few big wins for the ISCHEMIA trial:

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

 

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

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

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

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

 

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

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

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

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

 

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

 

References:

https://www.ischemiatrial.org/

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

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

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

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Can artificial intelligence save our lives?

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

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

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

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

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

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

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

References:

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

 

 

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What Does Tobacco 21 Mean for Adolescent Tobacco Use?

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

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

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

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

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

References:

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

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

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

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

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

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

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

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

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

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A Paycheck Away: Financial Fitness in Medicine Part I

Piggy bank with bandages

(source: flickr/teegardin)

Picture this. You’re an established cardiologist practicing in the city of your dreams. You have the car, the house, the second car, the country club membership, and a few luxury items in your wardrobe. Life is good. But it throws you a curveball, as it has the tendency to. You injure yourself while skiing in Aspen, and after a few painful operations, have to complete an intense rehabilitation program before returning to work. Can you afford to take a month off? How about two weeks?

A recent survey found that 69% of Americans have less than $1000 in savings, and one in three have $0 saved for retirement. I know what you may be thinking – these data primarily represent lower-income households. True. But that same survey found that 23% of respondents making greater than $150,000 had less than $1000 in emergency funds (6% had nothing set aside). A 2015 Nielsen study found that 25% of Americans earning more than $150,000 per year lived paycheck to paycheck. Couple that with this story of a physician-physician couple with a household income of $750,000 but a net worth of $0. This is the plight of many high earning but not rich yet Americans (or HENRYs as they’re referred to in financial circles).

How can you prevent yourself from becoming a perpetual HENRY? How can you break the Work = Income redundancy? If you’re reading this, it’s now. And it begins with changing your mindset towards money/finances. We, as physicians weren’t exposed to much of the finance world as we spent our income-free 20s buried in textbooks and Prometric centers. In fact, many of us resent money, we ignore money and whenever someone talks too much about money it makes us cringe (re: contract negotiations). Then, we received a few short years of lower-middle-class income before being thrust into the top 1% of earners. Like a first-round draft pick, we rush to the local dealerships and realtors with our big smiles and our big checks ready to make up for the lost time.

This is precisely the moment, in the first three to five years of being an attending, that we set our financial trajectory. Here are a few tips that I’ve gathered from people much smarter than I to hopefully help you set your trajectory high.

  • Don’t fall for bad advice

Most physicians don’t know much about personal finance, and an advisor is a great idea if that’s your situation. However, choose your advisor like you to choose your barber. Don’t just jump at the first offer. Do your research, ask your attendings, ask financially responsible friends/family. And don’t be afraid to do it yourself! Here are a few sources to check out: WhiteCoatInvestor podcast, Valuetainment on youtube, RyanScribner on youtube

  • Live like a resident initially

It’s easier said than done but hold off on buying that house or that car for the first few months or years. This allows you to pay off debt, improve your credit, save/invest and settle into your new income. If you have student loans, it also allows you to refinance them and determine what your new payment structure will be. Some rules of thumb for early spending: do not spend more than 15-20% of your annual income on a car, 20% goes to savings & investments, set up an emergency fund 2-5%, give to charity (variable). Check out this Charles Schwab survey on why people live paycheck to paycheck; the responses might surprise you.

  • Retirement is closer than you think

It’s not too early to start planning for retirement. Many physicians work well into their 70s and 80s due to the reliance on an income to maintain their lifestyle. Do a simple calculation now. How much per year of income would you need to live comfortably? Multiply that by 25. That is the amount of money you need to have for retirement by age 65. Check out this tale of two doctors for more.

It’s important for physicians to tend to our financial fitness as we tend to our physical fitness. Just like everything in life, practice makes perfect. Try saving 20% of your resident/fellow salary this month. Practice trading stocks using a simulator like Investopedia’s. If you’re going to be an attending in July 2020, plan out how the rest of the year looks for you financially, so it won’t be such a surprise when you get there. I hope this post was informative and even a little entertaining. Please look out for more on this topic in the future.

Back to your regularly scheduled programming…

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

References (embedded links):

https://content.schwab.com/web/retail/public/about-schwab/Charles-Schwab-2019-Modern-Wealth-Survey-findings-0519-9JBP.pdf

https://www.fa-mag.com/news/nielsen–even-many-high-earners-live-paycheck-to-paycheck-22704.html

https://drcorysfawcett.com/success-is-not-measured-by-income/

https://thephysicianphilosopher.com/tale-of-two-doctors/

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We Need to Be Better About Recognizing Sudden Cardiac Arrest

“10-year-old dies of an apparent heart attack on Delta flight,” “High School Football Player Dies Suddenly,” “Teen Dies on the Court,”— these stories shock the community, cause people to ask questions, and are too soon forgotten. We need to be better about recognizing cardiac arrest in the young, and that starts with better cardiac arrest education. Many people do not realize the difference between cardiac arrest and myocardial infarction or “heart attack.” While a heart attack is often preceded by chest pain and other symptoms, cardiac arrest is usually not.

Sudden Cardiac Arrest (SCA) is a life-threatening emergency that occurs when the heart suddenly stops beating; 1 this can be due to a structural abnormality of the heart, a rhythm disturbance, or often an unknown cause.2 A heart attack usually has a different cause, occurring when the supply of blood to the heart becomes blocked, typically by a plaque or blood clot in an artery.3

Sudden Cardiac Death (SCD) is the leading cause of death in athletes during a sport.4 Delay in recognition leads to a rapid decline in survival, with a decline of survival by 10% for every 1-minute defibrillation is delayed.5 Studies show that survival can be improved if AED is applied and used within 3-5 minutes of arrest. Schools with on-site AED demonstrate survival from SCA as high as 71%.4 However, in order for proper AED use to occur the arrest must be recognized quickly.

What makes it hard to recognize sudden cardiac arrest?

  • Lack of Education on the subject— SCA is not on peoples’ radar for the young patient. Our brains are programmed to think about heart attacks involving older people clenching their chest, sweating, proclaiming pain, and not about SCA, which is much more silent. Anyone who suddenly collapses and is non-responsive to verbal stimuli should be treated as a sudden cardiac arrest until proven otherwise.5
  • SCA may present with seizure-like activity; in as many as 20% of SCA events, there will be myoclonic jerking activity such as shaking, quivering, or twitching.5 This activity may lead to observers mistaking the arrest for a seizure and not applying the right emergency protocol.
  • A victim of SCA may still be “breathing”; Agonal respirations/gasping appear like chest and abdominal movement. These breaths can be mistaken for breathing, but are ineffective to sustain life.4
  • Lack of AED’s or access to AED’s and Emergency Action Plans (EAP); some schools may not have AED’s, or they are locked after hours in an office or locations far from the athletic venue. Surveys have demonstrated that low socioeconomic status, schools with primarily black race, and rural schools are the most common barriers to AED use.6

Recently, the Parent Heart Watch has started a campaign to make the use of AED’s easier and to educate the public on their use with the campaign Call, Push, Shock. In addition, Dr. Jonathan Drezner and the NFL to educate the public on recognizing sudden cardiac arrest (Recognize, React, Rescue). These resources are helpful in sending a unified message to the public, providers and to everyone involved to help save lives.

What can we do to improve?

  • Early recognition and emergency activation – Suspect SCA in any collapsed or unresponsive athlete/person and call 911 immediately.
  • Access to early defibrillation – the goal is less than 3-5 minutes until the first shock.
  • Provide high-quality CPR and early access to advanced life support/EMS – Currently, the average time of EMS arrival is 6.1 minutes and can be longer in some communities.4 The more people trained and educated to start CPR while awaiting EMS, the better the outcomes.
  • Make sure all venues have EAP’s that encompass the above and more. An EAP should be established at any athletic venue and should be specific to the athletic venue. An effective EAP should encompass emergency communication (working with local EMS and having a detailed location/address of the venues available, including directions to access points from major roads), personnel, and equipment. They should be reviewed and practiced annually to ensure they work with mock SCA scenarios.
  • Continue to push for legislation to enforce the use of AED’s in schools. As of 2017, only 17 states required AED installation in schools, and only 5 of these offered funding for AED equipment.7

Want to learn more? Check out the Call, Push, Shock page to explore the mission and find local organizations— chances are there is a passionate person in your state or city who has been directly affected by SCA and could use your support and help!

 

Sources:

  1. “You Can Save A Life from Sudden Cardiac Arrest.” Call, callpushshock.org/.
  2. Harmon, Kimberly G. “Incidence and Etiology of Sudden Cardiac Death in Athletes.” IOC Manual of Sports Cardiology, 2016, pp. 63–73., doi:10.1002/9781119046899.ch7.
  3. “Heart Attack.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 30 May 2018, www.mayoclinic.org/diseases-conditions/heart-attack/symptoms-causes/syc-20373106.
  4. Toresdahl, Brett, et al. “Emergency Cardiac Care in the Athletic Setting: from Schools to the Olympics.” British Journal of Sports Medicine, vol. 46, no. Suppl 1, 2012, pp. i85–i89., doi:10.1136/bjsports-2012-091447.
  5. Drezner, Jonathan A., et al. “Inter Association Task Force Recommendations on Emergency Preparedness and Management of Sudden Cardiac Arrest in High School and College Athletic Programs: A Consensus Statement.” Prehospital Emergency Care, vol. 11, no. 3, 2007, pp. 253–271., doi: 10.1080/10903120701204839.Soun ds
  6. Saberian, Sepehr, et al. “Disparities Regarding Inadequate Automated External Defibrillator Training and Potential Barriers to Successful Cardiac Resuscitation in Public School Systems.” The American Journal of Cardiology, vol. 122, no. 9, 2018, pp. 1565–1569., doi:10.1016/j.amjcard.2018.07.015.
  7. Lou, Nicole. “Few States Require AEDs in Schools.” Medical News and Free CME Online, MedpageToday, 27 Mar. 2017, www.medpagetoday.com/cardiology/arrhythmias/64159.

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

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ECPR: What is it? And what do we know in 2020?

Despite advances in the resuscitation field, cardiac arrest, especially cardiac arrest in the setting of cardiogenic shock, continues to carry significant morbidity and mortality. This topic continues to challenge healthcare providers on ways to improve outcomes in patients with refractory cardiac arrest. Extra-Corporeal Membrane Oxygenation (ECMO) is a type of mechanical circulatory support device utilized for various conditions, including cardiogenic shock and multi-organ failure. I heard about ECPR recently, so I wanted to share what is out there, and potentially motivate colleagues and professionals to share their thoughts on this important topic.

What is ECPR?

ECPR (Extra-corporeal Cardio-Pulmonary Resuscitation) is the implementation of ECMO in selected patients with cardiac arrest, and may be considered when conventional CPR efforts fail in a setting with expeditious implementation and support.by skilled providers When/where does ECMO cannulation occur in these patients?

Patients with cardiac arrest and ongoing CPR are transported to the hospital while ongoing resuscitation efforts are being taken. ECMO potentially provides the circulatory and respiratory support these sick patients need until reversible conditions are addressed. ECMO cannulation usually occurs at the healthcare center, where skilled personnel and healthcare providers have expertise in ECMO. Figure 1 shows a simple illustration veno-arterial VA-ECMO utilized in ECPR.

Figure 1: Simple schematic illustration of veno-arterial VA-ECMO utilized in EPCR.

Figure 1: Simple schematic illustration of veno-arterial VA-ECMO utilized in EPCR.

What is the scientific evidence for the use of ECPR?

Unfortunately, there are no randomized controlled trials (RCTs) on the use of ECPR in cardiac arrest patients at this time. The evidence supporting ECPR comes from observational studies in the past two decades, in patients with out-of-hospital cardiac arrest, and studies looking at ECPR in in-hospital cardiac arrest. Many, but not all, of the observational studies showed overall favorable neurological outcomes in those who receive ECPR compared to conventional CPR. It is important to note, however, that these studies had variable inclusion criteria, and potential risk for confounding bias, making their validity and generalizability questionable.

Are there any AHA guidelines supporting the use of ECPR?

AHA 2019 Guidelines Updates:

Recommendations—Updated 2019

  • There is insufficient evidence to recommend the routine use of ECPR for patients with cardiac arrest.
  • ECPR may be considered for selected patients as rescue therapy when conventional CPR efforts are failing in settings in which it can be expeditiously implemented and supported by skilled providers (Class 2b; Level of Evidence C-LD).

Why is this important?

Some studies in the past 2 decades have shown that ECPR might be associated with favorable neurological outcomes compared to conventional CPR. It is known that neurological outcomes in cardiac arrest patients have a significant effect on morbidity and mortality. As such, although these are observational studies with limited evidence, they shed light on a potential therapy that could lead to better outcomes in this very sick population. Future studies, including RCTs, are much needed to assess the outcomes of ECPR and identify patients who would benefit the most from this potential therapy.

I would like to say special thank you to my friend and colleague, Dr Khaldia Khaled, for her help on this blog.

Reference

Panchal et al: 2019 American Heart Association Focused Update on Advanced Cardiovascular Life Support: Use of Advanced Airways, Vasopressors, and Extracorporeal Cardiopulmonary Resuscitation During Cardiac Arrest: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2019;140:e881–e894. DOI: 10.1161/CIR.0000000000000732.

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

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Heart Failure Management and the Challenge of Systems-Based Practice Implementation for Optimization of Guideline Directed Medical Therapy

As the population continues to age, along with the addition of lifesaving and prolonging medical therapies, the prevalence of HF will continue to increase. In this article, we will solely focus on Heart Failure with Reduced Ejection Fraction (HFrEF), and the potential solutions to the issues with the optimization of guideline directed medical therapy (GDMT) on a systems level.

Robust evidence has established a mortality benefit of GDMT for patients with left ventricular dysfunction. Although the known benefits of GDMT have continued to solidify, there remains a visible gap among patients with HFrEF and the efficacy of treatment.

The issues that exist are likely not based on the individual pharmaceutical therapies profile. Furthermore, medication intolerance and incomplete prescription data can only partially be blamed. Nevertheless, the problems are on a bigger scale, and they involve many different components of our care system.

Let’s discuss some of the barriers to the optimization of GDMT in patients with HFrEF: patient providers and the care system. Providers, including non-cardiologists, should be trained adequately to be able to initiate patients on appropriate medications for HFrEF. They should also know the threshold to discontinue the medications, their side effects, the major contraindications, and, most importantly, when to seek help. HF patients are often complex, and it is essential to know that the different providers involved in their care should be in constant communication when it comes to their medical regimen. It is not enough to start the medication. It’s of utmost importance to continue increasing the dosages as tolerated by the patient to at least the dosages used in the different studies where these medications have shown the most benefits. Education is a key aspect, and it should involve the patient, patient’s family, providers, and everybody in the care system responsible for the patient including nurses and pharmacists. I propose 2 points among many out there:

  1. Standardized education for everybody involved in the patient’s care
  2. Standardized methods of communication between the different providers involved in the patient’s care including the patient and their families.
Heart Failure Summit 2017 Overview: Improving care and outcomes in heart failure

Figure 1. Heart Failure Summit 2017 Overview: Improving care and outcomes in heart failure1.

The purpose of this article is not to re-invent the wheel. The American Heart Association Heart Failure Summit in 2017 identified opportunities to improve care and outcomes and reduce disparities for patients with HF.(Figure 1). The purpose of this article is to remind us that we should be focusing more on implementation strategies for GDMT. We already have the tools, and, as we speak, we are adding new ones. It’s not just the tools; it is how you make use of them that will be the difference.

In summary, establishing and implementing systems of care that can help increase the number of patients on GDMT with the focus on improving medication adherence will ultimately lead to better outcomes. What is certain is that we must continue to meet the challenges of the realities of GDMT and their barriers. Our patients with heart failure depend on it.

References

  1. Pamela N. Peterson. Circulation: Heart Failure. The American Heart Association Heart Failure Summit, Bethesda, April 12, 2017, Volume: 11, Issue: 10, DOI: (10.1161/CIRCHEARTFAILURE.118.004957)

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

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Resolutions for 2020: Optimizing my Ikigai and the pursuit of happiness

While reflecting on an extraordinarily busy yet rewarding career year of 2019, I thought of my resolutions for 2020. I’m exceptionally bad at keeping new year resolutions, so I only made one: to be happy.

The concept of Ikigai

Happiness can mean different things to different people, and each of us, particularly medical professionals, is on a personal journey. There is a cool Japanese concept that encompasses multiple spheres of happiness, called Ikigai. Meaning “a reason for being”, it is well-depicted at the intersection of a quintessential Venn diagram that is really doing the rounds on the internet.

The concept of Ikigai

Image: Find your Ikigai. BODETREE, ADAPTED FROM FRANCESC MIRALLES

 

Fundamentally, it encompasses aligning one’s personal and career goals by combining the things one loves, is good at, what the world needs and what one is/could be paid for.1 Applied to physicians, it’s essentially the pinnacle of work-life balance.

While much is being discussed about physician wellness and work-life balance in recent times, for fellows in training and early career physicians, achieving a good work-life balance can be formidably challenging. In a formative and critical stage in your career, you want to maximize on all opportunities to learn and demonstrate competence. Given that conventional wisdom in medicine has always assumed that working harder and taking on more responsibilities is what makes one a better physician, you find yourself in a precarious position, and unable to say no, perhaps to avoid being considered “irresponsible” or “disinterested”, among others.

Thus “having it all” is way easier said than done. Thinking long and hard about this resolution, I went back to the concept of Ikigai. Seemingly, in order to discover your Ikigai, you must first find what you’re most passionate about, then find the medium through which you can express that passion.2

As cardiologists, or in fact medical professionals in general, I’d like to think that we’re already halfway there, having discovered our passion for the work we do. This got me thinking that a great part of my sense of happiness and fulfillment, my ikigai, could actually be achieved simply by getting better, more competent and efficient at my job, thus paving the way (and time) for doing the other things I also wanted to do.

While cardiology can be one of the most rewarding and emotionally fulfilling careers, it does come with significant sacrifices. In my sometimes unrealistic attempts to maintain a social life and achieve the so-called “work-life balance”, I recall doing exam revisions with my study buddy until midnight, forcibly satisfying a respectable quota of daily reading and “rewarding“ myself with a game of Settlers of Catan with my non-doctor friends late into the night, only to have to be present at rounds by eight the next morning. Especially during my initial years of training, in a pursuit to achieve work-life balance, I struggled trying to exclusively “slot out” time periods for work and leisure. As a result, my laptop became a mandatory accessory, finding a place at hangouts, parties and even vacations, where I’d squeeze in that little bit of work if I found the time.

P-squared: Matching passion with purpose

So, how do you effectively ensure time for other things in life, without compromising on expectations and quality at work? I found myself picking up handy tips from Morton T. Hansen’s fabulous book Great at Work: The hidden habits of top performers.3 One aspect that really resonated with me was the concept of P-squared, i.e. matching passion with a strong sense of purpose. He writes about how passion at work is not merely taking pleasure in the work itself, but can come from success, social interactions, learning and competence. In short, pursuing activities that are personally meaningful.

Working smarter over working harder

One way of ensuring one’s focus on meaningful activities is to prioritize and decide what work you will pour your heart and soul into.3 Naturally, each task is not guaranteed to trigger your interest to the maximum. While the “chores” that are one’s professional responsibility absolutely need to be done (and prioritized), it’s important to pick and prioritize ancillary projects, thus ensuring one’s full focus and ultimately better seeing it to fruition. Given professional hierarchy in medicine, it can sometimes be difficult to say no early on in one’s career. A piece of brilliant advice I’ve been given in such scenarios is: If it’s part of a project you happen to land but which can (and should) be done by someone else, delegate it smartly and oversee the work. The advantages are multiple: you facilitate an opportunity for someone else to gain that experience, you gain the experience of overseeing a job and most importantly, it reduces an unnecessary load on you, allowing you to make the time for the projects that matter.

Also, focusing on doing fewer things but doing them better, means that you have more time left over, which you can spend on your private life, effecting towards some degree of work-life balance.3

Share the load

A roster has a purpose and it’s important to share the load. Accepted that we all have our unique personal challenges, some more than others, I found myself chronically covering another person’s roster, stressing out and compromising on my own private time that I could very well have spent with family and friends. While mutual cooperation within a working unit is vital to good work-life balance, particularly in medicine, it should certainly not be at the expense of one’s happiness.

Take breaks

Doctor Hansen also writes about the importance of keeping one’s passion in check, and not allowing it to consume you.3 Grossly translated, it means making the time for one’s private life, be it travel, working out, reading or playing a sport. Thanks to a wonderfully supportive spouse, I might have gotten away with amalgamating work and life on most occasions, but I appreciate the necessity of making an effort to keep work passions in check, and actively make some quality time for family and friends.

“Work on how you work, not on protecting your life from work” – Morten T Hansen

All things said, I’m extremely grateful for being able to do something that I absolutely love, would hope I’m good at (!), get paid for and certainly what the world needs, neatly satisfying the central convergence of the multiple dimensions ikigai. One’s ikigai.is a deeply personal journey, and not one a mentor can spell out for you. However, actively making an effort to being efficient at work, being less stressed out and more balanced would certainly make one better at life too, translating to happier social and private lives. Achieving an Utopian level of work-life balance may not be possible, but finding happiness and fulfillment in what you do certainly is, and it’s a resolution I’m going to make an effort to keep this year. A happy new year to you all!

 

References

  1. Garcia H, Miralles F. Ikigai: The Japanese Secret to a long and happy life. New York: Penguin Books; 2016.
  2. Myers C. How To Find Your Ikigai And Transform Your Outlook On Life And Business. Feb 23, 2018. https://www.forbes.com/sites/chrismyers/2018/02/23/how-to-find-your-ikigai-and-transform-your-outlook-on-life-and-business/#6e99332a2ed4
  3. Hansen MT. Great at Work: The Hidden Habits of Top Performers. New York: Simon and Schuster paperbacks; 2018.

 

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

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How My Heart Failure/Transplant Fellowship Changed Me

When I started my Advanced Heart Failure/Transplant fellowship, my program director told me this year would change my life. I thought, “Yeah okay, whatever.” Boy, did that year change my life. The way I looked at the world changed entirely. Transplant is one of the most incredible medical therapies available to patients with end-stage heart, kidney, and liver disease, amongst others. Because of the generosity of the donor and the donor’s family, someone else is given a second chance at life. I always tell my heart transplant patients that they should now be celebrating 2 birthdays every year- to commemorate the gift of life given to them a second time over.

When I say that year changed my life, it truly did, and that change is lasting. When we’re on heart donor call and we’re evaluating hearts for suitability for our recipients, they’re usually younger hearts and cause of death is almost always unexpected. The stories are tragic- suicides, car accidents, freak accidents, and unintended drug overdoses, amongst other causes of death. As I sit in my pajamas (donor heart evaluations happen in the middle of the night a lot) on my laptop making sure I look through all personal and medical details available to me, I can’t help but create an image in my mind of who this donor is, what they may have looked like, where they worked, how much pain they must have been in if their death was intentional, and most gut-wrenching is all the people they left behind. Death is never easy, but when the donors are young, when the deaths are intentional, when the deaths are completely unexpected, it makes me realize how grateful we should be for this life we are living.

That year completely changed how I look at the world. No longer was I going to “sweat the small stuff” whether they were work related or personal. Every donor call reminds me that we sometimes spend so much time, energy, and emotions on things that, in the grand scheme of life, are truly insignificant. I became a happier and more content person. This year taught me that human connections are the most important thing in this world. My family, the friends I consider family, my friends at work, my patients, and all the people I cross paths with that have an impact on my life.

And on the other side of death, after I have pictured this life lost and the family and friends they’ve left behind, I get to tell one of our patients with end-stage heart failure that a heart “has become available” to them and now their life is going to change. I can’t imagine how they feel but I’ve heard all kinds of the emotions on the other end of that phone- tears, shock, anxious smiles that can be heard through the phone, and more tears. My patients tell me it’s a very emotional experience from the time they’re listing. Some have said it feels weird to be “waiting for someone to die” so that they can live. Some have noted guilt. Some of my patients have developed relationships with their donor’s families and I can only imagine how surreal that must feel.

What I do know is that I couldn’t imagine myself doing anything else and that being a Transplant Cardiologist has truly changed my life. I am grateful to the patients who have allowed me to play a small role in their journey and forever grateful to the donors and their families for this incredible gift of life.