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Live Streaming Into Scientific Sessions 2018

Trupti Shetty

AHA Scientific Sessions 2018 was a unique experience for me – unable to attend the meeting, I live-streamed the sessions (first time ever for a conference!). Two of my most favorite sessions this year were the panel discussion for advanced heart failure (HF) patients, “The Metabolic Face of Heart Failure,” and the mini-symposium on “Cutting Edge in Cardiovascular Science.”

One of the main highlights in the session Metabolic Face of HF, moderated by Dr Lynne Stevenson, was the talk by cardiovascular stalwart Dr. E. Braunwald, Brigham and Women’s Hospital. Dr. Braunwald spoke of the significance and latest practices in the use of Sodium-Glucose Cotransporter-2 (SGLT2) inhibitors, a class of FDA-approved drugs for type-2 diabetes. He indicated how SGLT2 inhibitors should be explored beyond diabetes treatment and these class of drugs can benefit HF patients as well. “I had to learn about blood clotting 30 years ago, which was difficult,” he modestly admitted as he clarified the renal effects of SGLT2 inhibition. His views also seemed to resonate with Dr. Subodh Verma, St. Michael’s Hospital, Toronto and Dr. John McMurray, Glasglow University, as they covered SGLT2 inhibitors in HF, as well.

Other speakers at this session, Dr. Neha Pagidipati, Duke University and Dr. Lewandowski, Ohio State University, touched upon aspects of stroke and metabolism regulating HF, respectively. While Dr. Pagidipati compared the risk of cardiovascular diseases and stroke with the risks of diabetes, Dr. Lewandowski explained how metabolic regulator PPAR-a (transcriber of genes in fat metabolism) could be a player explored in targeted therapy.

The session ‘Cutting Edge in Cardiovascular Science’ had presenters covering diverse strategies in dealing with cardiovascular therapy, ranging from computational screening to identifying small molecule compounds, to decoding neurovascular networks and the gut microbiome. Dr. Stanley Hazen from Cleveland Clinic presented his work on understanding the microbes in the gut and their role in driving cardiovascular diseases. Dr. Hazen explained how food like red meat, which are rich in components like phosphatidyl serine, activates the gut microbiome. He described the significance of trimethylamine N-oxide (TMAO) pathway in liver and its association with HF, stroke and cardiovascular diseases. He also strategized the use of enzyme in TMAO pathway as targets of small molecule inhibitors.

Dr. Joseph Loscalzo, Brigham and Women’s Hospital, explained how repurposing drugs and finding drug targets computationally could help precision medicine vastly. He also offered his expertise and tools as open access to AHA members. Finally, Dr. Costantino Iadecola, Cornell, elaborated on the heart-brain connectome. He brought attention to the fact that dementia, known to cause hardening of arteries, led to Alzheimer’s, but we all forgot about the vascular complications of this. He bridged this connection between neurovascular dysfunction and cognitive impairment and went on to explain his research on the intake of high salt in diet caused dementia in mice models. To learn of such versatile range of topics in a session was illuminating, to say the least!

Researchers must spend time thinking about applications of their current projects beyond their own niche – this is the only way we can widen our horizons with existing tools.

 
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Antithrombotic Medications: Is More Better?

Siddharth Sehgal, MD

During Scientific Sessions 2018, I was able to remotely attend several great and informative lectures pertaining to the management of cardiovascular diseases. I was especially interested in the sessions related to antithrombotic therapy as this directly applies to my daily practice of Vascular Neurology. One of those sessions focused on management of tricky situations in post PCI patients. Dr. Roxana Mehran discussed the management of patients with atrial fibrillation and a recent PCI.

Antiplatelet medications are used for secondary prophylaxis in patients with coronary artery disease and ischemic stroke. Patients are routinely prescribed dual antiplatelet therapy (DAPT), usually a combination of aspirin with a P2Y12 inhibitor such as clopidogrel, ticagrelor or prasugrel. This is usually continued for six to 12 months after a PCI.

Results from the recently published POINT (1) trial showed reduced risk of recurrent ischemic stroke in the  short term but an increased risk of hemorrhage with long term use of DAPT for patients with a recent TIA or minor stroke. Data from the SPS-3 (2) trial showed increased risk of hemorrhage with no clear benefit of using DAPT when compared to monotherapy in secondary stroke prevention for patients with a history of lacunar stroke. Therefore, patients who have experienced a recent transient ischemic attack or minor stroke are prescribed a short course of DAPT for 21-30 days.

DAPT has been shown to be inferior to warfarin for embolic stroke prophylaxis, with similar bleeding risk in atrial fibrillation(3). Therefore oral anticoagulants are the treatment of choice for atrial fibrillation. The AHA/ASA guidelines recommend against using DAPT in place of warfarin for atrial fibrillation in high bleeding risk patients.

About 5-10% of patients who undergo PCI are also taking an oral anticoagulant for atrial fibrillation. This creates a tricky situation where they need to be on triple therapy with DAPT and an oral anticoagulant. The triple therapy regimen has been associated with a significantly elevated risk of hemorrhage. WOEST (4) study data showed that using the combination of clopidogrel and an oral anticoagulant after PCI can reduce this risk as compared to the triple therapy regimen. The triple therapy arm 44.4% patients experienced a bleeding episode as compared to 19.4% in the double therapy arm (p<0.001). Moreover there was a higher rate of recurrent bleeding in the triple therapy group at 12% vs. 2.2% in the double therapy cohort. Most importantly, the double therapy did not cause an increase in the incidence of stent thrombosis or recurrent myocardial infarction. These data are encouraging and there are ongoing trials comparing various combination regimens of direct anticoagulants with antiplatelets in this difficult clinical scenario. These much awaited trials will hopefully provide some clarity regarding the optimal combination and duration of treatment. For now, we do have some evidence supporting the use of these triple therapy regimens for the shortest durations possible and periodically assessing the indications for continuing these combination regimens for our patients. When it comes to antithrombotic medications, more may not always be better.

 

References

  1. Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA. N Engl J Med 2018; 379:215-225
  2. Effects of Clopidogrel Added to Aspirin in Patients with Recent Lacunar Stroke. N Engl J Med 2012; 367:817-825
  3. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial. Lancet. 2006 Jun 10;367(9526):1903-12
  4. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. Lancet. 2013 Mar 30;381(9872):1107-15

 
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Trainees and Cardiovascular Conferences

Daniel Tyrrell, PhD

I recently viewed a live-streamed session from the American Heart Association’s Scientific Sessions 2018 from the comfort of my own home, and I also attended (in-person) a scientific conference for a different topic within the same month. I began to think of how scientific societies engage trainees, graduate students, and post-docs at conferences. This is all from my perspective as a post-doc, so my observations should be taken with a grain of salt.

The first thing I noticed is that, in my opinion, PI’s typically outnumber trainees at conferences. This is interesting because most labs usually have one PI and several trainees. You might expect a similar parity at conferences, and I believe the reason that most conferences I’ve attended have fewer trainees is the cost of attending. I have been extremely lucky in finding travel awards to attend conferences, yet there have been several that I wanted to go to or committed myself to attend without having funding to support the trip. This can be extremely stressful and is fairly common because as a trainee, your position is not very stable.

When I was a PhD candidate in 2015, I attended a non-AHA conference. At the conference, I volunteered to be the junior representative for the graduate student/post-doc section of the society. I was elected to the position and had to return to the conference in 2016 to accept and begin my term. I was obligated to attend the conference again in 2017 as I transitioned from junior representative to senior representative and again in 2018 as the outgoing senior representative. That means I was supposed to attend the conference 3 years in a row with no clear funding path to pay for any travel. To top it all off, I graduated with my PhD in 2016, just 3 months prior to the 2017 conference date, with no justification for why my post-doc advisor should pay approximately $1,500 for my expenses to present my graduate work. At the 2018 edition of this meeting, I could finally present my post-doc work and luckily received a travel award to offset the cost of the meeting. To make a long-story simpler, 3 or 4-year conference commitments for trainees can be valuable because over that time period I met and worked with many more senior scientists, but shorter commitments would likely entice more applicants to volunteer and greatly reduce the stress involved.

One of the reasons I was elected to the volunteer position in the first place was because I was one of the only graduate students/post-docs to apply. And when I asked other trainees why they hadn’t applied, most said they would be graduating before the 3-year term finished and they didn’t know what type of lab they would end up in. An alternative option for societies is one that I recently sought out and has been surprisingly refreshing. That is the Early Career Blogger Program from the American Heart Association. To lift the veil a bit, I applied after reaching out to one of last year’s early career bloggers, Shayan Mohammadmoradi, who is now a Senior Early Career Blogger with the AHA. This is a 1-year volunteer position, and while it requires attendance at the AHA scientific sessions (I’m planning to attend in 2019), there are some incentives as an official Early Career Blogger that make it possible to attend. First, the conference registration is covered, and if you want to attend other AHA meetings throughout the year, the registration is covered for those as well. AHA also provides access to live-stream their largest annual conference, Scientific Sessions.

I study cardiovascular diseases in the context of aging, and I think supporting early career professionals is a great strategic plan for AHA or any scientific society from the perspective of aging. Early career professionals eventually become middle- then late-stage career professionals and are the next generation of PI’s. By showing that they value early career scientists, AHA will likely reap the benefit in the future.

 
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New Cholesterol Guidelines From A Neurologist’s Perspective

Siddharth Sehgal, MD

The American Heart Association’s annual premier conference “Scientific Sessions 2018” concluded on Monday. This meeting showcases the latest advancements and discoveries in the field of cardiovascular medicine and is attended by clinicians and researchers from across the world.

Being a vascular neurologist, I have attended the International Stroke Conference organized by the AHA several times, however, this was my first time attending Scientific Sessions. I was able to attend the conference via Live Streaming while sitting in my office in Burlington, Massachusetts.

There are a lot of overlaps between cerebrovascular and cardiovascular disease and I was particularly interested in attending the sessions pertaining to stroke prevention and brain health. One of the most anticipated presentations was the release and discussion of the new AHA/ACC Cholesterol Clinical Practice Guidelines.

Some key takeaways from the updated guidelines:

  • The guidelines continue to underscore the role of lifestyle and dietary habits in addition to lipid lowering medication use to treat cholesterol disorders. There is emphasis on the concept of shared decision making with the patient which should include discussion of their individual risk and the treatment options to reduce that risk.
  • Addition of Ezitimibe and subsequently PCSK-9 inhibitors is now recommended in patients who cannot achieve target LDL levels despite maximum tolerated statin doses. There is some concern about the cost effectiveness of PCSK-9 inhibitors, but these medications are expected to become cheaper in the future.
  • Risk enhancing factors are introduced as part of a personalized approach to risk assessment prior to initiating statin therapy. These include persistent elevation of LDL>160 mg/dL, history of pre-eclampsia, family history of premature atherosclerotic cardiovascular disease, history of chronic kidney disease and chronic inflammatory disease, among others.
  • There is a recommendation for expanding use of calcium score as part of the risk assessment, especially in patients where risk benefit analysis is uncertain.

 

In addition to the guidelines for medications and lifestyle changes to treat cholesterol disorders, I especially enjoyed Dr. Laurence Sperling’s talk about the safety of statins.

Patients should be prescribed statins again at a lower dose or modified drug regimen if the reason for discontinuation was mild side effect symptoms. Although rare, but some patients do develop severe myopathy with statin use. These patients should be prescribed alternate non-statin therapies to achieve the target cholesterol levels. There has not been any proven benefit of Co Q10 to prevent or treat statin associated muscle symptoms. Despite the increased risk of diabetes mellitus with statins, it is recommended to continue the drug in patients who may be at risk or develop new onset DM. These patients should be counseled about the net clinical benefit of these drugs for long term cardiovascular event prevention. It appears reasonable to initiate statin therapy in the presence of an appropriate indication despite a history of stable liver disease. In patients without hepatic disorders, there is no clinical benefit of routine creatine kinase and liver enzyme measurements.

Very often patients have questions and concerns about initiating and continuing their statin medication. I believe that these data and recommendations further reinforce my personal practice to encourage patients to continue their statin medication as the risk benefit ratio remains favorable despite mild side effects.
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Live Streaming AHA18 – My First Experience

Daniel Tyrrell, PhD

The American Heart Association’s Scientific Sessions 2018 concluded this past Monday. Unfortunately I was unable to attend in-person, but I was able to catch some of the events virtually online via Scientific Sessions Live Streaming. While I have been to other scientific meetings hosted by the AHA, I have yet to attend the main event – Scientific Sessions. By live-streaming some of the sessions at the event, I was still able to hear about breaking scientific advances.

If you’ve ever felt like all of your colleagues were at a conference and you should have been there, but were prevented for whatever reason, that’s how I felt. Live-streaming some sessions at Scientific Sessions was a last-minute decision for me, but well worth it. I was able to watch Dr. Paul Ridker’s presentation at the AHA Distinguished Scientist Lecture. Not only did that provide the opportunity to hear Dr. Ridker’s update on new and exciting findings coming out of the CANTOS trial, I had never heard him speak until that moment. This was an opportunity I did not want to miss.

Another great opportunity that Live Streaming provided was the opportunity to connect in real-time with attendees who were at the Scientific Sessions in-person. As part of AHA’s Early Career Blogger team, I was able to live-tweet during the session and connect with other’s in the audience. It was a really great way to hear and feel connected to the cutting-edge science without being physically present.

This is my first blog post for the AHA Early Career Blogging team, so thanks for reading. My other posts will focus more on science in the fields of vascular biology and atherosclerosis, so if you’re interested, please stay tuned.

 
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Live Streaming, Cardiovascular Disease, and Violence: What I Learned at Scientific Sessions 2018

Jacqueline Leachman

Take a trip back down memory lane to your glory days as a happy and shiny nine-year-old. If your childhood was as amazing as I remember mine to be, then you spent your days running outside with friends, making mud pies, and then fabricating methods by which you could trick your little sister into eating said mud pies. Now even though life is all spick-and-span for you at that age, imagine that you have a close friend whose parents are experiencing some domestic problems – so bad in fact, that it results in the mother attempting to commit suicide by ramming the car, full speed, into a cement block with your friend and his/her two other siblings inside. In your present day and age, can you even begin to fathom the degree of trauma that this past event brought to your friend? Now, would you believe me if I say that if undealt with, your friend may not only experience mental health issues but also cardiometabolic problems? While this may not be your first thought, it is now becoming more widely known that violence (or stress) is an independent risk factor for adverse cardiovascular health. This story may seem just a tad over the top; however, this was the topic of discussion for the session titled Unpacking the Cardiovascular Biology of Violence at Scientific Sessions 2018 and was the eye-opening account given by physician Marjorie Fujara from Chicago during her presentation.

As a new graduate student, this was my first time experiencing Scientific Sessions and I was completely taken aback by the various works discussed. Presentations that I was luckily able to witness via Live Streaming. Yes, you read correctly, LIVE STREAMING. Complete transparency here, I definitely opened my iPad with the preconceived notion that I would not be as engaged watching from my tiny screen in comparison to what I would experience being presented live and in-person. However, from the comforts of my own home, I found myself unreservedly hooked on the late-breaking science from researchers across the country. From the new Physical Activity Guidelines, to the nature versus nurture of cardiovascular disease, it was without a doubt an exciting weekend for science!

Considering the variety of disciplines at the conference, there were a number of ways to personally connect to the science presented. For example, my lab studies the effects of early life stress (or adverse childhood experiences) on the development of obesity and its related diseases later in life. As a result, the cardiovascular biology of violence talks were the ones that resonated with me the most because of its applications to my own research and personal interests.

During the discussion on the connections between heart health and trauma exposure, one panelist considered the case of primordial violence on developmental programming. Key points stemmed around the idea that excessive punishment led to increased levels of circulating cortisol. This then results in damage to the hippocampus (memory and learning), amygdala (emotions), and frontal cortex (reasoning). This data has led to the implementation of “No Hit Zones” in various hospitals. At the genetics level, however, what makes the people who experience increased levels of violence different from the rest of the population? When considering the epigenetics of the situation, violence in one’s life results in alterations in DNA methylation patterns (either hypo- or hyper-) and eventually leads to a higher cardio-metabolic risk. During the discussion, it was mentioned that for a child, just hearing about violence in one’s own community resulted in a difficulty concentrating for periods ranging from two days to an entire month. You can easily begin to wonder, “What does this mean for children living in areas with high homicide rates?” Overall, people exposed to trauma, and are not properly dealing with it, are predisposing themselves to diastolic elevations much earlier in life consequenting in early onset of cardiovascular disease.

The question is now, “What interventional methods can we use to better help people who are experiencing cardiac alterations due to increased stress exposure?” One solution discussed is the Bright Star Community Outreach program. Bright Star is a nonprofit aimed at using science and research to aid members of the south side Chicago community in recovering from the trauma of violence. By confronting the trauma, instead of bottling it away, they hope to help people to end the cycle and limit violence-induced early cardiovascular insults.

As the reader, and possibly someone who was unable to attend (or live stream) AHA Scientific Sessions 2018, what else do you think can be done clinically to better serve this group in terms of cardiovascular health? Do you think they will need different pharmacological interventions compared to the “traditional” hypertensive patient, for example?

 

Disclaimer

“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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So Far, Yet So Near – Live Streaming Scientific Sessions 2018

Saurav Chatterjee, MD

This year I had to miss the Annual Scientific Sessions of the American heart Association #AHA18 due to a recent addition to the family. Through the generosity of the American Heart Association and the Early Career Blogging Program, I was offered an opportunity to be able to participate “virtually” in the meeting through Live Streaming and was offered a complimentary pass for streaming specific sessions. I gleefully excepted the offer and made full use of it over the weekend of the meeting intermittently between sessions. I had envisioned attending a meeting of this nature in the past when I had written a prior blog post on Cardioexchange.com in 2014. It seems a wonderful idea to be able to assimilate all the knowledge on offer from the comfort of one’s home. This year at the American Heart Association  Scientific Sessions 2018, I intended to fully experience and ‘test drive’ such a opportunity.

Just based on back of the envelope calculations, attending a meeting remotely is definitely a more cost efficient and pragmatic option. The ‘Sessions OnDemand’ was available for $299 (for the online-only version) and $399 for those requiring recorded sessions on a hard drive. When compared against the full registration fee, usual airfare on the weekend, at least a night’s hotel stay at premium rates at the time of a national conference, and add-in some commuting and ancillary expenses – it all adds up to significantly higher expenses compared with the remote access options, and it would have been a no-brainer if the remote options offered a comparable experience. And with the dwindling healthcare dollars everywhere, more and more programs are streamlining the educational benefits and leaves extended to fellows and early career professionals for attending conferences.

However in its current form, I think the remote option still has a fair bit of catching up to do with the live attendance format. While the streaming for individual presentations were quiet spot on and seamless, the options for discussing the same were limited. There was a ‘pop-up’ window to ask questions of panels/presenters, but the couple of questions I posed remained unanswered or unclear if the panelist/presenter even viewed them. For the “bigger” presentations like the Late-Breaking Clinical Trials or the new guideline releases, the sheer energy and ambiance of a room full of learned audience was also lacking. And of course the opportunities of networking in person, grabbing a coffee with a prospective collaborator, and plain-and-simple catching up with friends and ex-colleagues had to be passed on. Add on the fact that one’s study at home is hardly sacrosanct from interruptions from a young family! So, while the remote meeting at present has a cost-effective alternative, probably the experience of attending a live meeting especially for a relatively recent graduate/early career professional has yet to be matched by the virtual experience.