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Women in Electrophysiology

While I was chatting with a few fellows in our hospital hallway, I met one of the fellows who was very interested in electrophysiology (EP). We had a very interesting chat about her application and future career forward. In this blog, I summarize my chat with Jasneet Devgun, an aspiring electrophysiologist.

Question: Hi Jasneet, great to have you here! Let’s start with this question: When and how did you know you love EP?

  • Answer: EP is something I never really thought of pursuing initially. In fact, I was interested in interventional cardiology since my second year of medical school. It was not until I met an electrophysiologist at the University of Chicago during my third year of medical school that I thought of EP as a possible future career. He was so excited to show me the world of EP and frequently took me to the lab to see EP in action. I still remember the day he said, “we need more women in EP…you should consider it.” From then on, my curiosity grew. I found myself drawn to the lab, scrubbing in on cases in residency and fellowship. The unique therapeutics, cutting-edge procedures and technology, intellectual and logical nature of EP, alongside very memorable and rewarding encounters with patients and wonderful attendings, made me realized that EP was the right field for me.

Question: This is great!! What are your thoughts about women in EP?

  • Answer: Last year, Dr. Kamala Tamirisa wrote a very thoughtful piece for EP Lab Digest on the EP fellow shortage.1 At the time, the National Resident Matching Program (NRMP) demonstrated that approximately 40% of 130 EP fellowship positions in the US were unfilled.2 In 2021, that number drastically declined to 4%. Despite clear rising interest in EP, there remains a paucity of women in the field. The American Board of Internal Medicine (ABIM) reported that women comprised only 10% of first year EP fellows, while remaining steady at this rate for the past 10 years.3

The paucity of women pursing EP is a multi-faceted issue. A recent survey of cardiology fellows-in-training published in the Journal of American College of Cardiology showed that the most significant reasons women did not choose EP were greater interest in another field, radiation concerns, lack of female role models, a perceived “old boys’ club” culture, and discrimination/harassment concerns.4 Another reason was length of training. Reasons why women did choose EP were positive mentorship, unique features about the specialty, expertise, and the presence of a female role model, the latter being the major influencer.

These results are not surprising, but there are ways we can tackle the question at hand.

Question: Absolutely!! And this brings up the importance of mentorship, can you share your experience with that?

  • Answer: I cannot stress enough the value of a good mentor. A good mentor inspires and cultivates the foundations of turning one’s future into reality. This was personally a huge factor for me; I did not know anything about, let alone consider, EP until I met electrophysiologists who had a genuine interest in my career development. Interestingly, none of them were female. Our male colleagues can be some of our biggest advocates. I certainly see how a female role model is uniquely relatable and valuable. However, the gap will remain until more females in EP exist. That said, networking with female electrophysiologists through existing organizations, as well as creating outreach/interest groups in-person and on social media to involve residents, medical students, and even undergraduate students, would be very effective.

Question: What advice do you have for fellows who do not know much about EP or are not sure if they would want to pursue it? What are some possible barriers to developing interest?

  • Answer: Exposure is key! Many trainees do not have much exposure to EP, and therefore may not know enough to develop an interest for it. Fellows should be aware of the distinctive benefits and exciting features unique to EP, which can only be achieved by increasing their time with electrophysiologists and the EP lab. This can also dispel concerns about radiation safety. For example, female cardiology fellows concerned about radiation in the survey may not know about the use of 3D mapping systems and multi-modality imaging, affording “low-fluoro” or “fluoro-less” cases and reduction in procedure times. Moreover, the development of robotically assisted procedures has provided an avenue to reduce occupational hazards.
  • I was fortunate that my residency program offered an EP elective, where I met electrophysiologists who were excited to show me their world. A structured elective early in residency and more electives for medical students, with some exposure to the lab, may help bridge the gap and channel early interest. The earlier it is, the better, since interests develop quickly (as did mine!).

Question: What are your thoughts on the length of training and how this may be impacting fellows’ wellness and career decisions?

  • Answer: Length of training is an important issue.1,4 This time overlaps with childbearing years and critical family development. Fellows, both male and female, should not have to feel like they must choose one over the other. There must be a genuine culture of promoting work-life balance during the long years of training. Fellows are also consequently faced with prolonged financial strains from student loan debt. These are things that fellows consider when deciding to pursue another fellowship. As medicine progresses towards a milieu of sub-specialties requiring ever-more training, the training structure must be modernized to optimize the workforce. Unfortunately, many people, including female fellows, may be missing out on great sub-specialties like EP because of these issues. Some have proposed modifying the last 6 months of cardiology fellowship as the beginning of CCEP, which is a great short-term goal.1 A “fast-track” program in fellowship that may even extend into residency may be a proposition for much later in the future. These changes can make a major difference in fellows’ career decisions, health, and well-being.  

Despite the paucity of women in EP, I am positive that the great strengths of this field will surpass any barriers to recruiting them. Building exposure early, having more visible role models and mentors, modification of the training structure, and many other solutions previously stated will allow for tremendous progress. Even simple interventions can make leaps and bounds in bringing more women into the wonderful world of electrophysiology.

I would like to thank Jasneet Devgun, DO, who is currently a general cardiology fellow at Henry Ford Hospital, and an aspiring electrophysiologist, for sharing her experience and thoughts with us. A special thank you goes to Dr. Judith Mackall and Dr. Cristina Tita who helped in writing this blog.

References:

  1. Tamarisa, K. The Importance of Choosing Cardiac Electrophysiology as a Career: Thoughts on the EP Fellow Shortage. EP Lab Digest. Available at https://www.hmpgloballearningnetwork.com/site/eplab/importance-choosing-cardiac-electrophysiology-career-thoughts-ep-fellow-shortage. Accessed October 9, 2021.
  1. Fellowship Match Data and Reports. National Resident Matching Program. Available at http://www.nrmp.org/fellowship-match-data/. Accessed October 9, 2021.
  2. Percentage of First-Year Fellows by Gender and Type of Medical School Attended. Available at https://www.abim.org/about/statistics-data/resident-fellow-workforce-data/first-year-fellows-by-gender-type-of-medical-school-attended.aspx. Accessed October 9, 2021.
  1. Abdulsalam N, Gillis AM, Rzeszut AK, Yong CM, Duvernoy CS, Langan MN, West K, Velagapudi P, Killic S, O’Leary EL. Gender Differences in the Pursuit of Cardiac Electrophysiology Training in North America. J Am Coll Cardiol. 2021 Aug 31;78(9):898-909. doi: 10.1016/j.jacc.2021.06.033. PMID: 34446162.

“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 health matters. If you think you are having a heart attack, stroke, or another emergency, please call 911 immediately.”

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BREAKING: Trials From the Realm of Cardiac Electrophysiology to Look Forward to in AHA Scientific Sessions 2021

The most anticipated cardiovascular conference of the year, AHA Scientific Sessions 2021 is upon us! In the days and hours leading upto the event, speakers have been revising their presentations, moderators going over their notes, and organizers working hard to prevent any glitches for this fully virtual experience. For many attendees, including myself, the most exciting part of the conference is the release of new trial data that may have a bearing on clinical practice and set the direction for future research. This year’s program is heavily ‘charged’ with incredible science in the field of cardiac electrophysiology. Below is a short guide to the studies from the field of electrophysiology being presented in the late breaking science (LBS) sessions.

CRAVE Trial- The Coffee and Real-time Atrial and Ventricular Ectopy (CRAVE) Trial

Presented by Gregory Marcus, MD

LBS.03 Prevention to Intervention in Atrial Arrhythmias, Sunday Nov 14th 8-9 AM EST

Many people report experiencing palpitations with higher caffeine intake and cutting down on coffee is a common advice heard in EP clinics. However, this anecdotal link is not backed by evidence with large population studies showing no association between caffeine intake and arrhythmias.1 Hence, the investigators of the CRAVE trial set out to investigate the effect of caffeine intake on cardiac ectopy.2 Based in University of California, San Francisco, this N-of-1 trial enrolled healthy volunteers and assigned them to 2-day blocks of coffee on-and-off days for 2 weeks. Continuous heart monitors were used to assess the primary outcome i.e., premature atrial and ventricular contractions. The results of this study will be interesting and may finally provide an answer to the important question- to bean or not to bean?

GIRAF Trial- Dabigatran Versus Warfarin on Cognitive Outcomes in Nonvalvular Atrial Fibrillation: Results of the GIRAF Trial

Presented by Bruno Caramelli, MD

LBS.03 Prevention to Intervention in Atrial Arrhythmias, Sunday Nov 14th 8-9 AM EST

Prevention of stroke is one of the pillars of management of atrial fibrillation (AF). However, even in the absence of stroke, patients with underlying AF have an increased risk of cognitive decline and dementia.3 Direct oral anticoagulants (DOACs) such as dabigatran have less food and drug interactions and better safety profiles compared to warfarin and are now considered the preferred agents for long-term stroke prevention in non-valvular AF. However, whether this consistent and stable anticoagulant effect offered by DOACs compared to warfarin translates into prevention or progression of dementia in the elderly patient with AF remains unknown. Investigators of the GIRAF trial conducted a prospective randomized controlled trial (N=200) comparing the effects of dabitran with warfarin on cognitive and functional outcomes at 2 years in an elderly population with AF.4 Clinicians from different fields will be craning their necks for the results of this important trial.

PALACS- Posterior Left Pericardiotomy Reduces Postoperative Atrial Fibrillation After Cardiac Surgery

Presented by Mario F Gaudino, MD

LBS.03 Prevention to Intervention in Atrial Arrhythmias, Sunday Nov 14th 8-9 AM EST

Post-operative AF plagues one-third of patients after cardiac surgery and is associated with longer hospital stays, increased risk of stroke, and higher mortality.5 Drainage of the pericardial cavity into the left pleural place by performing a posterior pericardiotomy has shown benefit in preventing post-operative AF in small studies. In the PALACS study, Dr. Gaudino and colleagues aimed to further assess the impact of posterior pericardiotomy during cardiac surgery on occurrence of post-operative AF.6 If this study also demonstrates a benefit with posterior pericardiotomy, the case for performing this relatively simple surgical procedure will be strengthened.

aMAZE Trial- Outcomes of Adjunctive Left Atrial Appendage Ligation Utilizing the LARIAT Compared to Pulmonary Vein Antral Isolation Alone: The aMAZE Trial

Presented by David Wilber, MD

LBS.03 Prevention to Intervention in Atrial Arrhythmias, Sunday Nov 14th 8-9 AM EST

Persistent symptomatic AF resistant to catheter ablation is an old nemesis of many cardiac electrophysiologists. Pulmonary vein antral isolation (PVI) has a lower success rate in maintaining sinus rhythm for persistent AF as compared with paroxysmal AF. In addition to harboring thrombi, the left atrial appendage (LAA) has been implicated in the maintenance of AF. The surgical Cox-Maze procedure, involving exclusion of the LAA and elimination of foci from in and around the LAA, has shown good results. The aMAZE trial is a randomized open-label trial that evaluated the safety and effectiveness of the transcatheter LARIAT System as an adjunct to PVI in patients with symptomatic persistent and long-standing persistent AF.7 The primary endpoint studied was freedom from episodes of AF > 30 seconds at 12 months. The results of this trial will provide further insight into the utility of LARIAT device LAA occlusion in conjunction with PVI.

 

I-STOP-Afib Trial- Testing Individualized Triggers of Atrial Fibrillation: A Randomized Controlled Trial

Presented by Gregory Marcus, MD

LBS.04 Information Overload? Striving to Improve Care Delivery Through Digital Health and Automated Data, Sunday Nov 14th 2.45-3.45 PM EST

A group of researchers at University of California, San Francisco have been working to study the triggers of AF in partnership with patients through the Health eHeart Study and StopAfib.org. In preparation for the I-STOP-Afib trial, they conducted a survey of 1,295 patients and found that almost three-quarters of patients self-identified triggers for episodes of AF, most commonly alcohol, caffeine, exercise, and sleep deprivation.8 The I-STOP-Afib study randomized patients to either trials of exposure and elimination of self-identified AF triggers for 6 weeks or symptom surveillance only.9 They used a smartphone application to direct the 2 groups, record daily AF episodes, and assess daily the quality of life at the end of 10 weeks. Regardless of the results, this study will set an example of using technology to empower patients to take charge of their own health.

Detection of Atrial Fibrillation in a Large Population Using Wearable Devices: The Fitbit Heart Study

Presented by Steven Lubitz, MD

LBS.04 Information Overload? Striving to Improve Care Delivery Through Digital Health and Automated Data, Sunday Nov 14th 2.45-3.45 PM EST

Over the past few years, wearable tech has been making waves in the field of EP. Smartwatch based continuous rhythm monitoring has shown promise in the detection of undiagnosed AF. The Fitbit Heart Study is a remote single-arm trial of 450,000 Fitbit device users in the US.10 It is designed to study the validity of a novel software algorithm for detecting AF. The study used compatible Fitbit devices using pulse photoplethysmography to detect irregular heart rhythms and followed abnormal readings with a week-long ECG patch. The strength of the Fitbit Heart Study over prior studies like the Apple Heart Study will be a large, predominantly female population using both iOS and Android smartphone platforms.

Log into AHA Scientific Sessions to livestream the release of these and other exciting trials. Keep buzzing #EPEEPS!

References:

  1. Voskoboinik A, Kalman JM, Kistler PM. Caffeine and Arrhythmias: Time to Grind the Data. JACC Clin Electrophysiol. 2018;4(4):425-432. doi:10.1016/j.jacep.2018.01.012
  2. https://clinicaltrials.gov/ct2/show/record/NCT03671759?view=record
  3. Santangeli P, Di Biase L, Bai R, et al. Atrial fibrillation and the risk of incident dementia: a meta-analysis. Heart Rhythm. 2012;9(11):1761-1768. doi:10.1016/j.hrthm.2012.07.026
  4. https://clinicaltrials.gov/ct2/show/NCT01994265
  5. Greenberg JW, Lancaster TS, Schuessler RB, Melby SJ. Postoperative atrial fibrillation following cardiac surgery: a persistent complication. Eur J Cardio-Thorac Surg Off J Eur Assoc Cardio-Thorac Surg. 2017;52(4):665-672. doi:10.1093/ejcts/ezx039
  6. Abouarab AA, Leonard JR, Ohmes LB, et al. Posterior Left pericardiotomy for the prevention of postoperative Atrial fibrillation after Cardiac Surgery (PALACS): study protocol for a randomized controlled trial. Trials. 2017;18(1):593. doi:10.1186/s13063-017-2334-4
  7. Lee RJ, Lakkireddy D, Mittal S, et al. Percutaneous alternative to the Maze procedure for the treatment of persistent or long-standing persistent atrial fibrillation (aMAZE trial): Rationale and design. Am Heart J. 2015;170(6):1184-1194. doi:10.1016/j.ahj.2015.09.019
  8. Groh CA, Faulkner M, Getabecha S, et al. Patient-reported triggers of paroxysmal atrial fibrillation. Heart Rhythm. 2019;16(7):996-1002. doi:10.1016/j.hrthm.2019.01.027
  9. https://clinicaltrials.gov/ct2/show/study/NCT03323099
  10. Lubitz SA, Faranesh AZ, Atlas SJ, et al. Rationale and design of a large population study to validate software for the assessment of atrial fibrillation from data acquired by a consumer tracker or smartwatch: The Fitbit heart study. Am Heart J. 2021;238:16-26. doi:10.1016/j.ahj.2021.04.003

“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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AHA Scientific Sessions 2020: A Preview for Electrophysiologists

AHA 2020 kicks off today in its new virtual format. As we all adjust to the new normal, many won’t have the luxury of time off dedicated to physically attending the conference. Therefore, we would likely be tuning in intermittently, in the midst of our busy schedule, to attend some of the sessions that align with our interests. With that in mind, and as an electrophysiology (EP) enthusiast, I will try to highlight some live sessions from this year’s program that should be interesting to the EP community.

Friday, November 13th

Session: Late-Breaking Science (LBS.01) – Heart Failure and Atrial Fibrillation: Vitamins, Minerals, Nutrients, and More

  • Session start time: 10:30 am (to 11:30 am) CST
  • At 11:05 am, Dr. Christine Albert will present the results of the Vital Rhythm Trial: Omega-3 Fatty Acid and Vitamin D Supplementation in the Primary Prevention of Atrial Fibrillation.

 

Session: 01 – Cardiac Procedural Innovation for Special Patient Groups

  • Session start time: 12:00 pm (to 01:00 pm) CST
  • At 12:50 pm, Dr. James Freeman will present results from the NCDR LAAO Registry regarding Patterns of Post-procedural Anticoagulation and Anti-platelet Therapy and Associated Outcomes for Watchman Left Atrial Appendage Occlusion.

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Saturday, November 14th

Session: ME.578. Atrial Fibrillation: Time for a Paradigm Shift in Management

  • Session start time: 09:00 am (to 10:00 am) CST
  • A great line-up of speakers including Drs. Andrea Russo, Jennifer Wright, Rakesh Gopinathannair, Kim-Lien Nguyen, and Prashanthan Sanders will navigate through the paradigm changes that have taken place in AF management over the past decades, including updates and novel treatment approaches.
  • The session will be moderated by Drs. Christine Albert and Jonathan Dukes.

Session: CVS.650 – Novel Technologies for Arrhythmia Detection: The Data Tsunami is Around the Corner

  • Session start time: 10:30 am (to 11:30 am) CST
  • Another wonderful group of speakers including Drs. Leslie Anne Saxon, Marco Perez, Khaldoun Tarakji, Paul Varsoy, and Janet Han will discuss the use of wearable technologies, their impact on patient management, potential medico-legal, and ethical implications, and the interface with social media.
  • The session will be moderated by Drs. Miguel Angelo Leal and Richard Page.

 Session: CVS.281. Cardiac Physiologic Pacing – When, How, and Where?

  • Session start time: 12:00 pm (to 01:00 pm) CST
  • In this interactive session, a panel of experts that includes Drs. Kalyanam Shivkumar, Pugazhendhi Vijayaraman, Weijian Huang, Daniel Lustgarten, and Mina K Chung will share their pearls on how to access the distal conduction system for pacing and will debate the role of this approach in pacing and cardiac resynchronization.
  • The session will be moderated by Drs Gaurav Upadhyay and Kimberly Selzman.

 Session: 03 – Current Challenges in Coronary and Valve Disease

  • Session start time: 12:00 pm (to 01:00 pm) CST
  • At 12:40 pm, Dr. Otavio Berwanger will present the primary results of the RIVER Randomized Trial: Rivaroxaban versus Warfarin in Patients With Bioprosthetic Mitral Valves and Atrial Fibrillation or Flutter.

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Sunday, November 15th

Session: CVS.813 – Circulation and European Heart Journal Session

  • Session start time: 12:00 pm (to 01:00 pm) CST
  • At 12:40 pm, Dr. Harry Crijns will be presenting European Heart Journal: The Year in Arrhythmias, highlighting the most prominent science published this year in EHJ in the field of cardiac arrhythmias.

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Monday, November 16th

Session: Late-breaking Science (LBS.06) – To Screen or Not to Screen, and then What? Studies of Detection and Treatment of AF

  • Session start time: 9 am (to 10:00 am) CST
  • An exciting late-breaking session dedicated to clinical trials focused on screening, monitoring, and early intervention for atrial fibrillation.
  • At 09:05 am, Dr. Subodh Verma will present the primary results of the SEARCH-AF Cardiolink Randomized Trial: Enhanced Monitoring for Atrial Fibrillation Following Cardiac Surgery.
  • At 09:13 am, Dr. Steven Lubitz will present the results of the VITAL-AF Trial: Screening for Atrial Fibrillation in Older Adults at Primary Care Visits Using Single Lead Electrocardiograms.
  • At 09:21 am, Dr. Steven R. Steinhubl will present the results of the mSToPS Trial: 3-year Clinical Outcomes in a Nationwide, Randomized, Pragmatic Clinical Trial of Atrial Fibrillation Screening – mHealth Screening to Prevent Strokes (mSToPS).
  • At 09:37 am, Dr. Jason Andrade will present the results of the EARLY-AF Trial: A randomized clinical trial of an early invasive intervention for atrial fibrillation.

Session: CVS.582 – 2020 Update on Cardiovascular Clinical Guidelines

  • Session start time: 10:30 am (to 11:30 am) CST
  • At 10:30 am, Dr. Lin Chen will be presenting Atrial Fibrillation Management in 2020, summarizing the most recent clinical practice guidelines and evidence-based care for atrial fibrillation.

Session: CVS.697 – Electrophysiology Guidelines and Expert Consensus Statements: Top 5 New Releases and Updates

  • Session start time: 12:00 pm (to 01:00 pm) CST
  • This session will cover the most important new recommendations from the EP focused guidelines that have been released in the last 2 years, namely the 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay (By Dr. Kenneth Ellenbogen), the 2019 HRS/EHRA/APHRS/LAHRS Focused Update to 2015 Expert Consensus Statement on Optimal Implantable Cardioverter-Defibrillator Programming and Testing (By Dr Martin Stiles), the 2019 HRS/EHRA/APHRS/LAHRS Expert Consensus Statement on Catheter Ablation of Ventricular Arrhythmias (By Dr Usha Tedrow), the 2019 HRS Expert Consensus Statement on Evaluation, Risk Stratification, and Management of Arrhythmogenic Cardiomyopathy (by Dr Hugh Calkins) and the 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (by Dr. Douglas Packer).

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While there seem to be no EP-specific live sessions scheduled for that day, there will be plenty of exciting general events, including a series of COVID19-related sessions (definitely relevant to every cardiologist regardless of subspecialty). It may also be a good time to watch some of the terrific On-Demand EP sessions or simply catch up on any live EP sessions that you may have missed (should all be available to stream on-demand once presented).

I hope this was a helpful guide, and looking forward to an amazing conference and great science!

 

“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.”