women – The Early Career Voice

Let’s add Stress Reduction as the 8th step in the American Heart Association’s “Life’s Simple 7”

February 19, 2021February 16, 2021 Sheila Sahni, MD, FSCAI

February is Heart Month! An entire month dedicated to heart disease awareness in our community. During this month, we also educate the community on why heart disease is a women’s biggest threat. After all, heart disease takes more lives than all cancers combined. Globally, that equates to one woman dying every 80 seconds. More recently, research has revealed an emerging heart disease epidemic in young women resulting from uncontrolled risk factors such as obesity, blood pressure, elevated cholesterol and diabetes.

The good news is that 80% of heart disease can be prevented through risk factor management – this journey begins with a baseline assessment with a clinician. Starting this journey early is critical – research has demonstrated that if a woman can reach 50 without developing a major risk factor for heart disease, her lifetime risk for heart disease is only 8%. By contrast, women who have 2 or more risk factors for heart disease at 50 have a 50% risk of developing heart disease.

Heart month is a great time to start your journey to #knowyournumbers. The three most important numbers to check are:

Blood Pressure
Cholesterol
Blood Sugar (A1C)

It’s also a great time to review your diet and exercise plan with your physician.

Furthermore, in women, an increasingly important aspect of cardiovascular health is the presence of psychological, psychosocial, and emotional stress. Well-established epidemiological data has shown that psychological risk factors such as anxiety, depression, work-related exhaustion, or perceived home stress are significantly associated with heart attacks in women (1). Another large study of young women presenting with heart attacks revealed that women reported higher amounts of perceived stress before their heart attacks symptoms compared with men. Overall, women reported worse baseline physical and mental health before heart attacks compared with men (2). Therefore, an important assessment of a woman’s current emotional health status is imperative in my initial cardiac workup, particularly for women.

During the initial consultation and subsequent follow-up visits, I focus on learning details about my patients’ lifestyle habits including eating patterns, physical activity/exercise routine, sleep hygiene, and stress levels. The key is to begin the discussion to open the door to awareness of how one’s lifestyle could be setting them up for the greater cardiovascular risk. The American Heart Association (AHA) has created a campaign for workplace health called “Life’s Simple 7” which defines ideal cardiovascular health in terms of seven risk factors (Life’s Simple 7) that people can improve through lifestyle changes: smoking status, physical activity, weight, diet, blood glucose, cholesterol, and blood pressure. While I have leaned on AHAs “Life’s Simple 7”, I have added a very important 8^th step to reduce cardiovascular risk in my patients: Reduce Stress.

When it comes to my women patients, I have found that they are usually suffering from a compounded impact of accumulated stress from both families, interpersonal relationships, and/or work. To help improve mental health, I recommend practicing the 4-7-8 breathing technique, prioritizing self-compassion, and focusing on gratitude. These simple steps help to create the mindfulness that helps mitigate stress and its potential impact on the heart.

The 4-7-8 breathing technique popularized by Dr. Andrew Weil in the West is based on the ancient Indian yogic breathing technique called Pranayama. This technique can slow down the nervous system that controls the “stress response” and in turn enhance the relaxation response in the body and the heart. It is easily accessible for my “busy” women patients as it can be performed from any location without any equipment. The goal is to ensure your exhalation is twice as long as your inhalation.

While there are officially 8 total steps to use this technique, I often ask my patients to simply inhale for the count of 4 in the nose, hold for a count of 7, and exhale for a count of 8 through the mouth.

Self-compassion is another effective way to enhance well-being and reduce burnout. Self-compassion is the act of directing compassion towards oneself when dealing with a failure, a personal struggle, or negative thoughts about oneself. Self-compassion leads with kindness and understanding instead of self-criticism and self-judgment in response to personal shortcomings. Recent studies on self-compassion have revealed a direct relationship between self-compression and feelings of greater well-being.

Gratitude is another way to return kindness to one’s life. It is the quality of being thankful. The creation of a gratitude practice in one’s life may take many different forms: journaling, meditation, active daily reminders or even prayer. The common theme is opening the emotional heart to recognize and appreciate the simple pleasures in life which may be overlooked during times of stress. It is about cultivating a sense of thankfulness for what you have rather in your life no matter how small or simple.

Last year prior to a women’s heart disease awareness lecture series I delivered, I created a handout adapted from AHA’s “Life’s Simple 7” and added the additional 8^th step: Reduce Stress. [See caption below] The details of how to actually begin that journey of self-awareness of perceived stress as well as important stress reduction techniques can now be found in this blog and hopefully will find their way to our patients.

Reference:

Yusuf S, Hawken S, Ounpuu S et al. INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): a case-control study. Lancet. 2004; 364:937–952.
Xu X, Bao H, Strait K et al. Sex differences in perceived stress and early recovery in young and middle-aged patients with acute myocardial infarction. Circulation. 2015; 131:614–623.
Life’s Simple 7. https://heart.org/en/professional/workplace-health/lifes-simple-7. Accessed 2/14/2021

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

The American Heart and Go Red for Women Month!

February 6, 2020February 6, 2020 Lina Ya'qoub, MD

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

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

When was the first American Heart Month?

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

What is the Go Red for Women Initiative?

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

G: GET YOUR NUMBERS

Ask your doctor to check your blood pressure and cholesterol.

O: OWN YOUR LIFESTYLE

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

R: REALIZE YOUR RISK

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

E: EDUCATE YOUR FAMILY

Make healthy food choices for you and your family.

D: DON’T BE SILENT

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

How about “Research Goes Red” initiative?

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

What impact have these initiatives achieved?

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

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

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

Reference

Women and Heart Disease: CDC: https://www.cdc.gov/heartdisease/women.htm

Anxiety, Food Security, & Beyoncé: Addressing Young Women’s Cardiovascular Health

April 2, 2019April 2, 2019 Elizabeth Knight, PhD, DNP

What can you do to address gender disparities in health and health care? In my last post, I suggested working to identify your own bias by increasing your awareness. I’m walking this path, too. A few years ago, I made a concerted effort to diversity my reading habits after I noticed that a huge percentage of the work I was consuming was produced by white men. I spent a year choosing to read only books by women and people of color instead. I learned that it was not hard to do this, but it required that I pay attention. I read a lot of wonderful work that I might have otherwise overlooked, and I was exposed to much more diverse viewpoints. I continue to seek out broad representation, and I suggest a similar approach to reading scientific literature.

Start by paying attention to 1) study populations, and 2) authorship. Are you reading articles about (and by) underrepresented populations? In cardiovascular health, this includes women, who remain underrepresented in clinical trials (estimates as low as 34% of participants in trials supporting drugs for some CV conditions¹), clinical practice (just 20% of cardiology fellow are women²), and academia (check out the #nomanels hashtag on Twitter).

Clearly, we need more cardiovascular research by and about women. In this post, I want to highlight some exciting research by and about women.

Evidence of the pervasive male bias: we’ve programmed our machines to assume patients are male.

At the recent American Heart Association EPI/Lifestyle conference, a woman-led team from Boston Children’s Hospital presented their work on perceptions of cardiovascular risk among adolescent and young adult (AYA) women. The team recognized that young women didn’t seem particularly informed about or interested in their heart health. Based on this clinical insight, they designed a study to identify barriers to awareness and preventive behaviors among AYA women. I spoke with Courtney Brown, an early-career professional herself and the first author of the abstract³, who explained the team’s findings. First, noted Brown, AYA women have a low baseline knowledge of their cardiovascular risk— lower than expected. They also face competing demands to focusing on their cardiovascular health, such as limited time and financial resources. One key finding was the role of mental health concerns like depression and anxiety: it’s hard to care about something that might happen to you in thirty years when you’re worried about getting through your next few days. Some participants also noted that eating healthy seems too expensive, and sometimes healthy food just isn’t available. These barriers to healthy behaviors are real! Yet behaviors established in young adulthood tend to persist as we age, so AYA women are at a crucial time in their lives for their heart health.

A key point for intervention development, says Brown, is that lifestyle behaviors (including exercise and high-quality nutrition) that are good for mood are also good for heart health. So while cardiovascular health may not be this group’s priority, they will likely benefit from risk-reducing behaviors in multiple ways.

Delivering the message in the setting of competing demands is tricky— and important. When asked what might facilitate their adoption of heart-healthy behaviors, participants in the study indicated that family was their biggest influence, followed by their health care providers and celebrities (favorites were Drake, the Kardashians, and Beyoncé). They also talked about using Facebook, Snapchat, and Instagram to get information and communicate. This is rich data, and it suggests that a “meet them where they’re at” approach is likely to be successful. “We’d love for more people to take up this work— we have more steps to take,” Brown says. “We’d love to create and test materials.” It’s encouraging to see rigorous science targeting the needs of a group that’s often overlooked in cardiovascular research. As the body of evidence grows, perhaps some of the disparities in women’s cardiovascular health will fade.

There are also some great lessons here from a methodological standpoint. This study utilized mixed methods, including online focus groups. Courtney Brown, the researcher from the AYA study, stressed that the qualitative component of the work is highly valuable because it can help researchers develop interventions that will effectively reach the population of interest. “It lets us dig deeper into responses to find out what the unique barriers are and how to reach this population, not just what to tell them”, she says. When so much of existing clinical practice is based on research that excluded women, this approach is very relevant. In a climate where the RCT is king and the p-value determines whether or not a finding is considered significant, qualitative work is often undervalued, but these kinds of studies are crucial in understanding the needs, values, and preferences of patient populations— especially those, such as young women, that have been previously understudied and undertreated.

Have you read (or authored!) any great women’s health studies lately? Try to add some to your reading list!

References:

Scott, P, Unger, E., Jenkins, M. Southworth, M., McDowell, T., Geller, R., Elahi, M. Temple, R., & Woodcock, J. (2018). Participation of women in clinical trials supporting FDA approval of cardiovascular drugs. Journal of the American College of Cardiology, 71(18), 1960-9.
Lau, E. & Wood, M. (2018). How to we attract and retain women in cardiology? Clinical Cardiology, 41(2), 264-268.
Brown, C., Revette, A., de Ferranti, S., Liu, J., Stamoulis, C., & Gooding, H. (2019). Heart Healthy Behaviors in Young Women: What Prevents Teens from Going Red? Abstract presented at American Heart Association Epidemiology, Prevention, Lifestyle & Cardiometabolic Health Scientific Sessions, Houston, TX.

Who is writing what you’re reading? Look at the great mix of people on the AHA early career blogging team!

Women’s History Month: Cardiology Edition

March 5, 2019March 28, 2019 Christa Trexler, PhD

Somehow it’s already March, which means it’s Women’s History Month, so I wanted to take this opportunity to highlight some of the many amazing cardiologists and researchers (who also happen to be women) who have shaped our field.

Last month, I wrote about the importance of science outreach, especially with regard to promoting science and cardiology to young girls and women, because women still make up around only a third of scientific researchers and only around 13% of cardiologists are women. To learn more, Renee P. Bullock-Palmer’s most recent blog is a great resource.

This month I wanted to highlight some of the women who paved the way for the rest of us.

Now, unsurprisingly, simple Google searches for things like “scientists who shaped cardiology” or “most famous cardiologists” provide results that are pretty male and pale. There weren’t that many pieces that included women in their lists of cardiologists/researchers, and there were only a handful of sources I found that focused specifically on women. Lucky for you, I’ve collected what I found here! I’m also going to highlight several of the brilliant women who shaped our field – this is by no means an exhaustive list of amazing women in cardiology (or their accomplishments) because there are too many to fit on one list.

Maude Abbott, MD was a Canadian physician who invented an international classification system for congenital heart disease in the 1930’s. Her work the Atlas of Congenital Heart Disease became the definitive reference guide on the subject.

Helen B. Taussig, MD, FACC is widely regarded as the Founder of Pediatric Cardiology. In the 1940’s she developed the operation to correct the congenital heart defect that causes “blue baby” syndrome. She received the Medal of Freedom from President Lyndon B. Johnson and was the first female president of the American Heart Association.

Myra Adele Logan, MD was the first woman (and only the 9^th person!) to operate on a human heart in 1943.

Marie Maynard Daly, PhD was first African American woman to obtain a PhD in chemistry in the United States, whose research in the 1950’s was invaluable in demonstrating the relationship between high cholesterol levels and heart attacks.

Celia Mary Oakley, MD was one of the first women cardiologists in the United Kingdom and was part of the team that coined the term hypertrophic cardiomyopathy in the late 1950’s.

Sharon A. Hunt, MD was just one of seven women in her 1967 medical school class and she went on to revolutionize the field of heart transplantation by working to improve survival rates by identifying and treating rejection and determining how to reduce the side effects of the drugs.

Nanette Kass Wenger, MD, was among the first cardiologists to focus on heart disease in women, and to evaluate the different risk factors and manifestations of the condition, specifically coronary artery disease, in women and men. I was lucky enough to talk with her about her work at AHA Sessions 2018, which I wrote about here. You can also follow her on twitter @NanetteWenger.

Christine Seidman, MD, is a researcher who transformed the field of cardiovascular genetics with her research that uncovered the genetic basis of many human cardiovascular disorders, including cardiomyopathy, heart failure and even congenital heart malformations.

Elizabeth O. Ofili, MD, MPH, FACC is a clinical scientist who led the effort to implement the landmark African American Heart Failure Trial (AHEFT), whose findings improved the practice guidelines for the treatment of heart failure in African Americans. She also became the first woman president of the Association of Black Cardiologists in 2000.

Ileana Piña, MD, MPH, FACC is a nationally renowned cardiologist known for her work in heart failure and improving patient rehabilitation outcomes. Her work has also upturned preconceived notions about women in the medical community and she works tirelessly to get more women into clinical trials.

Rong Tian, MD, PhD is a leader in the field of cardiac metabolism whose work has been translated to clinical trials. Among her many contributions, she was the first to demonstrate that AMP-activated protein kinase (AMPK) acted to remodel cardiac energy metabolism, which critically informed the heart failure field. You can also follow her on twitter @Rongtian2.

I want to note, that these cardiologists and researchers are not important just because they are women – they are talented scientists and cardiologists who happen to also be women. But pieces like this are important because representation matters. It’s important for everyone, especially young girls and women, to see that it’s possible not just to be successful in this field, but also to revolutionize it.

Helpful sources & suggested reading:

A Timeline of Achievements For Women Cardiologists from the American College of Cardiology
Women in cardiology: the US experience by Nanette Wenger
Women as leaders in cardiovascular medicine by Mary Norine Walsh
Top 10 Women in Cardiology on Social Media

A Short History of Immunosuppressants And The Woman Who Invented Them

February 12, 2019March 28, 2019 Daniel Tyrrell, PhD

I’ve been thinking about the field of experimental transplantation research lately. There has been great research in this area recently, including work in Circulation Research on using nanoparticles to target potent immunosuppressants to key areas to suppress rejection (Bahmani, Uehara et al. 2018). There was also an interesting paper that used an aortic arch transplant model to study regression of atherosclerosis published in ATVB (Li, Luehmann et al. 2018). I began thinking about transplantation and the issue of acute rejection. There is also the problem of longer-term chronic vasculopathy and remodeling, but how did the field get over the first hurdle of acute rejection? It’s so fundamental to all organ transplantation that takes place in the clinic today. I decided to look into how we got to where we are today.

I found out that one of the earliest immunosuppressive agents was 6-mercaptopurine (6-MP). 6-MP was developed by a chemist named Gertrude Elion. I was delighted to find out that a woman developed this drug, especially as it was recently Women in Science Day on February 11^th. Elion was born in New York City and earned a Bachelor’s degree at Hunter College and a Master’s degree in chemistry at NYU. She submitted 15 applications for graduate fellowships which were all turned down, leading her to enroll in secretarial school. She moved through several other jobs before working in as an assistant at what is now GlaxoSmithKline (GSK). While working there, she began earning her doctorate at night but stopped due to the difficulty of the commute. It was at GSK that Elion developed 6-MP, but she was only getting started.

6-MP was first used in the late 1950’s as chemotherapy to suppress antibody formation in pediatric cancer which improved survival from 3-4 months up to 12 months. 6-MP was next used in rabbits that were injected with bovine serum albumin to stimulate a powerful antigen response, but 6-MP prevented it (Schwartz, Stack et al. 1958). Next, a British surgeon, Roy Calne wanted to test whether 6-MP’s immune suppression could be used to prevent rejection after a transplant. He treated a dog with 6-MP and then transplanted a kidney from another dog. Ordinarily, the recipient dog’s immune system would attack the new kidney as if it were an invader. The kidney in the 6-MP treated dog survived 44 days compared to only 10-days for dogs that weren’t given 6-MP (Calne 1960). This drug seemed promising, but it had a high risk of toxicity, and this is where the story gets interesting.

Roy Calne wanted to find a drug that was as effective as 6-MP but less toxic, so he asked Gertrude Elion. Elion suggested another compound that she had recently synthesized, which was azathioprine (AZA) (Elion, Callahan et al. 1960). Clinicians will be familiar with this drug, but as a PhD scientist, I had never heard of it before now (and I did my PhD in pharmacology, but don’t hold it against me). AZA is a pro-drug that that is activated by glutathione in red blood cells to produce the active metabolite 6-MP in plasma. AZA was not only superior to 6-MP for preventing alloimmune transplant rejection, it was far less toxic. In 1962, only 2 years after the kidney transplant study with dogs, AZA was being used in human kidney transplants together with prednisone (Murray, Merrill et al. 1963). From this point onward, kidney transplants using Gertrude Elion’s AZA compound skyrocketed.

In 1988, Gertrude Elion was awarded the Nobel Prize in Physiology or Medicine, just the 5^th woman to receive the award at the time. The development of AZA and more importantly, its use as an immunosuppressive agent allowed for the transplantation of many other organs, including livers, lungs, and hearts (Elion 1989). Other immunosuppressants have been developed which are in use for heart transplantation today but AZA is still being used for kidney transplants and chronic inflammatory diseases like rheumatoid arthritis and Crohn’s disease. Elion’s AZA is also listed as an essential medicine by the World Health Organization.

Gertrude Elion was an amazing scientist that had an enormous impact on health across the world. In addition to the synthesis and development of AZA, she is credited with the synthesis of allopurinol to treat gout and ancyclovir to treat herpes simplex virus. Both of these drugs are classified as essential medicines by the WHO. Her knowledge of both chemical synthesis and the biochemical basis of disease set her apart as a truly remarkable scientist who overcame many obstacles that women in science still face. Gertrude Elion should serve as a role model for anyone interested in science.

References:

“Gertrude B. Elion.” https://en.wikipedia.org/wiki/Gertrude_B._Elion

“Gertrude B. Elion Biographical.” https://www.nobelprize.org/prizes/medicine/1988/elion/biographical/

Bahmani, B., M. Uehara, L. Jiang, F. Ordikhani, N. Banouni, T. Ichimura, Z. Solhjou, G. J. Furtmuller, G. Brandacher, D. Alvarez, U. H. von Andrian, K. Uchimura, Q. Xu, I. Vohra, O. A. Yilmam, Y. Haik, J. Azzi, V. Kasinath, J. S. Bromberg, M. M. McGrath and R. Abdi (2018). “Targeted delivery of immune therapeutics to lymph nodes prolongs cardiac allograft survival.” J Clin Invest 128(11): 4770-4786.

Calne, R. Y. (1960). “The rejection of renal homografts. Inhibition in dogs by 6-mercaptopurine.” Lancet 1(7121): 417-418.

Elion, G. B. (1989). “The purine path to chemotherapy.” Science 244(4900): 41-47.

Elion, G. B., S. W. Callahan, G. H. Hitchings and R. W. Rundles (1960). “The metabolism of 2-amino-6-[(1-methyl-4-nitro-5-imidazolyl)thio]purine (B.W. 57-323) in man.” Cancer Chemother Rep 8: 47-52.

Li, W., H. P. Luehmann, H. M. Hsiao, S. Tanaka, R. Higashikubo, J. M. Gauthier, D. Sultan, K. J. Lavine, S. L. Brody, A. E. Gelman, R. J. Gropler, Y. Liu and D. Kreisel (2018). “Visualization of Monocytic Cells in Regressing Atherosclerotic Plaques by Intravital 2-Photon and Positron Emission Tomography-Based Imaging-Brief Report.” Arterioscler Thromb Vasc Biol 38(5): 1030-1036.

Murray, J. E., J. P. Merrill, J. H. Harrison, R. E. Wilson and G. J. Dammin (1963). “Prolonged survival of human-kidney homografts by immunosuppressive drug therapy.” N Engl J Med 268: 1315-1323.

Schwartz, R., J. Stack and W. Dameshek (1958). “Effect of 6-mercaptopurine on antibody production.” Proc Soc Exp Biol Med 99(1): 164-167.

Highlights of AHA18 – Bridging Lifestyle Medicine with Contemporary Medicine through Science

November 28, 2018March 28, 2019 Renee Bullock-Palmer, MD

This year’s annual scientific meeting of the American Heart Association (AHA) held in Chicago, Illinois November 10-12, 2018 was excellent. The abbreviated 3-day meeting received positive feedback as this allowed practicing physicians to attend the meeting over the weekend and be able to return to their practice early in the work week rather than having to spend an extended time away from the office. It was great being a part of the AHA Early Career Blogger group as this allowed access to many of the embargoed sessions. At these sessions I was able to listen to the AHA 2018 updated Lipid Management Guidelines¹ as well as The Physical Activity Guidelines for Americans, Second Edition² prior to their release at the meeting. This gave me a chance to ask the guideline committee several questions related to patient management.

Opening Session:

The opening session by Dr. Ivor Benjamin, the President of the American Heart Association, delivered very powerful messages throughout his speech. He highlighted the track of his career and the important role of strong mentors throughout his career and the impact it had on his advancement throughout the field of cardiology. He also discussed both the importance of mentoring and diversity in the cardiology profession highlighting the fact that African American men account for only 3% of Cardiologists in the United States and the need to bridge this gap. I found this session very inspiring and encouraging especially with regards to mentoring and supporting junior colleagues and being grateful for the mentors I have had thus far in my career. I also welcomed the message of the importance of diversity and inclusion as this leads to a healthier work and training environment.

Bridging Lifestyle Medicine with Contemporary Medicine through Science:

This year’s meeting highlighted the value of integrating lifestyle medicine with contemporary medicine to achieve the best outcomes for patients with regards to the prevention of cardiovascular disease. This was supported by the release of the updated 2018 American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines on Lipid Management on the first day of this meeting¹. This updated guideline emphasized the importance of the cholesterol management at all stages of adulthood along with the importance of therapeutic lifestyle changes¹. The utility of coronary artery calcium (CAC) scoring with cardiac CT was also emphasized as a useful tool to further refine patients’ risk to determine the best management for patients who are at intermediate risk for atherosclerotic cardiovascular disease (ASCVD)¹. This guideline also had included ezetimibe and PCSK9 inhibitors as having a complementary role when used with statin therapy in selected patients at high risk for ASCVD¹. The release of this updated guidelines will be a useful in my management of patients with regards to primary and secondary prevention of ASCVD. I appreciated the role of CAC scoring which will be very helpful for the management of the intermediate risk patients.

The release of the U.S. Department of Health and Human Services’ second edition of the Physical Activity Guidelines for Americans on the last day of the meeting was also well received². This second edition emphasized the importance of increasing physical activity for all age ranges throughout the population including women in pregnancy and the postpartum period, as well as adults with chronic diseases or disabilities². This guideline update will assist me with counseling patients with regards to increasing their physical activity to improve their overall cardiovascular health.

Networking Opportunities:

There were many networking opportunities during the meeting. These included the Council on Clinical Cardiology dinner on the first night of the meeting which honored Dr. Judith Hochman the recipient of the James B. Herrick Award for Outstanding Achievement in Clinical Cardiology. Dr. Stacy Rosen was also the recipient of the Women in Cardiology Mentoring Award. This dinner was attended by many leaders in the field of Cardiology and was a great opportunity for me to meet these leaders. The Women in Cardiology Committee also hosted a networking luncheon on the first day of the meeting during which Dr. Sharonne Hayes from the Mayo Clinic was the keynote speaker. Dr. Hayes gave a very riveting interactive talk on leadership for women in cardiology, she was also the recipient of last year’s Women in Cardiology Mentoring Award. Her talk was useful with very powerful messages on navigating your professional and personal life to achieve overall job satisfaction, career success and personal happiness. I learned several tips that I will apply to my own career as well. Dr. Annabelle Volgman and the faculty at Rush University was gracious to host a wonderful networking dinner for Women in Cardiology (WIC) on the second night of the meeting. This dinner provided a great opportunity for me to meet fellow WIC colleagues and to discuss several relevant issues related to our practice in the Cardiology field.

Social Media Coverage:

There was also a broad social media coverage of the meeting on Twitter and this was assisted by the AHA Early Bloggers writing group. I was able to share live tweets during several sessions and this generated a lot of discussion amongst members on Twitter. This also allowed many colleagues who were unable to attend the meeting to be able to follow and comment on several meeting highlights.

Looking Forward to AHA 2019:

This year’s AHA Scientific Sessions embrace of lifestyle medicine and the value of preventive cardiology was refreshing and empowering. This meeting highlighted the importance of not only treating ASCVD but also the importance of preventing disease and empowering our patients to take responsibility for their health as well. In the words of Goethe as mentioned in Dr. Ivor Benjamin’s opening session “Choose well….your choice is brief, and yet endless.” We look forward to next year’s AHA 2019 meeting in the beautiful city of Philadelphia.

References:

1. 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

2. The Physical Activity Guidelines for Americans: THe HHS Roadmap for an Active Healthy Nation. Second Edition. ADM Brett P. Giroir, MD.

AHA18 Reminded Me We Need to Do More for Women

November 28, 2018March 28, 2019 Christa Trexler, PhD

On the surface, it doesn’t really seem that surprising men and women develop heart disease differently or experience different symptoms for the same types of cardiac episodes. However, even though heart disease is the number one killer of both men and women, women have traditionally been omitted from clinical trials and female animals have either not been included in preclinical research studies or the two sexes have been combined¹. We just simply weren’t taking half of the population into account at every level of cardiovascular disease (CVD) research for quite some time. I spent my graduate career focused on understanding the baseline differences in the heart between the sexes, and was extremely passionate about this work. Since I spent most of my scientific career working in this field, I wanted to switch it up as a postdoctoral fellow and am currently not researching sex differences. However, when I went to AHA sessions this year, I made it a point to go to any events focused on sex differences and women to get updated on what I’ve been missing this past year. Luckily the “State of the Heart For Women: Top Ten Advances in Gender-Specific Medicine” session provided the perfect summary. After ten great talks focused on a variety of gender specific concerns ranging from heart failure to pregnancy, the take home message was clear: women are still very much at risk, more likely to be misdiagnosed, and are still under-represented in clinical trials. These issues are also worse for women of color.

While this is a widespread issue across disciplines, the cardiovascular field has been particularly biased with regard to including women in clinical trials for drug development, leading to drugs being either not as effective in women or causing different side effects². The good news is, things are changing. In the early 1990’s, reports from the Food and Drug Agency (FDA) demonstrated that less than 20% of participants in clinical trials were women and recent studies reveal that this number is steadily increasing – even in the cardiovascular field³. Fixing this imbalance is the result of the tireless work from many dedicated researchers over the past several decades. One of the main advocates this field has is Dr. Nanette Wenger, who was the first speaker of this session and actually let me ask her a some questions later during the conference while we were both in the Women in Science and Medicine Lounge. When I asked Dr. Wenger about her strategy for making this issue a priority in our field she explained the key steps to creating change:

Investigate — people can’t ignore what the data is clearly telling them
Educate — teach your peers & patients
Advocate for the change
Legislate — it took a long time, but we’re slowly transforming the strategic plan of the NIH

Dr. Wenger also stressed that since the emphasis in our field now is personalized care, many researchers and physicians are more supportive of including sex in their experiments and/or trials, but we need to move forward by not assuming that women are a homogeneous group. Other factors such as race are also important and must also be considered.

While progress has been made we still have a long way to go on many accounts. While there are more women in clinical trials than in the past, women still only make-up about 34% of the total participants in cardiac clinical trials³. Hopefully, with the passing of the 21^st Centuries Cures act and the NIH policy mandating sex be included as an biological variable in basic research studies in 2016, these numbers will progressively increase. At the session before the talks even began, I immediately noticed that all but one of the ten panelists were women (which is awesome, but strange for the cardiac field) and the majority of people in the audience were also women. We will need to continue to advocate for this issue and we need men to join us and take it seriously for real change to be made. Additionally, while I really enjoyed this unique session, the speakers were only given ~10 minutes each to summarize their extraordinarily complex topics, which just wasn’t enough time. It would be great if gender-specific cardiovascular issues were given more time at AHA Scientific Sessions as well as other conferences in the future. This session reminded me just how pressing making CVD treatment equitable for all truly is and thankful for the researchers making it happen.

References

Blenck CL, Harvey PA, Reckelhoff JF, Leinwand LA. The Importance of Biological Sex and Estrogen in Rodent Models of Cardiovascular Health and Disease. Circ Res. 2016;118(8):1294-312.
Regitz-Zagrosek V. Therapeutic implications of the gender-specific aspects of cardiovascular disease. Nat Rev Drug Discov. 2006;5(5):425-38.
Pilote L, Raparelli V. Participation of Women in Clinical Trials: Not Yet Time to Rest on Our Laurels. J Am Coll Cardiol. 2018;71(18):1970-2.

Women in the New Lipid Management Guidelines

November 14, 2018March 28, 2019 Mirvat Alasnag, MD

The American Heart Association‘s annual meeting, Scientific Sessions, remains a Mecca for cardiologists worldwide. Those of us who were unable to attend in person followed the scientific discussions virtually through the Live Streaming option. This year the much anticipated update to the Lipid Management Guidelines were presented at the meeting. A focus on women as a special population was addressed separately by Dr. Lynne Braun. As cardiologists, we are not trained to search for atherosclerotic cardiovascular disease (ASCVD) enhancers specific to women, namely premature menopause (less than 40 years old), pregnancy associated disorders such as preeclampsia, gestational diabetes and preterm labor. Moreover, we often fail to discuss pregnancy and contraception with women of childbearing age who require statin therapy based on their ASCVD risk assessment. The majority of our key performance indicators in a cardiac unit or clinic require that patients are discharged on a statin if they are at risk. Yet, women should be advised to discontinue statin therapy 1-2 months prior to attempting pregnancy. It seems counter-intuitive to discuss discontinuation of statin therapy in a system that measures performance by the intensity of the prescribed dose. This in itself requires retraining of cardiologists and the AHA offered a unique opportunity to highlight its importance during Dr. Braun‘s presentation.

Another related topic addressed extensively at this year’s meeting was the role of calcium scoring (CACS) in risk stratification in the new lipid management guidelines. It is noteworthy that several large studies demonstrated that CACS improves risk assessment when combined with the conventional risk parameters.^1-3 Women often have lower CACS compared to age-matched men. A meta-analysis by Kavousi et al in 2016 examined 5 large cohorts of women with an ASCVD risk <7.5% (low risk by current guidelines).⁴CACS was identified in 36% of the women which led to a 2-fold increase risk of ASCVD. Ensuant to this discussion, is the topic of a coronary artery calcium score of 0 that denotes a very low risk, ie 1.1–1.5% 10-year risk of ASCVD events. This is commonly referred to as the power of zero calcium.⁵ The latest guidelines suggest CACS may assist in further stratifying women particularly those in the intermediate and borderline categories of risk given the older age of onset of ASCVD in women. It may also assist in the shared decision making with women of different ages and women with additional risk enhancers as discussed above.

As this year’s meeting drew to a conclusion, I’m grateful I could keep pace with the discussions on lipid management in women from the other end of the globe. More importantly, as a woman cardiologist, I was able to go to work the next morning and reevaluate the discussions I have with my female patients. For the first time, I tailored my discussion on statin therapy to the woman sitting across from me, my patient.

References:

Paixao, A.R., Berry, J.D., Neeland, I.J. et al. Coronary artery calcification and family history of myocardial infarction in the Dallas heart study. JACC Cardiovasc Imaging. 2014; 7: 679–686
Elias-Smale, S.E., Proenca, R.V., Koller, M.T. et al. Coronary calcium score improves classification of coronary heart disease risk in the elderly: the Rotterdam study. J Am Coll Cardiol. 2010; 56: 1407–1414
Arad, Y., Goodman, K.J., Roth, M., Newstein, D., and Guerci, A.D. Coronary calcification, coronary disease risk factors, C-reactive protein, and atherosclerotic cardiovascular disease events: the St. Francis Heart Study. J Am Coll Cardiol. 2005; 46: 158–165
Kavousi, M., Desai, C.S., Ayers, C. et al. Prevalence and prognostic implications of coronary artery calcification in low-risk women: a meta-analysis. J Am Med Assoc. 2016; 316: 2126–2134
Nasir, K., Bittencourt, M.S., Blaha, M.J. et al. Implications of coronary artery calcium testing among statin candidates according to american College of cardiology/american heart association cholesterol management guidelines: MESA (Multi-Ethnic study of atherosclerosis). J Am Coll Cardiol. 2015; 66: 1657–1668
2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol
- Scott M. Grundy, Neil J. Stone, Alison L. Bailey, Craig Beam, Kim K. Birtcher, Roger S. Blumenthal, Lynne T. Braun, Sarah de Ferranti, Joseph Faiella-Tommasino, Daniel E. Forman, Ronald Goldberg, Paul A. Heidenreich, Mark A. Hlatky, Daniel W. Jones, Donald Lloyd-Jones, Nuria Lopez-Pajares, Chiadi E. Ndumele, Carl E. Orringer, Carmen A. Peralta, Joseph J. Saseen, Sidney C. Smith, Laurence Sperling, Salim S. Virani, Joseph Yeboah
  Journal of the American College of Cardiology Nov 2018, 25709

Women’s Heart Disease – The Interdisciplinary Road Ahead

March 16, 2018 Tanja Dudenbostel, MD

Every 80 seconds a woman dies from a heart attack or stroke. Once thought to be predominantly found in men, coronary heart disease remains the leading cause of morbidity and mortality for women in the US and worldwide. There have been significant improvements in cardiovascular mortality in women in the last two decades with narrowing of outcomes between women and men which have been attributed to improved therapy for established cardiovascular disease and to primary and secondary preventive interventions. However, women are less likely to receive evidence-based care and have worse outcomes than men. Gender differences have been recognized, but vast knowledge gaps in gender differences regarding pathophysiology, clinical presentation, diagnosis, and optimal acute and chronic treatment strategies for heart attacks and co-existing or resulting complications such as heart failure remain. The AHA Scientific Statement “Acute Myocardial Infarction in Women” provides a comprehensive review of the current evidence.

At the opening plenary session of the American College of Cardiology ACC.18 meeting in Orlando, Florida, the pioneer of women’s cardiology Dr. Nanette Kass Wenger gave her inspiring Simon Dack keynote lecture on Heart Disease & Women titled “Understanding the Journey-The Past, Present and Future of CVD in Women.”

In “Steps on the journey” Dr. Wenger gave a comprehensive review of the early beginnings and showed how far we have come. Some interesting anecdotes were also shared such as that the first women’s heart disease meeting in Iowa in the 1950s was to help women prevent heart attacks in husbands.

Her impactful vision on how to expand the landscape of women’s cardiovascular health research in the next decade struck a nerve with me and made me re-think some of the concepts we are applying in academic cardiology. Dr. Wenger called for an expansion of women’s cardiovascular health research to include social determinants of health as nearly 80% of heart outcomes depend on social factors. Women’s Heart Health is not solely a medical problem and clinical research cannot happen in a vacuum in the hospital. A variety of factors contribute to women’s cardiovascular health and need to be considered for maintenance of health and cure of disease. Women’s Heart Heath needs to be extended. Factors like beliefs and behaviors, the local community, economic, environmental, ethical, legislative/political, public policy – all these social determinants need to be included in heart disease research in women.

My take away for the future was that we cannot longer compartmentalize and that programs focusing on Women’s Heart Heath need to involve all programs available- not only cardiology. It needs to be an interdisciplinary approach to learn more about physiology, psychology and ecology of health for best outcomes and to tackle Women’s Heart Health.

Dr. Wenger quoted the French Victor Hugo in her inspiring lecture.

“There is nothing as powerful as an idea whose time has come.”
Victor Hugo
Histoire d’un crime, 1977

Tanja Dudenbostel is an Internist, Hypertension Specialist within Cardiology at the University of Alabama at Birmingham where I divide my time as an Assistant Professor between clinical research and seeing patients in cardiology.

Early Career Blog

November 13, 2017 Leonie Klompstra, MSc, PhD

Being at the American Heart Association makes me realize (again) that I have one of the greatest jobs in the world. There are so many inspiring people and talks and I am happy that I can share some of my experience in the Early Career blogging program.

Leonie in front of heart and torch at Scientific Sessions

The first day of the American Heart was all about the early career scientists. Speakers gave great advice on how to find a mentor, the transition to how to succeed in grants, the transition to faculty, how to respond to a rejection letter and how to get your name out there. Tips that were given you can read on the blogs by Bailey DeBarmore and Fawaz Abdulaziz M Alenezi. The second day of the American Heart were for me the day of awards. In this blog, I would like to acknowledge researchers who achieved awards for mentoring, research achievements or are finalists.

Cardiovascular Stroke and Nursing Counsel (CVSN) Kathleen Dracup award

This award highlights the importance of early-career mentoring in cardiovascular and stroke nursing to the CVSN. This year the award was given to Dr. Susan J. Pressler. I would like to congratulate her and thank her for being an example with her gifts and generosity in mentoring Early Career scientists.

Dracup Distinguished Lecture Program

Kathleen A. Lembright Award

This award recognizes and encourages excellence in cardiovascular research by established nurse scientists. This year winner is Dr. Shirley Moore. She gave a great talk about the responsibility of researchers to report on null trials.

Dr. Shirley Moore speaking at the Lembright Award

null trials slide

Martha N. Hill New investigator Award

This award recognizes the outstanding contributions of investigators in understanding, preventing, and treating cardiovascular diseases.

I would like to congratulate the finalists this year: Dr. Margo B Minissian and Dr. Billy Canceres.

Dr. Margo B Minissian conducted research in the association of spontaneous preterm delivery and postpartum vascular function.

Dr. Billy Canceres conducts research in high cardiovascular disease risk in sexual minority women.

Three people at Scientific Sessions
Congratulations to your all!

Leonie Klompstra is a Nurse Scientist at the Linköping University in Sweden. Her primary focus is on heart failure and rehabilitations.