Preventive

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A Career in Preventive Cardiology: It’s A Lot More Than Statins

Kyla Lara-Breitinger, MD

I spent the finale of #AHA20 Tuesday evening at the “What You Need to Know for a Career in Preventive Cardiology” fireside chat hosted by the lovely Dr. Anum Saeed with experts Drs. Ann Marie Navar, Andrew DeFillips, Seth Martin, Michael Shapiro, and Martha Gulati. The panel discussed the following topics:

Exploring the field of prevention when your program may or may not have a prevention program 

Certainly, one month of exposure is not enough to truly get a taste of the multiple flavors within this field which includes exercise, cardiac rehab, hypertension, advanced lipidology, multimodality imaging and risk scoring, diabetes, and obesity. That being said, it’s important to find a way to get involved even if your program doesn’t have a prevention program. Request to spend elective time in other specialties including Endocrinology where SGLT2 inhibitors are routinely prescribed, clinics where weight-loss medications are frequently used, and other areas in medicine that may intersect within prevention. If you do spend time in cardiac rehab, don’t just spend time with the physicians but also hang out with the exercise physiologists on the floor who engage with cardiac patients- there’s a lot to be learned from them.

Finding an academic position in prevention

Unfortunately, the current reality is that reimbursement for preventive services does not pay the bills for a cardiology division. This means that it’s extremely important for you to find a niche or expertise within cardiology that gets you paid. This can include an imaging modality, interventions (yes, there are interventionalists who practice as preventive cardiologists!), quality improvement care, research, healthcare delivery, technology, and clinical care.  The hope is that in the not-too-distant future, we will transition to more of a value-based care model.

Another very insightful pearl from the panel: when you ask for your position, know what you need early on and ask for what you want. DEFINE WHAT YOU NEED UPFRONT and where you need that time to develop a program, work on research, or start an initiative that will be productive for your department.

A day in the life of an academic preventive cardiologist

This varies widely depending on the unique interests and expertise of the individual. This can range from spending 2 week blocks caring for patients in the cardiac intensive care unit to then being off for 2 weeks followed by an outpatient clinic and research time. If you are primarily research, this may mean having a clinic one day a week with 70% of the time focusing on writing/research and attending national meetings, and collaborating with preventive groups across the world.

The future of prevention

“We’re more than giving statins.” The exciting areas of prevention and late-breaking science that were highlighted during #AHA20 speak for themselves. SLGT2 inhibitors, the promise of Inclisiran, and the polypill are just the tip of the iceberg within the field of prevention. With artificial intelligence and machine learning, polygenetics, implementation science, health equity, and digital technology, the field of prevention will be pivotal in improving outcomes such as myocardial infarction, for example, by tailoring therapy based on individual risk rather than covering everything with all available treatments. Lastly, if there is a silver lining of this #COVID-19 pandemic, it is that the cardiovascular risk factors and health disparities that have come to the surface are now being prioritized as the path for future research trials and public health movements.

I’ll leave you with a Chinese proverb one of our panelists shared: “A superior doctor prevents sickness; A mediocre doctor attends to impending sickness; An inferior doctor treats sickness.”

Stay well, be well, and be safe. And wear a mask.

 

“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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Preventive Cardio-Oncology: A Role For Cardiopulmonary Stress Testing

Sherry-Ann Brown, MD, PhD

Cardiopulmonary exercise stress testing can be useful in a variety of ways, particularly for Preventive Cardiology and Preventive Cardio-oncology. The test helps to assess for levels of fitness, causes of functional limitation, and evidence of ischemia. Test results can be used to counsel individuals, guide exercise prescriptions, and reassure, encourage, and motivate individuals for lifestyle modification and behavior change.

The exercise ECG portion of the test gives information regarding evidence of ischemia, exercise capacity, and adequacy of heart rate response, and response of blood pressure to exercise. The information of this portion of the test can help to determine whether there are any high-risk cardiac features that need to be addressed, such as evidence of ischemia or hypotensive response to exercise. Limited heart rate response is also useful to help determine whether rate-limiting medications or pacemaker settings need to be adjusted. Often, when medications like metoprolol or pacemaker heart rate response are adjusted, this can improve the function and experience of patients who are previously limited by their heart rate during activity. The exercise capacity information given by the exercise ECG, such as excellent, good, average, below average, fair, or poor can give an indication of individuals’ ability to meaningfully, safely, and successfully pursue exercise. Oftentimes, some patients who have had prior cardiovascular events may shy away from moderate or intense exercise for fear of cardiovascular injury as a result of exertion. Pursuing an exercise ECG portion of the cardiopulmonary stress test can help individuals in such cases recognize that they can perform moderate or intense exercise safely without injuring their heart. The exercise capacity reported on the test can help these individuals see that their exercise or aerobic capacity is poor because of their hesitation to pursue moderate or intense exercise. This can be motivating for individuals to recognize that they can benefit from doing more and that they can do more safely. This is particularly the case for individuals who have experienced a cardiovascular event from spontaneous coronary artery dissection, which does not have many modifiable risk factors, and understandably leads to apprehension in young women diagnosed with this condition. However, the exercise ECG portion alone lacks several informative parameters important for patient care in Preventive Cardiology and Cardio-Oncology.

The specific addition to the test provided by the ‘cardiopulmonary’ portion involves oxygen consumption. If oxygen consumption (or VO2) is below average, limited, or poor, there can be several reasons for this. The most common reasons include cardiac impairment, pulmonary impairment, deconditioning, excess weight, and limited heart rate reserve. There are various parameters in the cardiopulmonary stress test results that will indicate whether deconditioning plays a role, whether BMI plays a role, whether cardiac impairment plays a role (in which case this could be due to low flow from systolic dysfunction or due to diastolic dysfunction or even heart rate), or whether pulmonary impairment plays a role (which could be of varied etiology). This addition to the test also helps patients to objectively see data supporting the suspicion that they have become deconditioned after a cardiovascular event or after cancer therapies. They get to see that the cancer therapies or their subsequent levels of activity following their cardiovascular event could currently or potentially affect their function, and may explain any current functional limitation or in fact set them up for functional limitation going forward. The test can also help patients see the effect of any excess weight on their compromised oxygen consumption. Given that cancer therapies for breast cancer, for example, will often include radiation, surgery, and chemotherapy that can injure the heart and/or the lungs, it is helpful to determine the suggested underlying causes of functional limitation as assessed by oxygen consumption in these patients who have had treatment involving the chest. Performing the cardiopulmonary stress test at baseline before treatment helps individuals see their level of fitness, deconditioning, weight effect, cardiac impairment, or pulmonary impairment, even before ever undergoing cancer therapy. Given that fitness levels and injuries to the heart or the lungs can be affected by cancer therapies, then repeating the test after therapies can show patients the change that has occurred as a response to therapies. This can be helpful for patient to have a sense of their original baseline and goals that they can work towards to supersede even that baseline. For individuals who are not going to undergo cancer therapies, obtaining a baseline also helps individuals with a sense of how much they could potentially achieve. Then, once they have achieved a particular goal, the test can be repeated to show the improvement and continue to inspire motivation. This objective collection of evidence and data that can be used for motivation, reassurance, counseling, and exercise prescription is all key for lifestyle modification and behavior change in Preventive Cardiology and Preventive Cardio-Oncology. Thus, for all these reasons and more cardiopulmonary stress testing will evolve to play a large role in Cardio-Oncology prehabilitation, habilitation, and rehabilitation1,2,3, as we help individuals prepare for, experience well, and long outlive their cancer therapies.

 

References

  1. https://earlycareervoice.professional.heart.org/preventive-cardio-oncology-the-rise-of-prehabilitation/. Accessed April 20, 2019.
  2. Squires RW, Shultz AM, Herrmann J. Exercise Training and Cardiovascular Health in Cancer Patients. Curr Oncol Rep. 2018 Mar 10;20(3):27. doi: 10.1007/s11912-018-0681-2.
  3. Gilchrist SC, Barac A, Ades PA, Alfano CM, Franklin BA, Jones LW, La Gerche A, Ligibel JA, Lopez G, Madan K, Oeffinger KC, Salamone J, Scott JM, Squires RW, Thomas RJ, Treat-Jacobson DJ, Wright JS; American Heart Association Exercise, Cardiac Rehabilitation, and Secondary Prevention Committee of the Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; and Council on Peripheral Vascular Disease. Cardio-Oncology Rehabilitation to Manage Cardiovascular Outcomes in Cancer Patients and Survivors: A Scientific Statement from the American Heart Association. Circulation. 2019 Apr 8:CIR0000000000000679. doi: 10.1161/CIR.0000000000000679. [Epub ahead of print].