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Alzheimer’s Disease: Prevention is the Best Treatment

Alzheimer’s disease (AD) is a progressive neurodegenerative condition and the most common cause of dementia. It accounts for about 60-80 % of all cases of dementia1. There are currently no curative or prevention therapies available for the disease. Medications prescribed for Alzheimer’s disease (AD) symptoms can temporarily help individuals with thinking, memory, or speaking skills and can help with some of the behavioral and personality changes associated with AD.  everal lines of evidence indicate that lifestyle habits and genetic factors play an important role in determining a person’s risk of developing AD2.

There have been a few recent disappointments with AD therapies when Biogen and Esai released negative results from a promising drug trial (3) and then Novartis, Amgen and Banner Alzheimer’s Institute announced in July their decision to not pursue further studies with a potential AD drug4. But new research presented at the Alzheimer’s Association International conference held in July at Los Angeles has provided evidence of a potential preventive strategy. Results from this study indicate that certain healthy lifestyle habits can reduce the risk of developing AD and even overcome the genetic risk in some susceptible individuals5.

During this retrospective cohort study,196 383 individuals aged at least 60 years, without evidence of cognitive impairment or dementia at baseline were followed for a median of 8 years. Risk assessment was performed using lifestyle and genetic risk scores. Lifestyle risk score was determined by a combination of smoking status, alcohol consumption, physical activity, and dietary habits. During the follow up period, a total of 1769 patients were diagnosed with new onset dementia. The incidence of dementia was noted in 1.23% of the high genetic risk group as compared to 0.63% in the low genetic risk cohort. The genetic risk was seen to be independent of the lifestyle factors.

About 68% participants followed a favorable lifestyle and 8% were noted to have an unfavorable lifestyle.

Dementia risk was seen to increase with worsening of lifestyle scores in a linear fashion. In the unfavorable lifestyle group, 1.16% persons developed dementia while 0.82% in the healthy lifestyle were diagnosed. Favorable lifestyle was associated with a lower risk of dementia despite an unfavorable genetic risk profile.

Favorable lifestyle habits in this study included: no smoking, limiting alcohol consumption to moderate levels, regular physical activity and maintaining a healthy diet. Regular physical activity was defined as per the American Heart Association (AHA) guidelines: 150 minutes of moderate or 75 minutes of vigorous activity per week (or an equivalent combination). This level of exercise, along with a healthy lifestyle, has also been associated with lowered risk of stroke and cardiovascular disease. Moderate alcohol consumption was defined according to the US dietary guidelines: 14g/day or less for women and 28g/day or less for men. Healthy diet was based on the dietary recommendations for maintaining optimal cardiometabolic health: this included regular consumption of at least 4 of the 7 food groups which constitute a healthy diet6.

This study provides evidence to support the benefits of a healthy lifestyle in reducing risk of dementia, even in individuals who may be at a higher genetic risk of developing dementia, including AD.  These results reinforce the American Heart Association’s healthy lifestyle recommendations for a healthy heart and healthy brain.

 

References:

  1. https://www.alz.org/alzheimers-dementia/what-is-dementia
  2. MangialascheF,KivipeltoM,SolomonA, Fratiglioni L. Dementia prevention: current epidemiological evidence and future perspective. Alzheimers Res Ther. 2012;4(1)
  3. http://investors.biogen.com/news-releases/news-release-details/biogen-and-eisai-discontinue-phase-3-engage-and-emerge-trials
  4. https://www.novartis.com/stories/discovery/stopping-alzheimers-disease-it-starts
  5. Ilianna Lourida, PhD1,2; Eilis Hannon, PhD1; Thomas J. Littlejohns, PhD3; et al. Association of Lifestyle and Genetic Risk With Incidence of Dementia. JAMA. Published online, July 13, 2019.
  6. Dietaryandpolicyprioritiesfor cardiovascular disease, diabetes, and obesity: a comprehensive review. Circulation. 2016;133(2): 187-225
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The Key Messages from 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease

The newest ACC/AHA guidelines were just published and is exclusively discusses the primary prevention of CVDs and excludes the care of patients with known atherosclerotic cardiovascular diseases as they are classified as “secondary prevention.”1

Here are the most important messages from the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease.1

 

Promotion of healthy lifestyle.

nutrition

physical fitness to promote healthy lifestyle

 

Prevention in patients with known cardiovascular risk factors.

 

high blood pressure in prevention

high blood cholesterol in prevention

overweight and obesity

prevention in type 2 diabetes

prevention with smoking

 

Aspirin Use

Aspirin is well established for secondary prevention of ASCVD and is widely recommended for those with existing heart disease2. As per the new guideline, most adults without a history of heart disease should not take low-dose daily aspirin to prevent a first heart attack or stroke. Alow dose daily aspirin is recommended in the following instances.

aspirin use

 

References

  1. Arnett Donna K, Blumenthal Roger S, Albert Michelle A, Buroker Andrew B, Goldberger Zachary D, Hahn Ellen J, Himmelfarb Cheryl D, Khera A, Lloyd-Jones D, McEvoy JW, Michos Erin D, Miedema Michael D, Muñoz D, Smith Sidney C, Virani Salim S, Williams Kim A, Yeboah J and Ziaeian B. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Circulation. 2019;0:CIR.0000000000000678.
  1. Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney MT, Corra U, Cosyns B, Deaton C, Graham I, Hall MS, Hobbs FDR, Lochen ML, Lollgen H, Marques-Vidal P, Perk J, Prescott E, Redon J, Richter DJ, Sattar N, Smulders Y, Tiberi M, van der Worp HB, van Dis I, Verschuren WMM and Binno S. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016;37:2315-2381.
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Preventive Cardio-Oncology: The Rise of Prehabilitation

Figure 1 Prehabilitation: optimization of overall health, wellness, and fitness prior to initiation of therapies that might adversely alter fitness, strength, quality of life, or function.

Figure 1 Prehabilitation: optimization of overall health, wellness, and fitness prior to initiation of therapies that might adversely alter fitness, strength, quality of life, or function.

As I near the end of my job search process and prepare to review offers and sign a contract, it is absolutely incredible to me to consider that I am completing training at just the right time for me in cardiology. While sitting in a preventive cardiology team room, I overheard two exercise specialists describing a project that they plan to present in several weeks at a national conference. I overheard them use the word ‘prehabilitation’. While the word is not brand new in their professional world or even in cardiology, at that time the word was novel to me. I felt excitement rise within me as I recognized the word ‘prehabilitation’ as a concept that I have envisioned for quite some time to be key to what I would like to achieve and develop in the emerging field of preventive cardio-oncology. As a senior cardiology fellow, my training has been particularly enriched in cardio-oncology (see CardioOncTrain.Com), preventive cardiology, heart disease in women, and precision medicine. I plan to have a heavy emphasis on prevention in my practice, and with eventual incorporation of maturing tools in precision medicine. If you too are interested in preventive cardiology and cardio-oncology, you may want to consider a combined practice of preventive cardio-oncology.  If you are also interested in heart disease in women, then you may want to consider preventive cardio-oncology particularly in women, e.g., women with breast cancer.  Yes, that is quite focused, but can be an incredible niche.  Yet, let us take a step back from the idea of preventive cardio-oncology in breast cancer or any other cancer and first consider how far we have come in the broader field of cardio-oncology.

In the burgeoning field of cardio-oncology, one could argue that we are doing quite well as a community with epidemiology and management of cardiovascular toxicities from cancer therapies. Our ability to completely predict cardiovascular toxicity in individuals is still in progress. Nevertheless, the field has come so far regarding what we now understand about pathophysiology, risk factors, and incidence of cardiovascular toxicity. In particular, due to the continuous and rapid innovation in cancer therapies, cardio-oncology continues to grow exponentially. If you are interested in or planning to join the field, now is a great time!

While the main focus in cardio-oncology has been on secondary and tertiary prevention of cardiovascular toxicity and its sequelae, an era is approaching that may focus even more so on primordial and primary prevention of cardiovascular toxicity. What if we could figure out ways to prevent cardiovascular toxicity before it even happens? What if we can even avoid development of risk factors themselves? These two questions point towards a focus on primary and primordial prevention, respectively. Indeed, for decades we have been focusing largely on secondary and tertiary prevention in Cardio-Oncology. Perhaps it is now time to focus more on what would appropriately be termed preventive cardio-oncology, a merger between preventive cardiology and cardio-oncology.

A hallmark of preventive cardiology has long been cardiac – and in fact cardiopulmonary – rehabilitation. This usually would occur in the setting of secondary or tertiary prevention. As such, ‘rehab’ generally has at least a few purposes. One purpose is to help individuals get back to the level of cardiopulmonary function they had prior to their cardiovascular event. A second purpose is to actually optimize their cardiopulmonary function, regardless of their original preexisting starting point, and help them develop a sustainable lifestyle modification program that can hopefully help prevent another event. A third purpose is to provide support and camaraderie that can help individuals regain the confidence they need to develop and maintain heart healthy lifestyle habits, by knowing they’re not alone in the process. For young patients, such as young adult women with spontaneous coronary artery dissection, this third purpose can be particularly beneficial.

Studies are now showing that cardiopulmonary rehab can also be useful in patients who have completed cancer therapy – in a sense as their ‘event’1,2. This is in part because cancer therapies can impact the heart, vasculature, and lungs, as well as other organ systems. In addition, while undergoing therapy for cancer, individuals often tend to lose fitness, energy, strength, and motivation for lifestyle modification, which is entirely understandable. Studies are therefore also showing that individuals who pursue exercise in the form of ‘habilitation’ while undergoing cancer therapies will also often have improved fitness and cardiovascular function and outcomes following the completion of therapy1,3.

Notably, newer studies are suggesting that exercise prior to the initiation of cancer therapies can further improve fitness, strength, quality of life, and cardiovascular function during or upon completion of cancer therapy1,4. This concept of ‘prehabilitation’ is catching on and will most certainly become a centerpiece and hallmark of primary prevention and perhaps even primordial prevention of cardiovascular toxicities.

Essentially, we need to recognize the impact and power of hysteresis, which suggests that the cardiopulmonary fitness starting point for a patient diagnosed with cancer will determine their cardiopulmonary fitness endpoint after treatment for cancer. This of course is intuitive, but not usually the focus early on in cancer survivorship. Since one in three individuals develop cancer in their lifetime5, it would be reasonable to recommend that all individuals optimize their cardiopulmonary fitness and prioritize lifestyle modification to ensure a desirable cardiopulmonary starting point if ever one is unfortunately diagnosed with cancer. If we take a step back, we realize that is quite similar to the argument for optimizing cardiovascular health in the general population. One in three individuals dies from cardiovascular disease each year6. It is therefore reasonable to recommend that all individuals optimize their cardiovascular health and prioritize lifestyle modification to hopefully help avoid cardiovascular events. When we view (i) cardiopulmonary fitness after cancer therapies and (ii) cardiopulmonary fitness associated with cardiovascular health in the general population through similar lenses, it becomes clear that preventive cardiology and cardio-oncology could potentially come together in an emergent subspecialty of preventive cardio-oncology.

For all individuals, the overarching goal is optimal cardiovascular health based on life’s simple seven: diet, physical activity, obesity, cholesterol, diabetes, blood pressure, and cigarette smoking, in the context of non-modifiable and also nontraditional modifiable risk factors. For individuals with cancer, who become survivors at the moment of diagnosis7, additional goals are preserving  strength, endurance, quality of life, and function.

To achieve long-lasting success in preventive cardio-oncology, we will need to consider three Ps: protocols, partnerships, and payments. In this hot new field of preventive cardio-oncology in which you and I might be trailblazing, together we need to develop standard protocols that can be used across the nation – and in fact across the world – to provide the best care for our patients. We will need Scientific Statements and Guidelines as the backbone of our practice. To facilitate evidence-based prevention, we will need a combination of retrospective, cohort, and case studies, as well as clinical trials. We will need to be sure to practice team-based care and forge lasting partnerships among clinicians, exercise specialists, and others in order to guide patients along gentle, individualized pre-habilitation, habilitation, and rehabilitation care plans. Importantly, relevant payment structures will need to be developed and adequately compensated by government, state, and private insurance.

An exciting path is before us Early Career folks in preventive cardio-oncology, as we shape the opportunity to practice in cardio-oncology from the perspective of primordial, primary, secondary, and tertiary prevention in women and in everyone.

 

References

  1. SquiresRW, Shultz AM, HerrmannJ. Exercise Training and Cardiovascular Health in Cancer Patients. Curr Oncol Rep. 2018 Mar 10;20(3):27. doi: 10.1007/s11912-018-0681-2.
  2. Lee K, Tripathy D, Demark-Wahnefried W, Courneya KS, Sami N, Bernstein L, Spicer D, Buchanan TA, Mortimer JE, Dieli-Conwright CM. Effect of Aerobic and Resistance Exercise Intervention on Cardiovascular Disease Risk in Women With Early-Stage Breast Cancer: A Randomized Clinical Trial. JAMA Oncol. 2019 Mar 28. doi: 10.1001/jamaoncol.2019.0038.
  3. https://journals.lww.com/oncology-times/pages/articleviewer.aspx?year=2019&issue=02050&article=00014&type=Fulltext. Accessed April 4, 2019.
  4. https://www.acc.org/about-acc/press-releases/2017/03/08/14/42/history-of-exercise-helps-prevent-heart-disease-after-breast-cancer. Accessed April 4, 2019.
  5. https://www.cancer.org/cancer/cancer-basics/lifetime-probability-of-developing-or-dying-from-cancer.html. Accessed April 4, 2019.
  6. https://professional.heart.org/idc/groups/ahamah-public/@wcm/@sop/@smd/documents/downloadable/ucm_503396.pdf. Accessed April 4, 2019.
  7. Rock CL, Doyle C, Demark-Wahnefried W, Meyerhardt J, Courneya KS, Schwartz AL, Bandera EV, Hamilton KK, Grant B, McCullough M, Byers T, Gansler T. Nutritionand physical activity guidelines for cancer survivors. CA CancerJ Clin. 2012 Jul-Aug;62(4):243-74. doi: 10.3322/caac.21142.

 

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A Profile in Mentorship: Dr. Thomas Pearson

Every scientist, even those who are particularly good at hiding away in their offices, will have an impact on others. Most of the time, this impact is a byproduct of our everyday work. We don’t give it much thought – it just happens. But what if that impact was not accidental, and instead was a deliberate, strategic path of choices that build up those around us – even those who disagree with us, compete with us, and threaten us? That is the path that has been trodden by Dr. Thomas Pearson who was awarded the 2019 AHA Council on Epidemiology and Prevention Mentoring Award.

Dr. Pearson has an impeccable academic pedigree and an enviable career. After an early start at the University of Wisconsin, he earned his Bachelor of Arts, MD, MPH, and PhD all from the Johns Hopkins University. He has achieved the goal of every early career scientist – over 35 years of continuous NIH support and is a Fellow of the American Heart Association, American College of Cardiology, the American College of Preventive Medicine, and the American College of Physicians. But the degrees, grants, and accolades are a byproduct of a man driven to service for the love of science.

Dr. Pearson’s own mentors reflected his insatiable curiosity. As a student, he drew from a broad mentoring team that left lifelong impressions of the qualities of good mentor. While excellent teaching was important, more so was the “utterly frank” assessment and advice they provided him. He states, “from them I learned that the primary role of a mentor is to provide an honest, encouraging perspective on the mentee’s ideas, plans and experiences. While some mentors may be tempted to acquiesce or tell mentees what they want to hear- that is abrogation of their responsibility of a mentor.” Such frankness can be tough in today’s academic environment, so to help cultivate this skill, Dr. Pearson’s University of Florida developed the Mentorship Academy. Equally important to learning how to deliver a frank assessment of the mentee is helping the mentee learn how to receive and act upon such advice without taking umbrage to it.

Additionally, Dr. Pearson offered this advice on how early stage professionals can intentionally become effective mentors, including:

  • Be a good communicator. Communication is the basis of mentoring. Good communication should include developing shared expectations of the goals, responsibilities, and processes of the mentor-mentee relationship. Many of the problems that occur in the mentoring relationship result from a misalignment of expectations and reality. An honest conversation, with both parties being active listeners, about the mentor and mentee’s strengths, weaknesses and goals early on in the relationship can set both parties up for success.
  • Broaden your network. Every day we hear about new grants, interesting conferences, and visiting professors. Yet because they are just starting their career, mentees may not hear about the same opportunities. Part of being a good mentor, Dr. Pearson suggests, “is to continually be looking out for opportunities for your mentee and actively encouraging them to pursue them”. This includes inviting a mentee to a lecture and offering to introduce her to the speaker. Opening this door can help a mentee broaden her professional network and embolden her to pursue new opportunities.
  1. Focus on the mentee. The mentor must recognize the mentee is not “hers.” Rather the mentor should focus on the mentee’s needs and goals and, if she finds another investigator can provide a better opportunity for the mentee, help to arrange it. Dr. Pearson states, “Mentoring and selfishness are like oil and water- they don’t mix.”
  2. Stay curious. In his acceptance speech, Dr. Pearson talked about how much he learned from each of his mentees. They taught and inspired him as much as he did them. But that can only happen by accepting that mentoring is a partnership in which each person has a lot to offer. Good mentors need to be curious about their mentees and excited about learning from them.

Dr. Pearson has mentored over 60 people during his career. Many have gone to have equally enviable careers where their impact reverberates into every corner of our profession. He told me, “You never really stop mentoring a mentee. People I mentored still call me and talk about their career, their family. At some point, they start being friends.”

Mentors – true mentors – view their work not as a requisite service but as a thread that weaves together the knowledge of the current and past generations to the next. Mentors are the foundation upon which scientific progress is made; and their impact is the greatest when their mentoring is done with humility, enthusiasm, compassion, curiosity, and an infallible sense of optimism. These are the traits Dr. Pearson embodies; and are the ones that all who seek to see further should strive to emulate.

 

 

 

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Behind Our Backs: A Flurry of Complementary Health Approaches 

As a cardiologist who trained in a quaternary care hospital, I am used to treating the sickest patients, such as those with large heart attacks, shock and cardiac arrest.  When I go to my weekly clinic, I have to suddenly shift my focus. Much healthier people walk through the door and we spend the majority of the time discussing preventive strategies to reduce their risk of future heart events through prescription treatments and lifestyle changes.

In my clinic, I am exclusively focused on treating or preventing heart disease using a defined armamentarium of evidence-based approaches that I’ve learned over my years of training.  As healthcare providers, we set a cut-off of patient conditions and respective treatments that are “doctor-worthy.” Those are health complaints that are serious enough for us to treat, and their treatments have met high thresholds of evidence to make recommendation guidelines. The reality however is that health is not merely the absence of disease, and patient priorities regarding their health are not always aligned with our recommended item list. They realize that their priorities might be “non-doctor worthy,” so they turn behind our backs to online and community resources for guidance.

If you’re a healthcare provider, the next time you review a patient’s medication list, I encourage you to look at the number of naturals, vitamins, and supplements on it. When I did this exercise myself, I found that around 90% of my patients take at least one non-prescribed item, and often several of them. I then researched the statistics and found that my patients are not far off from the general U.S. population. More than two-thirds of Americans take a vitamin, mineral or supplement. Nearly half of older Americans take vitamins and minerals. Almost 18% of adults take a natural product, including the 7.8% of Americans who take fish oil.  This does not include complementary therapies such as acupuncture, massage, and mind-body practices which are used by more than 30% of adults.

This flurry of complementary health approaches is happening behind our backs. As a result, people are left unguided and sometimes misguided by a flourishing market. For example, there are thousands of ingredients, each being packaged and marketed in hundreds of products. For a single health condition, people can choose from a list of nearly a thousand products. The result is a fruit salad containing the effective and the ineffective, the safe and the unsafe, the appropriate and the inappropriate…

https://nccih.nih.gov/health/meditation/overview.htm

https://nccih.nih.gov/health/meditation/overview.htm

Turning our backs is not the answer. Complementary health approaches could be powerful resource to help with patient’s wellness. Integrating those approaches into mainstream medicine is key. This is why many top academic centers now have integrative medicine departments, and the NIH dedicates an agency for scientific research on the subject.

Guidance is critical for three reasons. First, it ensures that people only use complementary approaches when appropriate. This means that they do not replace treatments by their doctors with less potent or effective approaches and they do not not delay seeking medical care when necessary. Second, it is important to distinguish ingredients and practices with the highest level of evidence for effectiveness for a condition (the minority), from those with evidence for lack of effectiveness or those with insufficient evidence (the majority). Third, guidance regarding safety of naturals, vitamins, and supplements as well as their interactions with prescription medications would help avoid detrimental consequences.

Climbing the ladder starts with a first step. I recently started asking my patients about their vitamins, naturals, and supplements, including why they take them, how they learned about them, and what are the results they’re achieving. You should do the same. You’ll be surprised!

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The Significant Areas of Interest in the Field of Cardiac Imaging in 2018

There were several exciting developments in 2018 with regards to cardiac imaging. The role of the cardiac imager is becoming increasingly relevant in today’s cardiology practice environment and bridges across several subspecialties in Cardiology, such as electrophysiology with the use of transesophageal echocardiography (TEE) in the placement of left atrial appendage closure devices. These devices include Watchman and interventional cardiology with structural and valvular heart disease and echocardiographic guidance with transaortic valve replacement (TAVR), percutaneous mitral valve repair with MitralClip, as well as atrial septal and ventricular septal closure devices. The field of cardiac imaging has matured over the years and not only includes echocardiography and nuclear cardiology, but also includes advanced imaging with cardiac magnetic resonance imaging (cMRI) and cardiac computed tomography. In addition, there has been the rise of the interventional echocardiographer specializing in the use of echocardiography in guiding percutaneous and surgical treatment of structural heart disease. In fact, there has been recognition of cardiac imaging by several professional societies such as the American College of Cardiology with publication of the state-of-the-art paper, The Future of Cardiac Imaging Report of a Think Tank Convened by the American College of Cardiology1. There have also been several disease states that have been positively influenced by the development of new diagnostic technology in cardiac imaging, such as cardiac amyloidosis. Cardiac imaging has also positively influenced preventive cardiology with release of the latest American Heart Association (AHA)/ American College of Cardiology (ACC) 2018 Cholesterol Management Guidelines2. The following areas were, in my opinion, considered topics of great interest in 2018 in the field of cardiac imaging.

 

Nuclear Imaging

Cardiac Amyloidosis. For several years, cardiac amyloidosis, particularly transthyretin type (ATTR type), was thought to be a diagnosis that was very difficult to make with endomyocardial biopsy being the only method to confirm the diagnosis. However, nuclear cardiac imaging has changed the landscape of this disease with the novel application of old technology with the use of technetium 99m pyrophosphate (Tc-99m PYP) in the diagnosis of ATTR type cardiac amyloidosis3. The sensitivity and specificity of this technique in diagnosing this disease state is >95%, and oftentimes avoids the need for endomyocardial biopsy to make this diagnosis4. The development of this technique in diagnosing the disease has increased the recognition of this disease in many patients with diastolic heart failure, and even in patients with severe aortic valve stenosis undergoing TAVR. This has also led to greater research and development of new treatments for this disease, such as tafamidis, patisiran and inotersen. The development of these medications will hopefully improve the overall prognosis for patients with this disease.

 

Echocardiography

The Rise of the Interventional Echocardiographer in Structural Cardiac Imaging. There has been increasingly relevant areas of interest in structural heart disease, such as percutaneous mitral valve repair with MitralClip, especially with the release of the study findings from the COAPT trial5.  In addition, transaortic valve replacement (TAVR) has become increasingly available for many patients with severe aortic valve stenosis, and many institutions have began offering this therapy to many of their patients. Additionally, left atrial appendage occlusive devices such as the Watchman device are being increasingly used in patients with atrial fibrillation who are at high risk for hemorrhagic complications with anticoagulation, despite having indications for thromboembolic prophylaxis. With these new developments, there has been the rise of the interventional echocardiographer, who serves a vital role with the use of echocardiography in guiding the placement of these devices in the treatment of structural heart disease. Many fellows are now seeking additional training in this field to meet this demand, as this area has invited a growing interest in the cardiology field and has attracted many trainees.

 

Cardiac Computed Tomography

The revisiting of Coronary Calcium Score as a Powerful Tool in Preventive Cardiology. The release of the latest AHA/ACC Cholesterol Management Guidelines has been an area of great interest in the field. The latest guidelines have included the use of coronary calcium scoring with cardiac CT as a tool to further risk stratify patients to guide the use of pharmacologic therapy for patients with hyperlipidemia2. This has led to  the resurgence of Cardiac CT for coronary calcium scoring as a valuable tool for cardiologists in the field of preventive cardiology.

Utility of Cardiac CT in the assessment of Women with suspected Cardiovascular Disease.  There has also been the increasing recognition of Cardiac CT as a useful diagnostic tool for women suspected of having cardiovascular disease (CVD)6. Hopefully, this will result in the increased appropriate use of Cardiac CT in the management of CVD in women.

 

Cardiac MRI

The complementary role of Cardiac MRI with echocardiography and assessment of valvular and structural heart disease. Cardiac MRI has become an established imaging modality in the assessment of valvular heart disease. This has been embraced by the American Society of Echocardiography’s latest Valvular Guidelines, which includes cardiac MRI as playing a complementary role in the assessment of the severity and etiology of valvular heart disease7. The use of Cardiac MRI is also useful in the assessment of other disease states, such hypertrophic cardiomyopathy and risk assessment for sudden death8.

The rise of Cardiac MRI compatible devices. There has also been the development of Cardiac MRI compatible devices which now allows many patients with these devices to be able to have cardiac MRIs performed safely. Cardiac MRI is therefore a viable diagnostic tool for these patients.

The first administration of certification board exam in cardiovascular magnetic resonance imaging (CBCMR).  With the maturation of Cardiac MRI as a viable imaging modality, 2019 will see the inaugural administration of the first certification exam in cardiovascular magnetic resonance imaging (CBCMR), which will occur between May 7 – June 7, 2019, and the 2019 application window will open on January 15, 2019. ​​

 

Conclusion:

With the dawn of a new year in 2019, it is clear that the future of cardiac imaging is very bright. I am looking forward to many more promising developments in this field and hope that this field will continue to attract many more talented cardiologists in this area of cardiology.

 

References:

  1. Douglas PS, Cerqueira MD, Berman DS, Chinnaiyan K, Cohen MS, Lundbye JB, et al. The Future of Cardiac Imaging Report of a Think Tank Convened by the American College of Cardiology. J Am Coll Cardiol Img 2016;9:1211–23.
  2. Grundy SM, Stone NJ, Bailey AL, Beam LT, Birtcher KK, et al. 2018AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol. JACC Nov 2018, 25709; DOI: 10.1016/j.jacc.2018.11.003.
  3. Dorbala S, Bokhari S, Miller E, Bullock-Palmer RP, Soman P, Thompson R. ASNC Practice Points: 99mTechnetium-Pyrophosphate Imaging for Transthyretin Cardiac Amyloidosis (American Society of Nuclear Cardiology website). 2018. Available at: https://www.asnc.org/Files/Practice%20Resources/Practice%20Points/ASNC%20Practice%20Point-99mTechnetiumPyrophosphateImaging2016.pdf.
  4. Gillmore JD, Maurer MS, Falk RH, Merlini G, Damy T, Dispenzieri A, et al. Nonbiopsy Diagnosis of Cardiac Transthyretin Amyloidosis. Circulation. 2016 Jun 14;133(24):2404-12. Doi: 10.1161/CIRCULATIONAHA.116.021612. Epub 2016 Apr 22.
  5. Stone GW, Lindenfeld J, Abraham WT, Kar S, Lim DS, Mishell JM,et al. COAPT Investigators.Transcatheter Mitral-Valve Repair in Patients with Heart Failure. N Engl J Med. 2018 Dec 13;379(24):2307-2318. doi: 10.1056/NEJMoa1806640. Epub 2018 Sep 23.
  6. Truong QA, Rinehart S, Abbara S, Achenbach S, Berman DS, Bullock-Palmer R,et al. SCCT Women’s Committee.Coronary computed tomographic imaging in women: An expert consensus statement from the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr. 2018 Nov – Dec;12(6):451-466. doi: 10.1016/j.jcct.2018.10.019. Epub 2018 Oct 23.
  7. Zoghbi WA, Adams D, Bonow RO, Enriquez-Sarano M, Foster E, Grayburn PA, et al. Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation A Report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr. 2017 Apr;30(4):303-371. doi: 10.1016/j.echo.2017.01.007. Epub 2017 Mar 14.
  8. Weng Z, Yao J, Chan RH, He J, Yang X, Zhou Y, He Y.Prognostic Value of LGE-CMR in HCM: A Meta-Analysis. JACC Cardiovasc Imaging. 2016 Dec;9(12):1392-1402. doi: 10.1016/j.jcmg.2016.02.031. Epub 2016 Jul 20. Review.

 

 

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Highlights of the 1st Annual Sex and Gender Conference at AHA18

Walking into the Palmer House Hotel, the longest continuously operating hotel in the United States, you can’t help but pause in awe at the intricate décor and take in the most photographed ceiling in the world. I make my way to the Honoré Ballroom, named after Bertha Honoré Palmer, the wife of Palmer and an astute businesswoman and well-known Chicago socialite of her time, not knowing what to expect for the 1st annual Sex and Gender Influence on Cardiovascular Disease (CVD) conference.

Annabelle Volgman, medical director of the Rush Heart Center for Women, kicks off the evening by thanking the speakers and planning members, and encouraging photography and social media sharing. The many photos of the evening include Bertha Honoré’s portrait adjacent to the colorful and modern logo that, I think, will become a recognized image at future AHA Scientific Session meetings.

Dr. Annabelle Volgman welcomes attendees to the 1st Annual Sex and Gender Influences on Cardiovascular Disease at the Palmer Hotel in Chicago, IL (November 11, 2018).

 

Dr. Nanette Wenger of the Emory Women’s Heart Center starts the conversation with her presentation titled “Why is Mortality from Cardiovascular Disease Rising in Men and Women?” She flashes a graph of CVD mortality on the screen, highlighting the steep decline in the past decades, but the leveling off and reversal in recent years, particularly in women under the age of 55 years. The parallel rise in obesity and diabetes, as well as “non-traditional” CVD risk factors such as depression and perceived stress disproportionally affect women, she explains, and may be responsible for this reversal in CVD death rates. Summarizing the recent paper, “Defining the New Normal in Cardiovascular Risk Factors” by Dr. Donald Lloyd-Jones and Dr. Philip Greenland she points to a combination of health behaviors and ideal levels of total cholesterol, blood pressure, and fasting blood glucose, as key factors in achieving cardiovascular health.

“Behavior change,” she says, “is the ‘Holy Grail’ of heart health” and as “health professionals take back the role [of health educator] and address lifestyle behaviors” we will see favorable trends in biomarker targets we’re so interested in.

Later during the Q+A panel, when asked about the best way to approach behavior change with patients, she advises to first, “Give information – if your patient does not have the information, they can’t make a change. Then, let them start with what they would like to start with. Don’t give them 8-10 [health behaviors] to change – they will tune you out.” Dr. Gina Lundberg, co-director of the Emory Women’s Heart Center, chimes in that the clinician’s “approach to weight loss is similar to smoking cessation. Identify the obstacles in the patient’s way – money, time, desire – and often just identifying those hurdles will lead to improvement.”

Dr. Laxmi Mehta, director of the Women’s Cardiovascular Health Program at the Ohio State University Wexner Medical Center, adds that she includes an emotional appeal – “Where is the patient going and what do they want?” Seeing a child’s wedding or playing with their grandkids, developing rapport with patients and fitting your recommendations to their goals can start the health behavior change process, even in a 5 minute clinician-patient discussion.