How My Hospitalization During COVID Changed Me as a Physician

Takatsubo Cardiomyopathy, known as “broken heart syndrome,” is a form of heart disease that occurs following a traumatic or stressful event; people may present after the death of a loved one or other tragic accident. Thanks to COVID-19 we are currently in a time of great stress. The stress response of a global pandemic is something that we will see the effects of long after the treatment and vaccine are developed. There are many new reports and articles focusing on the stress related to COVID-19, tips to help combat that stress and guide wellness, and even some hospitals setting up wellness teams and meetings in the hospital to support the staff.

Early on we saw the stress associated with staying home— stress of the unknown and the lack of human contact, as well as stress with going to the hospital for any illness. Many saw a decrease in typical ER consults and patients who wanted to come to the outpatient clinics for fear of the disease, many were furloughed or lost their jobs. Patients admitted for COVID and non-COVID alike have experienced a different kind of stress: on top of the typical stress of hospitalization, there are often no visitors or family allowed at their side.

Visitor restrictions have left patients and parents facing already stressful admissions, with less support from family and/or caretakers. While hospital staff have adapted and learned unique ways like video chat and providing more frequent updates to families to bridge this isolation, it is still a difficult and stressful process.

I experienced being a patient during COVID-19 when I delivered my first baby this May, followed by what any pediatrician, including myself, would consider a minor/routine readmission for my daughter a few days after birth. We were admitted at the hospital where I work, so it was more familiar to me, and my husband was allowed to visit us during the birth (but not my daughter’s admission). While there was no lack of empathy or care from the staff, this was still a very stressful time for me without the physical presence and support of my family and friends being allowed in the hospital with us. I cannot imagine how much more stressful this would have been for someone who does not work in a hospital, had never been in a hospital, or was not allowed any family members present.

One positive thing that came out of this stress for me was a new appreciation and respect for my patients and their parents. Despite being able to FaceTime family, I was surrounded by new faces and a new experience; it was a scary and isolating few days. I realized that something I always felt was routine or minor as the treating physician, didn’t seem that way when I was laying in the hospital bed myself or hovering over my newborn’s crib. I realized that I can use this experience to better myself as a clinician and that what may be routine or minor for me the physician, may be that patient or parent’s worst day.

The way healthcare workers have gone above and beyond to try to engage and support those in the hospital is to be applauded and respected, and I think the lessons learned during this time will go a long way into life after COVID-19. We need to continue to find ways to incorporate family and friends who cannot physically be present, and reduce some of the stress and isolation that admission to the hospital carries.

COVID-19 doesn’t discriminate based on age, race, gender, occupation, identity, or even infection status; it affects everyone whether you have the virus or not. The physical effects of stress may not always be as obvious as something like Takatsubo Cardiomyopathy, but they are nonetheless important to recognize and treat. We as physicians should continue to take the time to respect and assess the mental health of not only ourselves, but all of those around us, and engage the full person into our care while adapting to new and uncomfortable situations.

“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.”


COVID-19; Patients with Congenital Heart Disease (CHD)

This week, the ACHA (American Congenital Heart Association) hosted a webinar in regards to Coronavirus aka SARS-CoV-2, and the illness it causes, COVID-19, 3,000 attended (view the recording here.) CHD patients, parents of CHD patients and CHD providers had the same question, how does this virus affect this special population? Unfortunately, the data is lacking on coronavirus those with CHD and there is a lot we don’t know.

A recent study1 in China looked at 2143 pediatric patients with COVID-19, the majority (94.1%) were asymptomatic or mild, more severe cases, were seen in infants (<1 year old) than older children, and there was only one death. This study lacks details, such as what other medical conditions they may have. Severe cases were 5.9% compared to 18.5% in adult population studies. Although reassuring for the general pediatric population, we still don’t know how this applies to pediatric patients in the United States and those with CHD.

What we do know.

There is a trend toward overgeneralization of “heart disease,” particularly in the media. It has been noted that the COVID-19 affects older adults and those with “heart disease,” meaning cardiovascular disease(CVD), such as coronary artery disease and hypertension, more severely.2 This does not include Congenital Heart Disease.

The virus may also cause myocardial injury, with reports of myocarditis and arrhythmias in those with severe cases.2-4 The effect is thought to be related to Angiotensin-converting enzyme 2(ACE2), which, in animal studies, has a role in the cardiovascular, and immune system and has been identified as a functional receptor for coronaviruses.2,3

Many patients with CVD and CHD take a medication known as ACE inhibitors or an Angiotensin Receptor Blockers (ARBs). The use of these medications is common in both populations, but for different indications, as their “heart disease” is not the same. There are trials assessing the use of these medications and effect on COVID19 in adults, and varying theories on whether they are protective or not, with that said, the HFSA/ACC/AHA currently recommends continuing these medications as prescribed.5

Are patients with CHD considered high risk?

The answer is we don’t know. With a wide range of congenital heart disease, from repaired/“normal” hearts, to those with altered blood flow, lung abnormalities, and arrhythmias. As  mentioned, the CDC places those with “heart disease,” meaning those with CVD, and older adults, at high risk of severe illness,6 this does not include CHD, however, CHD patients aren’t immune to CVD and if a patient has CVD and also CHD they are considered high risk.

With data lacking in many populations, it is important for those considered at high risk for other viruses, like influenza, such as CHD, asthma and those who are immunocompromised, to take appropriate precautions. It is better to be over prepared and over cautious.

Follow up and Communication.

CHD patients should keep in close contact with their medical team and stay updated with recommendations of their team and the CDC (found in detail here), like social distancing, good hand hygiene and staying home if you are sick. Concerning symptoms that require further evaluation include shortness of breath (or fast breathing in infants), chest pain, and palpitations.

 As far as visiting your doctor, you will likely be asked to either re-schedule or have a telephone visit. You can ask your medical team about this option and even anticipate it for the next few months. Elective procedures, catheterizations and imaging will likely be delayed. If one good thing comes out of this pandemic, it may be better options and availability for telemedicine in the future.

Keep your Mind Healthy

Use this time to support your mental health— pay attention to the news and social media, but set timers so you don’t over-saturate yourself. Find the book you’ve had on your shelves that you’ve been too busy for and set aside time every day to read, call or FaceTime friends, and maybe even fill up your bathtub and relax!

Meditation and exercise are also great options, and many apps offer free trials. Calm and Headspace have some free mediation content and free trials. Peloton & DailyBurn offer free day trials with a variety of classes(Tip: If you do choose a free trial, be sure to set an alarm on your calendar before the free trial is over so you can choose if it’s worth continuing for a fee or not.) There are also options to support your local gyms and studies virtually with on demand classes, just check out their websites and/or Instagram.

There is so much unknown, which causes us to worry and discomfort, but we are learning more each day. Stay informed, stay safe, wash your hands and try to keep your mental health in check.

For more on coronavirus and heart health, read Noora Aljerhi’s blog (3/9/2020) on the early career voice.

  1. Dong, Yuanyuan, et al. “Epidemiological Characteristics of 2143 Pediatric Patients with 2019 Coronavirus Disease in China.” Pediatrics, 2020, doi:10.1542/peds.2020-0702.
  2. Hui, Hui, et al. “Clinical and Radiographic Features of Cardiac Injury in Patients with 2019 Novel Coronavirus Pneumonia.” 2020, doi:10.1101/2020.02.24.20027052.
  3. Zheng, Ying-Ying, et al. “COVID-19 and the Cardiovascular System.” Nature News, Nature Publishing Group, 5 Mar. 2020, nature.com/articles/s41569-020-0360-5?code=85e25438-46d1-4753-bfdd-84496a98b564.
  4. Hu, Hongde, et al. “Coronavirus Fulminant Myocarditis Saved with Glucocorticoid and Human Immunoglobulin.” European Heart Journal, 2020, doi:10.1093/eurheartj/ehaa190.HFS/ACC/AHA statement
  5. “HFSA/ACC/AHA Statement Addresses Concerns Re: Using RAAS Antagonists in COVID-19.” American College of Cardiology, 17 Mar. 2020, acc.org/latest-in-cardiology/articles/2020/03/17/08/59/hfsa-acc-aha-statement-addresses-concerns-re-using-raas-antagonists-in-covid-19.
  6. “If You Are at Higher Risk.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 12 Mar. 2020, www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html.

“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.”


The American Heart and Go Red for Women Month!

It is February: The American Heart and Go Red for Women Month!

February has just started with all its excitement and optimistic thoughts!! I would like to talk about some of the amazing initiatives, including American Heart Month and Go Red for Women initiatives, that are in place to inspire and encourage more of my colleagues, women and men equally, to step up and be proactive about women’s health and education!

  • When was the first American Heart Month?

It was in February 1964, proclaimed by President Lyndon B. Johnson, and Congress subsequently requested the President to issue a proclamation designating February as American Heart Month annually.

  • What is the Go Red for Women Initiative?

It is an initiative, launched in 2004, to end heart disease and stroke in women; by increasing awareness of these diseases in women and removing barriers women face to achieve a healthy life. Here is what GO RED means:


Ask your doctor to check your blood pressure and cholesterol.


Stop smoking, lose weight, exercise, and eat healthy.


Know your risk; heart disease is responsible for 1 in every 5 female deaths [1].


Make healthy food choices for you and your family.


Tell every woman you know that heart disease is our No. 1 killer [1].

  • How about “Research Goes Red” initiative?

It is an initiative to increase women’s participation in scientific research. Both healthy women and those with acute or chronic diseases are encouraged to participate.

  • What impact have these initiatives achieved?

The impact of these initiatives has been remarkable and quite impressive!! Here are some of their achievements:

  • More than 25,000 women registered for the Research Goes Red initiative!
  • Around 19 million women interact with Go Red through digital platforms annually.
  • $600 million raised to support research, education, advocacy, prevention and awareness programs.

Seeing the impact of these initiatives, I am hopeful not only that these initiatives continue to include and support more women, but also I am optimistic that more initiatives are launched to: (1) increase awareness of different heart diseases in women, (2) empower women to know the differences in the clinical presentations of different diseases, (3) implement strategies to avoid health care disparities based on gender and race, and (4) help more women and minorities access health care, not only across the nation but also across the globe.




“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.”


Seeing and Serving Invisible Populations

Like many of you, I chose to be a nurse because I wanted to serve people during their most vulnerable times, knowing that this work would make a difference. Working with people at their most vulnerable has taught me a lot, including that my patients can be braver, kinder, more frightened, angrier, disappointed, lovelier, and in general more surprising than I expect when I walk in the door.

A growing and perhaps surprising population at disproportionally high risk for heart attacks are individuals who identify as transgender. Transgender individuals are those whose gender identity is different from the sex they were assigned at birth. People identifying as transgender can be any age or race, from any background, and reside in all 50 states. In 2016 there were approximately 1.4 million people in the United States who identified as transgender.  Given the increase in the transgender population, new initiatives are attempting to understand the unique health needs of this population in order to provide high-quality health care. Little is known about the cardiovascular health of this population, which prompted a recent study by Dr. Alzahrani from George Washington University who found that the transgender population had a higher reported history of heart attacks compared with the cisgender (those whose gender corresponds with their birth sex) population.

This first-of-its-kind study examined approximately 720,000 U.S. adults who completed the telephone-based Behavioral Risk Factor Surveillance System survey, conducted by the Centers for Disease Control and Prevention between the years of 2014-2017. Of these, 3,055 adults identified as transgender. In gender stratified analyses, Dr. Alzahrani and colleagues found that after adjusting for known cardiovascular risk factors transgender men had (i.e. they were told by a doctor, nurse or health care professional that they had a heart attack) compared to cisgender men and women. And transgender women had a 2-fold increase in the rate of heart attacks compared with cisgender women. Importantly, the investigators also found that transgender men and women were more likely to smoke and be sedentary, and that these and other traditional risk factors were associated with increased odds of experiencing a heart attack. This suggests that while there are about the long-term cardiovascular risk of gender affirming-hormones, mitigating these traditional risk factors are important first line targets for this and all populations.

In an accompanying editorial Dr. Paul Chan evoked Ralph Ellison’s Invisible Man, citing the narrator “I am invisible, understand, simply because people refuse to see me.” Dr. Chan states that today transgender individuals are invisible. But they don’t have to be. We have to actively reject any implicit or explicit expectations we have about this population and simply see them and treat them as they present. This sentiment is echoed by Dr. Billy Carceres, Nurse and Post-Doctoral Fellow at Columbia University Program for Study of LGBT health, “There’s this perception that we can spot transgender people; but if we don’t ask the question about gender identity we might be missing out on people who are at risk. Patients want to have conversations with health care providers about things that influence their health.”

Table 1 lists several steps that can help us start to have these conversations. Adopting such steps in our clinical practice and research are critical against the backdrop of the increased social stress, poor socioeconomic status, health disparities, violence, and a perpetuating fear of mistreatment by healthcare professionals experienced by transgender populations. These steps will help us to see this invisible population, gain their trust, and ultimately help engage them in activities to improve their cardiovascular health.

Table 1. Steps to Reducing Cardiovascular Risk in Transgender Populations

  1. Assess the gender of all your patients or research participants on multiple levels
  2. Ask which pronouns they would like you to use
  3. Understand the terminology used by the trans community
  4. Recognize that transgender people may avoid seeking out health care because of fear of discrimination and create a safe and welcoming environment
  5. Assess all potential cardiovascular risk factors for transgender patients and work with them to collaboratively develop a plan to reduce their risk factors
  6. Learn more about the unique health care needs of your transgender patients. Your health care institution may have good local resources and the Center of Excellence for Transgender Health at UCSF and the World Professional Association for Transgender Health have up-to-date resources.

While Dr. Alzahrani’s new article highlights a significant disparity in an often overlooked and vulnerable population, ultimately we need a lot more data before we can develop and tailor cardiovascular treatment guidelines for transgender populations. As Dr. Sangyoon Shin, Medical Director of Co-Management Service for Gender Affirmation Surgery of Mount Sinai stated, “Its important to realize that the transgender population has specialized needs because they are more marginalized and face high rates of discrimination; But the health care practices the guidelines geared towards them need to be just as evidence-based as with any other population.“ Anything less would be a disservice.

People who seek out a health care provider – a nurse, physician, physical therapist, or pharmacist – do so because they need our help. Our job is to serve them, all of them, as they are, with high quality evidence-based health care. How we treat invisible populations, no matter how different or perplexing they are to us, is the true mark of our professionalism.



Five Lessons From My Heart Attack Patients

In only few months, I leave my clinic where I have been seeing patients with heart disease for the past three years. It was not until I started discussing with them the transition to a new cardiologist that I appreciated the unique relationship we have built.  It has only been few years since we first met in in the Emergency Department in the middle of the night as they were having a heart attack, but somehow this journey feels longer.  I witnessed their heart attacks change their lives in many different ways, as they learned to cope, recover and carry on in life with a story to tell. Being one of the characters in their stories, I learned five lessons about life that will stay with me.


1- You can make any terrible event a wake up call or the beginning of the end.

A big heart attack or sudden cardiac arrest is arguably the most terrible event one could experience. As my patients recovered from such an event and came to see me in clinic, I could tell that the event changed them, either to the better or to the worse. While some lost weight, started training regularly, left their high stress jobs, or decided to travel the world, others became even more sedentary, gained weight, and started lamenting their bad luck and “missed opportunity” for good health.  It was striking to observe those two trajectories of opposite directions. Like my heart attack patients, when you are faced with a terrible event in life, you can either use it as a wake up call to do better afterwards or fall off a ledge and spiral down. You decide your own fate.


2- A supporting family is worth all the medicine of the world.

One patient after another, it became clear to me that the presence of a supporting family member that cares for you during difficult times is worth the most state-of-the-art medicine. It is that person that ensures that your food is low in salt and has no butter, that you do your daily exercise and not miss your medication, that you come to your appointments and ask all the right questions, or that simply hold your hand and tell you it’s going to be okay when things turn sour.


3- You’re as old as you think you are.

I met a 90 year-old woman who had a big heart attack and went for the most aggressive therapies. A year later she still shows to my clinic fully groomed and cheerful telling me she picked up dancing and life could not be any better.  I also met a 50 year-old man who after a small heart attack gave up on enjoying life or hoping for better future and couldn’t be convinced otherwise.


4- Faith, hope, and courage are your best friends when you’re not in control.

When patients are waiting for a high risk surgery or intervention, they simply are not in control of their fate. I found that those that fared well had three unique characteristics. First, they had faith in themselves, their doctors, or God. Second, they always hoped for the best. Third, they had the courage to face a difficult reality when things don’t go as well.  Whenever you’re not in control, let faith, hope, and courage always be your best friends.


5- Write your best story today because you never know when it ends.

While I learned so much from the stories of those patients who made it to my clinic, many did not, and their stories ended in the hospital. As you go through life, live every day to the fullest and write your best story page by page, because you really never know when it ends.


Precision Medicine: Is It The Future For Heart Diseases?

Cardiovascular disease is famously known as a disease that “rose from relative oblivion to the uno numero killer worldwide.” Globally, there were an estimated 422.7 million cases of cardiovascular diseases (CVD) and 17.92 million deaths in 2015. Over the past 50 years, significant efforts have been made to suppress or even eradicate cardiovascular diseases. The figure1 to the left is adopted from Havlik and Feinleib illustrates the various strategies applied to reduce the deaths associated with coronary heart disease, which are also relevant for CVD more broadly.

While discussions are aimed towards who or what deserves the credit for this decline, the prevention and cure still remain obscure, highlighting that we need a shift in management of these patients. Currently, the approach to CVD treatment is evidence-based medicine. This supposes “one size fits all,” that individuals with common symptoms share the same disease and will respond to similar management strategies, and ignores that patients are unique at large. Moreover, current healthcare is expensive and inefficient at most part.


Precision Medicine

Precision medicine represents a new approach where patient care is targeted towards prevention and cure considering individual differences of patients. The goal is to identify what’s best for a particular patient than what benefits the average population. As figure to the left shows, it is aimed to achieve through the accumulation of personalised data (clinical, biological, environmental & genetic) and computed predictive models that will inform logical therapy for each patient2.

The success of precision medicine relies on extensive clinical testing, electronic health records, genetic profiling, big data sets, and novel analytical and implementation methods to create a person-specific information that can then be used to identify an optimal intervention with minimal risk.

The benefits of precision medicine included better medical management, safer dosing options, reduced adverse events, reduce inappropriate procedures and medical interventions, and improved patient management.


Precision Medicine in Cardiology and Challenges

Cardiology has been slower than other disciplines in pursuing precision medicine. This is now changing as several attempts are beginning to take shape. Efforts are in place to define distinctive patient groups, identify molecular targets, develop risk models and evaluate the effects of drugs through genome scale metabolic models.  But there are several barriers in precision medicine that also limits the widespread application and advancement of it in modern medicine. First of all, the multidisciplinary approach requires synchronisation between several departments, calls for advances in technology, regulatory oversights, big data storage, and ethical concerns with the use of genetic information storage.

There is also a large concern that precision medicine is just like stem cell revolution, where the promise to become what it is may not be achievable but will have incremental gains on a case by case basis. But by comprehensive understanding, united efforts, clinical application, evidence-based practices and technological advancements, precision medicine could change the entire landscape of cardiovascular health care system in the near future.



  1. Jones DS and Greene JA. The decline and rise of coronary heart disease: understanding public health catastrophism. American journal of public health. 2013;103:1207-1218.
  2. Duffy DJ. Problems, challenges and promises: perspectives on precision medicine. Briefings in Bioinformatics. 2015;17:494-504.



Thiamine: An Important Nutrient to Consider in Treatment of Congestive Heart Failure

Thiamine deficiency is an uncommon nutritional deficiency in the developed world. The population most at risk in North America and Europe has been noted to be alcoholics with poor diets. This nutrient deficiency can manifest as several different syndromes, one of which is “beriberi.” Beriberi was first described by Dr. Wenckebach in the early 1900s who observed the presence of dependent edema, elevated venous pressures, and an enlarged heart in patients who had three or more months of a thiamine deficient diet, with recovery after thiamine administration. What followed years after were several case reports of alcoholics with signs of congestive heart failure who improved drastically with administration of thiamine.

Although today beriberi heart disease is a rare diagnosis, what it does show is that thiamine is an important micronutrient for the heart, and lack of thiamine can cause symptoms of heart failure.

Given that thiamine is excreted through the urine, another population that has been deemed to be at risk for thiamine deficiency is those on high doses of diuretics such as furosemide1. Interestingly, this population includes the difficult-to-control heart failure patients that we see on the wards every day. Biochemically, one study has shown that thiamine uptake in cardiac cells can be inhibited by furosemide2.

Yet, treatment of patients with congestive heart failure on diuretics with thiamine is not currently standard of practice.

Looking at the literature, there have been only two randomized double blind placebo controlled trials on thiamine use in patients with congestive heart failure: Shimon et al 19953 and Schoenenberger et al 20124. Both of these trials showed a statistically significant increase in left ventricular ejection fraction with the use of thiamine in patients presenting with symptomatic congestive heart failure. Granted, the ejection fraction only improved by 3-4% which we could say was due to echocardiography interpretation variability. However, being that thiamine is cheap and there is evidence that points towards its use as a medication in heart failure, should we institute it into our daily practice?

What do you think?



  1. Katta N, Balla S, Alpert MA. Does Long-Term Furosemide Therapy Cause Thiamine Deficiency in Patients with Heart Failure? A Focused Review. Am J Med. 2016;129(7):753.e7-753.e11.
  2. Zangen A, Botzer D, Zangen R, Shainberg A. Furosemide and digoxin inhibit thiamine uptake in cardiac cells. Eur J Pharmacol. 1998;361(1):151-5.
  3. Shimon I, Almog S, Vered Z, et al. Improved left ventricular function after thiamine supplementation in patients with congestive heart failure receiving long-term furosemide therapy. Am J Med. 1995;98(5):485-90.
  4. Schoenenberger AW, Schoenenberger-berzins R, Der maur CA, Suter PM, Vergopoulos A, Erne P. Thiamine supplementation in symptomatic chronic heart failure: a randomized, double-blind, placebo-controlled, cross-over pilot study. Clin Res Cardiol. 2012;101(3):159-64.




Red Dresses & Red Ribbons: What Every Health Care Provider Needs to Know about Cardiovascular Disease and HIV in Women

Lead Image (created by Cynthia Rentrope):

Lead Image (created by Cynthia Rentrope):

Each February, we celebrate Go Red for Women – a time for healthcare providers to reacquaint ourselves with the shocking fact that on average one woman dies from cardiovascular disease (CVD) every minute – and recommit to doing better. In the United States and the around the globe, women living with HIV are at higher risk for developing cardiovascular disease, yet not all women are affected equally. There are disparities in the quality of cardiovascular care in women, especially younger women, compared to men. Simultaneously, women living with HIV are at increased risk for cardiovascular disease than HIV uninfected women and receive less guideline-based cardiovascular care. In order to provide better preventative, diagnostic, and curative care we have to understand why women living with HIV are at higher risk for cardiovascular disease and stroke and what we can do about it.

Women living with HIV are at higher risk for CVD and stroke

The reasons why women living with HIV are at higher risk for CVD and stroke are not entirely understood. However, scientists have described several likely reasons. HIV is an inflammatory disease and women infected with HIV have higher levels of inflammatory cytokines and markers of immune activation. In turn, this inflammation may increase the risk of CVD by accelerating development of atherosclerotic plaques and making these plaques more ‘vulnerable’ to rupture, causing more heart attacks and strokes. Additionally, we recently reported that inflammation was also associated with reduced cardiorespiratory fitness in adults living with HIV, which may help explain this increased risk. Women living with HIV have elevated rates of depression, obesity, stigma, and homelessness, also associated with increased CVD.

However, there are also unique biological factors that increase the risk for CVD in women living with HIV, particularly with aging. According to Dr. Sara Looby RN, PhD, Assistant Professor of Medicine at Harvard Medical School and Massachusetts General Hospital, hormone changes experienced during menopause such as estrogen loss and reduced ovarian reserve may negatively influence immune activation and the development of subclinical CVD in women living with HIV.  Her current study funded by the National Institute of Allergy and Infectious Disease is exploring this and the results are expected in the next 4 years.

Strategies to Reduce the risk of CVD in Women Living with HIV

Yet it is not enough to know there is a risk and even to partially understand why; health care providers- cardiologists, nurses, primary care providers, and HIV and emergency room physicians -chose their profession because they wanted to improve health. And all of us have an important role in helping women living with HIV accomplish this goal. There are several evidence-based strategies we can use to improve cardiovascular health in this population.

  • Take HIV medications. This strategy is well known among HIV nurses and physicians but those not trained in HIV may not realize the significance of HIV medications to reducing CVD in this population. Having a suppressed HIV viral load, obtained through adherence to effective HIV medicines, is consistently associated with reduced CVD.
  • Recognize and treat the cluster of traditional cardiovascular risk factors in HIV. Increased traditional cardiovascular risk factors in women living with HIV, including hypertension, dyslipidemia, diabetes, and obesity, need to be effectively addressed using guideline-based care. For a good resource on how to do this, check out the American Heart Association’s Life Simple 7
  • Assess sex-specific risk factors in women including menopause history. This may not be routine for HIV, cardiovascular or family health providers but it is important for understanding cardiovascular risk. Increasing evidence indicates we should use a woman’s menopause history to improve understanding of her risk of CVD and provide good cardiovascular treatment. Other health conditions unique to women, such as a history of pre-eclampsia, can also influence risk and are recommended as “risk enhancers” in the most recent AHA Cholesterol Practice Guidelines.
  • Engage women in their cardiovascular health. While this may be the hardest strategy to implement, it is the most important because for so long, women living with HIV have focused on surviving HIV that they do not perceive they are at elevated CVD risk. Dr. Looby acknowledges, “It can be difficult to find time to do this given the competing demands of clinical care, but education is essential to empowering women living with HIV to become active participants in their care. Delivering education in plain language that is easily understood by patients. Asking patients basic questions like, “Do you know what heart disease is?” or “Do you know your cholesterol levels and what they mean?” can provide simple snap shots of important information that can be built upon at subsequent visits, or followed up by providing supplemental educational materials.” Through this patient-focused engagement women living with HIV will be able to take charge and reduce their blood pressure, cholesterol, weight, and smoking resulting in improved cardiovascular health.

Almost every minute a woman dies from heart disease. But they don’t have to. We are privileged to serve in a profession dedicated to improving the health of our fellow humans. But human health is complex and, for women living with HIV, we cannot just treat their HIV or their CVD or their depression or their symptoms of menopause- we have to treat these intertwining conditions together. There are countless barriers to doing this well, and as new models of delivering cardiovascular care in HIV are under investigation, I am confident we will learn how to do this better. In the meantime, we have start today and commit to implementing strategies in our own practice to improve the heart health of women living with HIV.



Eye: A Window To The Heart

An eye oftentimes feels like the most underappreciated systems in the field of vascular biology. An eye is a highly vascular organ then it gets credit for and here’s why – ranging from high blood pressure or diabetes to early signs of stroke, an eye exam can tell a physician a lot about one’s health.

In a series of blog posts, I decided to highlight these key connections between the eye and the human body. This article will focus on the current knowledge linking eye and the heart.

There are quite a few similarities between the vasculature (or simply put, blood vessels) of the eye and heart. Not only are there functional and structural similarities, but the eye and heart also share many of the common risk factors. For example, risk factors like high cholesterol, high glucose, hypertension that contribute to atherosclerosis, can also lead to eye diseases like macular degeneration and retinal vein occlusions. Photo taken of the back of the eye, that clinicians refer to as a fundus image, lets ophthalmologists look at blood vessels directly (as shown in the picture) – an eye is possibly the only organ that gives one an all-access backstage pass to its performances. Researchers and clinicians, rightfully call the eye as the window to one’s heart (this could probably apply beyond just biomedical sciences!).

Changes in the small micro-vessels of the eye can be directly correlated to underlying cardiovascular disorders. In the late 1970’s, clinical researchers learned that atherosclerotic lesions in the retinal vessels were indications of coronary artery disease and this was found by simple observation of fundoscopic images of patients. It is also possible to measure vessel dynamics like tortuosity (twists and turns) and caliber (diameter) with retinal exams coupled with flicker-light. With advanced imaging techniques, researchers are also able to calculate small changes in the microcirculation by simply imaging the retinal vessels. An interesting study performed in twin children, measuring the retinal arteriole, was able to predict signs of myocardial infarction as well.

The non-invasiveness of imaging the retinal vessels can certainly be an appeal to clinicians who otherwise rely on angiography to diagnose coronary complications. The retinal vessels can be quite information rich, but one only needs to look closely.



Diabetes Makes Heart Disease Worse

Global awareness has made us cognizant that people with diabetes are susceptible to various disorders involving eye, kidney or nervous system and blood circulation affecting the limbs in the long run. Along these lines, type 2 diabetic patients are more likely to develop heart disease and have a greater incidence of heart attack. According to American Heart Association (AHA), diabetes is one of the major contributing factors for cardiovascular disease and accounts for at least 68 percent of diabetic population of age 65 or older to die from some form of heart disease.

Diabetic heart disease (DHD) is a broader term used to explain heart problems in patients who have diabetes. DHD may include conditions like coronary heart disease, where plaque accumulating in your arteries reduces the blood flow to the heart eventually leading to heart failure, a condition where your heart cannot pump enough blood to meet your body’s requirements. Another consequence of diabetes can be diabetic cardiomyopathy where the damage is extended to the structure and function of the heart. Patients with diabetic cardiomyopathy are more predisposed to develop irregular heartbeat disorders called arrhythmias.

Arrhythmias are conditions in which there is a problem with the rate or rhythm of your heartbeat. It is observed when the electrical signals to the heart that coordinate heartbeats do not function properly. This leads to increase in heart rate (basal rate of more than 100bpm), a condition called trachycardia or decrease in heart rate (basal rate less than 60bpm), called bradycardia. The detailed illustration of these conditions can be found at AHA website. While these conditions can have serious complications in patients, the condition becomes far worse in patients with DHD.

Under normal conditions, mitochondrias which are the energy sources of the cell, give rise to dangerous chemicals known as reactive oxygen species (ROS), byproducts of aerobic metabolism. Oxidative stress occurs when there is excessive production of ROS and if these chemicals are not removed, they possess damage to proteins, tissues and genetic material of the heart cells. However, mitochondria have antioxidant defense systems which decrease ROS production. Under pathological conditions such as diabetes, glucose fluctuations far exceed the ROS production than the oxidative defense systems are capable of cleaning and thus the problem becomes far more intense.

At this year’s Scientific Sessions, one of my colleagues presented his work establishing an interesting link between oxidative stress and arrhythmias. His project focused on protein which is a key enabler of ROS- mediated cardiac arrhythmias, known as mitochondrial translator protein (TSPO). TSPO is an outer mitochondrial membrane protein, previously described as peripheral benzodiazepine receptor, a secondary binding site for diazepam. It’s primarily associated with cholesterol transport to inside the cell, while the group explains its potential role in mitochondrial instability during arrhythmias by mechanism, where excess ROS generated in diabetic patient positively up-regulates its own levels – a process called ROS induced ROS-release (RIRR). Thus, TSPO can be a potential therapeutic target against arrhythmias in diabetic patients. Preliminary data by the group confirmed the increased levels of TPSO in hearts of diabetic rats, which might be responsible for increased propensity of diabetic hearts to arrhythmic events. While TPSO is probably upregulated as compensatory mechanism during type 2 diabetes, its global gene silencing may interfere with essential homeostatic function including cholesterol import and mitochondrial biogenesis. In relation to that, the group is further looking into avenues for targeted and specific TSPO inhibition in the areas affected after heart attack.

Personally, I am not only proud of his work but also hopeful that research studies like his help us to identify potential targets for curing serious conditions like DHD.



Ilkan ZAkar FG. The Mitochondrial Translocator Protein and the Emerging Link Between Oxidative Stress and Arrhythmias in the Diabetic Heart.Front Physiol. 2018;26;9:1518

Ilkan Z, Strauss B, Akar FG. Reversal of TSPO Upregulation in the Diabetic Heart by Chronic TSPO Gene Silencing Causes Metabolic Sink via an Increase in ROMK Expression. Circulation. 2018;138:A16826.