What I Took Home – “BRUISES” With EP-Devices

This year’s AHA Scientific Sessions in Anaheim, CA provided the cardiology community with a number of important trials. Large clinical studies have the possibility to directly impact clinical practice. In the subspecialty of electrophysiology, there was an important trial with significant relevance to physicians who implant or provide perioperative care for patients with pacemakers/ defibrillators (“EP device procedures”).
A frequent dilemma which implanting physicians face is whether or not to suspend anticoagulation prior to insertion of an EP device. Suspension of anticoagulation raises the risk of stroke for many patients and this cannot be ignored. The obvious postoperative concern is the attendant risk of pocket hematoma which is not only a painful experience for the patient, but can also dramatically increase the risk of infection. The latter is considered a potentially disastrous complication with high morbidity and mortality. In 2013, Birnie et al published the results of BRUISE-CONTROL which was a randomized controlled trial with sought to determine outcomes between continued warfarin use, and suspension of warfarin while bridging with intravenous heparin at the time of surgical implant (NEJM 2013). The results were categorically in favor of continued warfarin use. With that study, patients in the uninterrupted oral anticoagulation arm had a marked reduction of postoperative pocket hematoma (3.5% -16%). For some time, many implanting physicians had observed the benefits of continued oral anticoagulation with warfarin during device implants, however the data from this trial provided validation of this practice.
In the past several years, a group of new oral anticoagulants have emerged (NOACs). While the pharmacological mechanisms vary (e.g. factor ten, direct thrombin inhibition) the clinical effects aim to provide systemic anticoagulation. These agents have increased in popularity as an alternative to warfarin. As experience with these agents (e..g. Apibixan, Rivaroxaban, Dabigatran) grew, a determination of their effects on device implants was needed and to ascertain their risk for postoperative hematoma formation. A new trial was launched: BRUISE CONTROL-2. The clinical question was to determine any difference in the development of a hematoma subsequent to a NOAC’s uninterrupted use versus suspension of the NOAC drug two days prior to the procedure. To further add complexity to the matter, only one of these medications has a commercially available reversal agent (dabigatran), hence there is a natural apprehension of performing a procedure under the influence of anticoagulant whose effects cannot be stopped. BRUISE CONTROL-2 presented by Dr David Birnie on 11/12/17.
Surprisingly, there was no difference in pocket hematoma formation (2.1% vs 2.1%). The study was terminated due to futility. The authors concluded that either approach is reasonable. Since the study was not blinded, one might question whether the implanting physicians modified their surgical approach and perhaps could have used different methods to curtail bleeding (e.g. the use of hemostatic or antithrombotic agents introduced into the pocket).
Overall, there was a low complication rate. A size categorization of the incisional hematomas would be helpful as well: a large tension-creating hematoma clearly does not have the same clinical impact as mild swelling. In my opinion the results further validate the safety of NOAC use perioperatively. A subanalysis of how the individual agents performed would be helpful to further elucidate whether there exists a drug superiority, or better yet a BRUISE CONTROL-3 could help address this.

Christian Perzanowski Headshot

Christian Perzanowski is an electrophysiologist in Tampa, FL. His main interests are in ablation techniques for atrial fibrillation and device therapy for congestive heart failure.


Tardiness Of Science Leads To Public Skepticism

Man with heart surgery scar

AHA17 introduced the new and controversial blood pressure measurement guidelines during its annual conference in Anaheim, CA, raising skepticism among the masses. However, before I get into what the new recommendations are, let’s review how blood pressure measurements were initially established. Historically, over the last century blood pressure was unstudied by the scientific and clinical communities. The realization of the importance of blood pressure to health was first observed over 4,000 years ago by Huang-Ti, the yellow Emperor of China, with the discovery that people who ate too much salt had “harder” pulses and subsequently suffered from more strokes. Precise blood pressure measurements did not come about until Samuel Siegfried Ritter von Basch developed the sphygmomanometer for clinical use in 1880. The concept of hypertension, previously termed hyperpiesia, did not make an appearance until 1896 with the introduction of auscultating Korotkoff sounds (the sounds heard through the stethoscope when the artery is occluded by the sphygmomanometer and pressure released slowly). Having this new technology revolutionized the means of measuring blood pressure.

As the technique for blood pressure measurement developed over the years, so did the basis for the clinical diagnosis of hypertension. However, there was still debate as to how to treat it. In 1949, Charles Friedberg suggested in the textbook “Diseases of the Heart” that mild ‘benign’ hypertension (210/100 mmHg) should not be treated. During this era, blood pressure treatment was so controversial that the common thought was, ‘the greatest danger to a person with high blood pressure was knowing, because some fool will try to reduce it’. To put that statement into perspective, this was still a time when people were bled by leeches to reduce blood pressure leading to increased incidences of death due to the treatment regimen. The next era of treatment was to do nothing. Researchers started to explore the idea that high blood pressure was a compensatory mechanism, which should not be tampered even if clinicians were certain it could be controlled. This line of thinking lead to a significant increase in morbidity and mortality due to the prevalence of cardiovascular disease caused in part by the untreated blood pressure. With this revelation, high blood pressure treatment and diagnosis was forever changed, starting with the level that is considered to be high (140/80 mmHg).

The first clinical breakthrough in hypertension treatment was the discovery of diuretics. The addition of this drug class reduced strokes and ischemic heart disease by ~50% between 1972 and 1994. Once beta blockers came on the scene for the use of angina, researchers found, by accident none the less, that they additionally lowered blood pressure. How about that?! With research advancing in the area of hypertension, there have been several drugs to come on the market to lower blood pressure including calcium channel blockers and sartan drugs. These medications have had enormous benefit in reducing cardiovascular disease.

This leads us to the new classifications of normal and high blood pressure. At AHA17, the new range for defining systolic/diastolic blood pressure in patients is as follows: normal (90-119 mmHg/60-79 mmHg), prehypertension stages I (120-139 mmHg /81-89 mmHg), and stage II (≥160 mmHg/ ≥100 mmHg), as well as isolated systolic hypertension (≥140 mmHg /<90 mmHg). These measurements are based on the average seated, relaxed blood pressure reading obtained over two or more office visits. Although these are the new recommendations, these numbers are interpreted in conjunction with the clinician’s understanding of the patient’s history. For example, if a patient has a blood pressure of 130/80 mmHg coupled with other chronic diseases, such as diabetes mellitus type 1 or 2 or kidney disease, then this might require more aggressive treatment than a patient with no underlying disease. Physicians will furthermore take into account a patient’s age and overall health when making the decision of how or when to medicate. For example, a patient with resistant hypertension (blood pressure that fails to be reduced with appropriate antihypertensive medicine) may require additional drugs. Because we know that hypertension can be a consequence of both environmental and behavioral factors, AHA still suggests that we adopt a healthy lifestyle that includes a diet focused on heart health, as well as incorporating exercise into our activities of daily living.

There has been some controversy in the news and on social media about these changes. Whether these changes are in the best interest of the general population or in the interest of those who stand to gain from more people having hypertension. This could indeed lead to more patients taking medicine, and consequently more people having higher insurance premiums. It could also lead to more income for primary physicians and pharmaceutical companies. With these things being considered, none of them are more important than one’s health! There are things that cannot be controlled, such as age, sex and genetics, but that does not change the fact that it is the individual’s responsibility to live a healthy lifestyle and take control of their health care. This starts by knowing your risk, eating healthy, and regular exercise.

I know this is a lot of information to take in, but the real message here is: (1) do not allow social media to dictate your health. There are going to be a lot of things said by all types of people, but the best resource is your clinical staff. (2) Yes, regular medical appointments are still necessary to determine whether blood pressure should be treated or how it should be treated. (3) Although the blood pressure scale has changed slightly to incorporate more hypertensive stages, the definition of a healthy blood pressure has not really been modified. Experts (clinicians and scientist) are at odds as to whether patients over 70 years of age should be treated with additional medicines in order to reduce blood pressure. To add more antihypertensive drugs to a patient in such a vulnerable age group could lead to increased side effects such as hypotension, dizziness, increased prevalence of renal failure, enhanced fall risk, and alterations to activities of daily living. There are guidelines published in the JAMA for more information on the recommendations for the geriatric population. Science takes time. It takes a lot of studying to get the results that change the way experts view our clinical practice. It may seem to the general public that these data are tardy, but they are, in my opinion, timely.

I am interested in knowing more about the benefits of the new blood pressure scale and how this will tangibly change the occurrence of cardiovascular disease, cardiorenal disease, and chronic renal disease. I also wonder what questions will now arise in the general population regarding these new developments.

Anberitha Matthews, PhD is a Postdoctoral Fellow at the University of Tennessee Health Science Center in Memphis TN. She is living a dream by researching vascular injury as it pertains to oxidative stress, volunteers with the Mississippi State University Alumni Association, serves as Chapter President and does consulting work with regard to scientific editing.


Back To Reality: Incorporating Scientific Sessions Into Everyday Life

Nearly 2 weeks after AHA Scientific Sessions 2017, I’m back at home, sipping coffee on a chilly Sunday morning and thinking about Anaheim. The larger-than-life convention center, the numerous and packed sessions, and the built-in-a-day pharma fueled exhibit halls.

Working backwards, I remember fitting in a lunch sponsored by Amgen, given by Dr. Alan Brown, Director of Cardiology at Advocate Lutheran General Hospital. It boasted boxed lunches but lacked elbow room, but by the end of the hour, I was impressed.

As a trained dietitian, I’m aware of at least some of the challenges in providing patient care. With new lipid guidelines, new blood pressure guidelines, new everything guidelines, up until now, the ease of popping a pill has seemed to rise above the effectiveness of lifestyle changes.

For the first time, I heard physicians calling on one another to sit face-to-face and eye-to-eye with their patients, and ask them about their physical activity. And their eating habits. In Dr. Brown’s words, by asking about these topics, you communicate to your patients that they are important.

Vegetables on the kitchen counter

(The DASH Diet stands for Dietary Approaches to Stop Hypertension and is rich in fruit, vegetables, low-fat dairy while reduced in saturated fat and cholesterol. Content Provider: CDC/Amanda Mills. 2011)

At this same conference, Dr. Stephen Juraschek presented his results using the DASH diet – “The Effects of Sodium Reduction and the DASH Diet in Relation to Baseline Blood Pressure,” published just a few weeks ago. The investigators randomized adults with pre- or stage 1 hypertension (and not using blood pressure lowering medications) to DASH diet or control diet. Then in random order, over 4 weeks with 5-day breaks, participants were fed at 3 sodium levels: 50, 100, 150 mmol/day at 2,100 kcal. And what did they find? Adopting the DASH diet in combination with reduced sodium intake achieved “progressively greater reductions at higher levels of baseline SBP [≥150 mmHg]”.

So why am I talking about lifestyle modifications in a post about incorporating conference learnings back into your everyday reality at work? Well, a big announcement that came out of AHA17 was the new hypertension guidelines. I noticed recurrent statements and questions about these guidelines, in presentations, on social media, and from my peers when I returned home. 

At our first peer led research meeting back from AHA17, I printed off a few copies of the Top Ten Things To Know (PDF) about the 2017 hypertension guidelines. We touched on the implications of new classification categories – more treatment, higher prevalence, changes in comparisons over time in our epidemiologic studies. 

Connie Alfred (left), of the National Center for Infectious Diseases (NCID), was shown having her blood pressure taken by Robyn Morgan, of the National Center for Chronic Disease Prevention and Health Promotion

(Connie Alfred (left), of the National Center for Infectious Diseases (NCID), was shown having her blood pressure taken by Robyn Morgan, of the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), during a free blood pressure screening event that was held on all CDC campuses in 2005. Content Provider: CDC/CDC Connects. 2005.)

We were happy to see the focus on accurate measurement of BP, ensuring adequate rest time and taking averages of measurements, a technique we use in epidemiologic studies to minimize measurement error. Those of us particularly interested in physical activity and nutrition epidemiology rejoiced at the lifestyle modification efforts. We closed the discussion with an acknowledgement of conflicting and numerous other guidelines, the reality of putting them into practice – from primary care to cardiology clinics – as well as misinformation in the media coverage of the guidelines, such as misquoting the relaxed recommendations for older adults. 

With so much to chew on, I closed the discussion encouraging everyone around the table to think more on the implications of new guidelines, and our role in developing them, implementing them, and evaluating them.

Bailey DeBarmore Headshot

Bailey DeBarmore is a cardiovascular epidemiology PhD student at the University of North Carolina at Chapel Hill. Her research focuses on diabetes, stroke, and heart failure. She tweets @BaileyDeBarmore and blogs at baileydebarmore.com. Find her on LinkedIn and Facebook.



Put Me In, Coach!

My family goes through the same motions every Thanksgiving: Mash the potatoes. Carve the turkey. Hang the “house divided” flag above the front porch and howl at figures on television colliding bodies over a wayward pigskin. This Thanksgiving weekend coincided with the greatest college rivalry football games of the year for us. My mom attended the University of Louisville and my dad is a proud University of Kentucky alumnus – victory in the battle of the bluegrass is as sweet and as savored as the last slice of pumpkin pie. I went to a liberal arts school; I’m exempt from choosing a side.

Thanksgiving and The Big Game followed shortly after the American Heart Association’s Scientific Sessions, an experience that supplied my football-loving family with robust dinner discussions as we feasted on creamy, roasted, gravy-drenched fares. What better place to ponder heart health than when seated before a minefield of artery-clogging treats? The beautiful irony is that AHA had some things in common with my holiday weekend. That convention center in Anaheim felt like a pep rally – the crowds, the lively conversations, the comradery—but like we were all rooting for the same team.

Tens of thousands of people congregated at Sessions, each with their own position in the lineup, all working to tackle cardiovascular disease. I’m a member of the Council on Basic Cardiovascular Sciences (BCVS), and I was drafted into my lab to advance our scientific understanding of cardioprotection. My basic science colleagues gave excellent talks at the conference. They demonstrated the advances made in our field by harnessing the powers of bioengineering, gene editing, and cell and tissue culture to discover new drugs, personalize treatments, and model, predict, or diagnose disease. I thought the basic science sessions, as always, were incredible. Indeed, there is tremendous value in foundational, translational research to solve the world’s toughest challenges in cardiovascular disease.

However, AHA is made of many Councils, and the week in Anaheim offered an opportunity to venture beyond my comfort level and learn of the advances in other research circles. When I arrived at Scientific Sessions, I was concerned that I would fumble through the clinical seminars. I’ve always admired the work of clinicians in my field, but I was anxious that their Sessions would go over my head, the equivalent of sitting in a class after skipping the prerequisites. Boy, was I wrong. The clinical seminars were among the most captivating events of the conference! In the Late-Breaking Science: Innovative Therapies and Novel Applications session, I heard updates on a device to shunt blood between the atria, neurotoxin injections that might calm a quivering heart, and tiny, powerful lipid bubbles called exosomes to ease the scars and maladaptive muscle wall changes of cardiovascular events in select patients’ hearts. These sessions deeply moved and inspired me, as I understood very clearly in that moment that, in fact, we were all working toward the same goal. These were my allies. My friends. My teammates.

This blog is where the football analogies end for me, and these days, I spend far more time in the lab than I do watching sports anyway. I just want to emphasize how Scientific Sessions made me feel like I was standing in the nose-bleed section with a clear view of the hypothetical game. I could see how the work we are doing in our labs at the kickoff could potentially push all the way through to a touchdown in the clinic’s end zone. It made me feel like I was part of something much larger than myself. I boarded the plane to Chicago fired up with “team spirit,” eager to don my uniform (er, lab coat…) and get back in the game. Go team!

See AHA’s recommendations on what to do with your halftime snacks.

Annie Roessler Headshot

Annie Roessler is a PhD Candidate at Loyola University in Chicago, IL. Her research focuses on the neurobiology and molecular mechanisms of electrically-induced cardioprotection. She tweets @ThePilotStudy and blogs at flaskhalffull.com


New Hypertension Guidelines: Should They Inform The Way We Care For Pediatric Cardiology Patients?

In reflecting on my time at the 2017 AHA Scientific Sessions, I can summarize my thought process about the new AHA Hypertension Guidelines as a complete 180.  When I first heard about the guidelines, my inner monologue went something like this:

“I don’t need to pay attention to these guidelines – they don’t affect me or my patients.  We already have separate pediatric guidelines.  Wasn’t there a new set of guidelines this year?  Maybe I should look at them a little closer…”

After reviewing the 2017 pediatric hypertension guidelines, I was pleasantly surprised how well they align with the AHA adult guidelines.  Of course, the pediatric guidelines are a little more complicated, since all of our patients have different cutoffs based on age, gender, and height.  And the cutoffs are now lower, due to the exclusion of overweight/obese children in the normative data.  But once our patients become adolescents, the cutoffs are the same as the new AHA adult guidelines.
After hearing that now nearly half of all U.S. adults will meet the diagnostic criteria for hypertension under the new guidelines, I realized: “OMG! Almost all of my patients are going to turn 13 and be hypertensive!”

Of course, as pediatric cardiologists, our patients are at especially high risk of cardiac events in adulthood, and the adult congenital heart disease population continues to grow every day, so we should be even more aware of hypertension as a significant risk factor for these children.  As Bradley Marino, MD (Chair of the Council on Cardiovascular Disease in the Young) stated during the CVDY Council Dinner, in light of current changes in the hypertension guidelines and national trends in increasing rates of obesity and heart disease-related morbidity, our role as pediatricians and cardiologists in prevention is becoming more and more important.

By the end of Scientific Sessions and in the weeks thereafter, I have become more cognizant and appreciative of my role in preventing my own patients from becoming hypertensive.  Of course, my ability to encourage lifestyle changes and long-term nutritional improvements is quite limited in the CVICU, but I am much more appreciative of my colleagues in the outpatient world and those who specialize in preventative pediatric cardiology.  I have also made a few lifestyle changes myself, since I am now uncomfortably close to meeting hypertension criteria.

David Werho Headshot

David K. Werho, MD is an Assistant Clinical Professor at the University of California San Diego and a Pediatric Cardiac Intensivist at Rady Children’s Hospital – San Diego.  His research focuses on pediatric cardiac ICU outcomes as well as interventions and curriculum development in medical education.  He tweets @DWerho and contributes to the Pediatric Cardiac Intensive Care Society Newsletter as editor and contributor.


How To Conference Like A Rock Star: Tips For First-time Conference Attendees.

Approach a large national meeting like it’s a Target run.  You know the scenario – you go into Target to get just one thing and leave with 10 items you didn’t know you needed.  Likewise, you can go to a scientific meeting thinking your priority is to get CME, or to network, or to share your research.  But really it’s all of this and more.  Below are my 2-cents on how to get the most out of professional meetings.
…Ready for it?
Do a bit of prep work before the conference starts.  Download the mobile App since this will have the most up-to-date session details.  Pick out the sessions that are most relevant to your career or research interests; 2-3 per day would be reasonable.  Plenary and late-breaking clinical trials sessions are usually worth attending. Then schedule in the miscellaneous which are just as important: Early Career networking, class reunions, meetings with mentors, sponsored dinners, etc.
Shake it off.
The national AHA meeting can seem terribly overwhelming.  There’s 6-8 talks going on at the same time, vendors and poster abstracts spread out over an area equivalent to a football field, council meetings and sponsored lunches/dinners in adjacent hotel venues.  My first whoop-de-do was an American Society of Nephrology conference (back when it was still called Renal Week) and I recall feeling lost and worrying whether I was making the right choices about how I was spending my time.  Such anxiety is pointless – just breathe, do a bit of preparation (see above) and steer away from fear-of-missing-out mentality.
Talk to people.
It’s easy to hang back and blend into the masses – there’s nothing wrong with that, but you will gain more if you are actively engaged.  Introduce yourself to leaders in the field, whether to ask a question or to just let them know you’re a fan of their work.  Share ideas with other early career colleagues.  Chat with reps at the vendor booths (a good way to learn about new devices and drugs on the market, since pharma representation is tightly restricted at academic centers).  Most folks are happy to talk and will appreciate your interest.
Taking breaks is okay.
You are not obligated to sit in talks for 8 hours straight.  Have a coffee, tea, or smoothie break.  Grab lunch to reconnect with friends or colleagues.  Browse the vendor booths and play a spin-the-wheel game.  Relax at the Early Career lounge; post a tweet or two.  At a meeting in Atlanta I joined a tour of the Coca Cola museum then went back to sit in on an evening research abstracts session.  The break cleared my mind and allowed me to re-focus.
Blank space.
For Early Career peeps with a young family: This is your professional development time.  Probably best not to bring your dependents.  It is much harder to focus on the new hypertension guidelines if you’re wondering whether your kids ate a good breakfast and whether they’re doing okay at the hotel pool.  Just saying.
End game.
Keep an open mind and you’ll find a learning opportunity at every turn.  While it’s normal to initially feel a little intimidated, after the first day you’ll be navigating scientific meetings like a pro.  And definitely take advantage of the awesome Early Career events and resources at AHA meetings!
(How many Taylor Swift song titles did you spot?)

Wei Ling Lau Headshot

Wei Ling Lau, MD is Assistant Professor in Nephrology at the University of California-Irvine, where she studies vascular calcification and brain microbleeds in chronic kidney disease.  She is currently funded by an AHA Innovative Research Grant, and has been a speaker for CardioRenal University and the American Society of Nephrology.


Improving Scientific Presentations: Lesson 1

man in front of audience

American Heart Association Annual Scientific Session consists of hundreds of talks from a wide range of presenters including students, post-doctoral scholars, and faculties at different levels. Seating in various #AHA17 sessions makes me think about what William Yeats, one of the foremost figures of 20th-century literature, said years ago:

“I always think great speakers convince us not by force of reasoning but because they are visibly enjoying the beliefs they want us to accept.”

I still believe that this is one of the most important fundamental points to successfully convey your scientific message; what you will not always see in scientific presentations. So let’s discuss basic points of executing a good talk by tackling the most common problem: Podium Panic. In order to overcome this problem, I like to do the “4 Ps” method – Plan, Prepare, Practice, and Perform.

To plan, make sure you know your audience and the range of their knowledge and why you are talking to them. Is it a summary of your progress to your advisory committee or it is a special seminar to prove your concept. The answer to these questions helps you to form your story.

To prepare, study what you have to study, make ready your handouts (if there are any) and start working on your slides. Do not have “sliduments”, slides that look like documents. 

To practice, make sure to find at least one person to listen to your talk and do not forget to get feedback. Another crucial point is NOT to memorize your talk, rather learn what you will discuss. The latter helps significantly to reduce stress.

To perform, when you planned, got prepared and practiced; now you can just go on the stage and perform. Do not forget to show everyone how excited you are about what you are talking about. 

Shayan Mohammad Moradi Headshot

Shayan is a caffeine-dependent Ph.D. Candidate at the Saha Cardiovascular Research Center, University of Kentucky. His research area is focused on vascular biology and lipid metabolism. He tweets @MoradiShayan, blogs at shayanmoradi.com and he is the Winner of World’s Best Husband Award (Category: nagging).


Closing The Gap On Cardiovascular Health Disparities

Kicking off the #AHA17 session on Closing the Gap on Disparities: Practical Strategies and Implementation, Dr. Michelle Albert out of UCSF fits an astonishingly large amount of information into a succinct 15-minute talk on Improving Cardiovascular Risk in African Americans. She alludes to her research on psychological stress in the context of cardiovascular well-being being a function of adversity and resilience, divided by wealth, and cautions against interpreting wealth as income.

A feature article by the UCSF Cardiology department quotes her well as she explains that “some forms of adversity” are similar to post-traumatic stress disorder, and that while “…stress is a normal part of life…chronic, persistent stress…accompanied by a lack of control [of that stress]…is associated with hypertension, obesity, [and] inflammation.”

I hope that quote makes you think of the term “microaggressions”, a concept that has received note by many social media groups such as Buzzfeed, and a brief online search returns an article from Psychology Today in 2010 both defining the term, and providing examples.

She adds in today’s presentation that sleep disturbances disproportionately afflict African Americans, who are 5 times more likely to experience shorter sleep times compared to whites (adjusted for sex, age, and site).

Her closing call to action gave life to thoughts I’ve had the past few months as a doctoral epidemiology student.

“Epidemiologists are accustomed to describing things but we need to move on to taking those associations and putting them into practice, whether designing trials or conducting community based research for interventions”.

In the epidemiologic world of causal inference, I’m glad I am not the only one who’s asking when we will move from associations to interventions.

 Bailey DeBarmore Headshot
Bailey DeBarmore is a cardiovascular epidemiology PhD student at the University of North Carolina at Chapel Hill. Her research focuses on diabetes, stroke, and heart failure. She tweets @BaileyDeBarmore and blogs at baileydebarmore.com. Find her on LinkedIn and Facebook.



The Pediatric Side Of AHA17: Advice And Lessons-Learned From The Council On Cardiovascular Disease In The Young (CVDY) Early Career Networking Luncheon

At large meetings like the AHA Scientific Sessions, the pediatric presence is usually smaller and less ubiquitous than our adult counterparts.  For trainees and junior faculty, it can be intimidating to navigate for the first time, but the CVDY Early Career Networking Luncheon is a great way to ease into it.  Not only do you get ample opportunities to meet leaders in our field, but they are open, accessible, and eager to give out free advice. 

There were faculty represented from almost every sub-discipline within pediatric cardiology (cath, echo, ICU, transplant, etc), and also representing nearly every type of career niche (division chiefs, program directors, researchers, clinicians, educators, etc).  We were able to sit in small groups and have round-table discussions about assorted topics.

Here are a few (paraphrased) nuggets I picked up from the round-tables:

  1. Dr. Peter Lang on Finding What You Love: No matter what you think you want to do within pediatric cardiology, you never know where you’re going to end up…you may love more than one thing…keep an open mind… it’s not completely crazy to change what you’re doing.
  2. Dr. Katie Bates on Finding Your First Job: You shouldn’t expect perfection – this probably won’t be the last job you ever have.It’s unreasonable to expect your perfect job in the perfect location, but it does seem to work out most of the time. As far as waiting to hear back from programs, you should not freak out if you don’t get immediate feedback. There is a big priority gap between you as the applicant and the program that’s potentially hiring you, and a great deal of things are going on behind-the-scenes, so it’s a slow process to get an offer. Once you have an offer, have mentors help you out, and consider reading a book about negotiation. Her suggestion is Getting To Yes by Roger Fisher and William Ury.
  3. Dr. Daniel Penny on Work-Life Balance: Finding interesting or exciting things to occupy your time outside of work will actually enhance your ability to do more productive work rather than detracting from it. Mindfulness can be very helpful, but it’s also important to find a hobby that you love and devote some time to it.

After the round-tables, we were able to hear take-home points from around the room.   Here’s just a small selection:

  1. There’s never a good time to have kids – just do it
  2. Be adaptable in your first job, but don’t say yes to things that you aren’t going to be able to honestly put your best efforts towards
  3. Find a mentor early and it’s ok to have more than one
  4. You can’t always control circumstances at your new job, as things can change, but you can leverage some challenges into opportunities for growth
  5. Make clear priorities – make time for things that are important (including schedule requests for things like spouse birthdays well ahead of time, etc.)

And finally, here are a few tips regarding involvement in AHA and time spent at Scientific Sessions:

  1. AHA and CVDY are full of opportunities for interested people; you just have to seek them out
  2. You can get involved in committees and find collaborators even very early in your career
  3. Don’t be afraid to introduce yourself – people are here to meet their colleagues and exchange ideas
  4. Everyone you meet is potentially a future colleague, friend, mentor, or boss
  5. Getting involved with the AHA has great potential to shape your career and long-term engagement in CVDY can be extremely rewarding

David Werho Headshot

David K. Werho, MD is an Assistant Clinical Professor at the University of California San Diego and a Pediatric Cardiac Intensivist at Rady Children’s Hospital – San Diego.  His research focuses on pediatric cardiac ICU outcomes as well as interventions and curriculum development in medical education.  He tweets @DWerho and contributes to the Pediatric Cardiac Intensive Care Society Newsletter as editor and contributor.


Back To Square One: Normal Saline For Prevention Of Contrast-Associated Kidney Injury

I was in medical school when the JAMA paper came out that reported superiority with sodium bicarbonate IV fluids over normal saline in preventing contrast-induced acute kidney injury.  This was a Big Deal.  Kidney injury is associated with prolonged hospital stays and increased risk of death.  I recall carefully making a note of the exact sodium bicarb formulation and pre- and post-contrast infusion rates, carrying this index card around in my coat pocket.  Later during residency, I would diligently order the sodium bicarb fluids for high-risk patients pending contrast procedures and spell out the protocol in my chart notes.
A barrage of studies followed the JAMA report but the robust benefit in preventing kidney injury was not replicated.  While some investigators were able to detect a modest benefit with sodium bicarb fluids (for urine alkalinization) or oral N-acetylcysteine (NAC, for scavenging of reactive oxygen species) other groups reported no difference, and small cohort sizes with low outcome rates was a prevailing limiting factor.
The PRESERVE trial (Prevention of Serious Adverse Events Following Angiography) definitively lays to rest all the uncertainties surrounding sodium bicarb and NAC.  In a very anti-climactic fashion.  Sodium bicarb was no better than normal saline, and NAC was no better than placebo.  The study was funded by the Veterans Affairs Cooperative Studies Program and included about 5,000 high-risk patients with stage 3-4 chronic kidney disease (80% were diabetic) from 53 medical centers in the US, Australia, New Zealand and Malaysia.  (I was born and raised in Malaysia, and am simultaneously impressed and bemused that Malaysia was the only Asian country involved in PRESERVE.)  Rates of acute kidney injury were ~9% and death by 90 days ~2.5% across all treatment groups.  PRESERVE trial findings were published in NEJM to coincide with Dr. Weisbord’s presentation at the #AHA17 late-breaking clinical trials session.
I chatted with Dr. Pastor-Soler, a nephrologist from University of Southern California who was the discussant at the media briefing session, expressing my disappointment that we don’t have more effective prevention strategies for contrast-induced kidney injury.  In pragmatic fashion, she pointed out that the PRESERVE trial is important since sodium bicarb fluids often have to be prepared to-order by hospital pharmacies, and there are intermittent shortages plus increased cost.  Based on the PRESERVE trial findings, we can confidently proceed with normal saline which is readily available, with more efficient patient care.  (I’ll make a plug here for Women In Nephrology (WIN) where Dr. Pastor-Soler is President-Elect… if you’re a female in the field of nephrology, consider joining!)
So how much normal saline should we give?  The PRESERVE investigators allowed a great deal of flexibility to participating medical centers: “1 to 3 ml per kilogram of body weight per hour during a period of 1 to 12 hours for a total volume of 3 to 12 ml per kilogram before angiography, 1 to 1.5 ml per kilogram per hour during angiography, and 1 to 3 ml per kilogram per hour during a period of 2 to 12 hours for a total volume of 6 to 12 ml per kilogram after angiography… In patients with a BMI of more than 30, we capped fluid-administration rates on the basis of a weight of 125 kg.”  It sounds like if you give some NS before, during and after, you’re a winner!
To end on a sobering note, the PRESERVE statistics indicate that in high-risk stage 3-4 chronic kidney disease patients who require IV contrast procedures, about 1 in 10 will develop acute kidney injury and 1 in 40 will not survive past 90 days.  Medical necessity for IV contrast should always be carefully weighed.  And normal saline hydration – yes, definitely! – while keeping in mind that 1 liter of NS contains 3.5 grams of sodium and it is prudent to avoid excessive salt/water loading (volume overload being another key predictor of poor hospital outcomes).

Wei Ling Lau Headshot

Wei Ling Lau MD is Assistant Professor in Nephrology at the University of California-Irvine, where she studies vascular calcification and brain microbleeds in chronic kidney disease. She is currently funded by an AHA Innovative Research Grant, and has been a speaker for CardioRenal University and the American Society of Nephrology.