The recent American Heart Association Annual Scientific meeting held in Philadelphia, Pennsylvania was filled with many sessions centered around the area of Cardiac Imaging with emerging areas in Nuclear Cardiac imaging,Echocardiography, Cardiac CT as well as Cardiac MRI. There was also the long awaited results of the ISCHEMIA trial. In addition, the Women in Cardiology (WIC) Committee had several sessions related to professional development including several networking opportunities with the WIC networking luncheon as well as a networking WIC dinner that was sponsored by the University of Pennsylvania. In this blog I will discuss several of these highlights.
Heart Disease in Women- Focus on Cardiac Imaging
Drs. Viviany Taqueti and Parham Eshtehardi moderated an excellent session on the multimodality assessment of microvascular coronary artery disease (CAD) in women.
Invasive Assessment of Microvascular Coronary Artery Disease:
During this session Dr. Carl Pepine discussed invasive assessment of microvascular disease in women. He discussed the use of coronary TIMI frame count (cTFC) to predict adverse events in women with symptoms/signs of ischemia with no obstructive coronary artery disease (INOCA). He discussed the results of a pilot study from the National Heart, Lung and Blood institute ( NHLBI) sponsored Women’s Ischemia Syndrome Evaluation (WISE) which showed that in women with INOCA, resting cTFC provided independent prediction of hospitalization for angina1. He also discussed the pros and cons of the three invasive methods for the assessment of coronary microvascular function: Thermodilution (IMR), Doppler wire (hMR) and Continuous Thermodilution (MVR). IMR being most user friendly of the 3 methods and has also been a method that has been validated against clinical outcomes. IMR is also feasible in every coronary anatomy. However, IMR is adenosine dependent. hMR and MVR both have reasonable reproducibility. hMR has also been validated against clinical outcomes while MVR provides a direct assessment on coronary blood flow and is adenosine free. However, IMR and hMR are dependent on the use of adenosine2. The indications for invasive coronary function testing (CFT) include (a) Evidence of ischemia with persistent chest pain and no obstructive coronary artery disease (CAD) (b) Chest pain refractory to medical management and (c) Preference for definitive diagnosis. Invasive CFT has excellent safety data with <0.6-0.7% serious adverse event rate (coronary dissection, myocardial infarction)3-5. Invasive diagnosis of coronary microvascular disease in women was associated with worse angina and hospitalization free survival compared to women without evidence of microvascular CAD6.
Role of Positron Emission Tomography (PET) assessment of Microvascular CAD (CMD) in Women:
Dr. Sharmila Dorbala gave an excellent talk on the use of Cardiac PET to assess the presence of CMD with myocardial blood flow and coronary flow reserve assessment with robust evidence data with over 35 years of research data involving over 20,000 patients. The presence of severely impaired coronary flow reserve (<2.0) is associated with excess cardiovascular risk in women relative to men referred for coronary angiography7. She had also discussed the evidence showing that CMD diagnosed with PET was associated with an increased risk of heart failure with preserved ejection fraction (HFpEF). The future of myocardial blood flow assessment with Cadmium Zinc Telluride (CZT) SPECT cameras was also discussed. The key points for the diagnosis of CMD with nuclear perfusion imaging are the following:
- Nuclear stress imaging is required to assess stress myocardial blood flow (MBF) and to assess myocardial flow reserve: stress MBF/rest MBF
- The stress agent used for assessment of MBF is typically done with vasodilatory agents such as regadenoson, adenosine or dipyridamole. Cold pressor test is usually done in research labs to assess endothelial dysfunction. Exercise MBF is not very feasible.
- Epicardial CAD has to be excluded
- CMD is typically defined as MBF <2.
Quantitative Blood Flow assessment with Cardiac MRI (CMR):
Dr. Chiara Bucciarelli-Ducci gave a very informative talk on the use of CMR to assess myocardial blood flow. The general principles of quantification of blood flow requires knowledge of the amount of contrast agent in the myocardium and knowledge of the amount of contrast agent in the blood pool (arterial input function). The challenge in this assessment is the lack of linearity between signal and contrast concentration. The main sources of non-linearity and bias includes spatial signal variations (sensitivity profile of the surface coils), imperfect saturation of magnetization during contrast bolus passage, T2* decay and signal loss by contrast concentration in the blood pool and non-linear signal response (inherent to saturation recovery). Novel CMR techniques such as perfusion mapping and extracellular volume (ECV) assessment were also discussed. The assessment of cardiac perfusion imaging with inline quantitative flow mapping was also discussed, including the fact that this is a fully automated workflow without any user interaction.
Artificial Intelligence in Cardiac Imaging with Cardiac CT and Cardiac PET imaging
There was a very innovative session that discussed the use of machine learning and deep learning in FFR Cardiac CT (FFRct) to improve diagnostic accuracy. Cardiac CTA has been shown to be an established diagnostic tool in clinical practice with FFRct offering functional information for intermediate and severe lesions. FFRct has also showed good correlation with invasive FFR. Machine Learning improves FFR-ct algorithms with improved accuracy, decreased analysis stime, potential to increase the availability of this FFRct technology and potential cost reduction. Deep Learning (DL) in automatic calcium scoring on cardiac CT using paired convolutional neural networks was also discussed. Assessment of ischemic myocardium with Cardiac CTA with DL was also discussed with the use of tissue segmentation and tissue characterization. The use of DL in cardiac PET was also discussed with regards to its utility in cardiovascular event prediction.
The ISCHEMIA trial
The long awaited ISCHEMIA trial results were released at the AHA 2019 and my take home points were outlined in my last blog, https://earlycareervoice.professional.heart.org/my-top-10-take-home-points-from-the-ischemia-trial/
The ISCHEMIA trial is the largest trial studying an invasive versus conservative strategy for patients with stable ischemic heart disease8. The overall conclusions of the ISCHEMIA trial were:an initial invasive strategy compared with an initial conservative strategy did not demonstrate a reduced risk over a median follow up period of 3.3 years with regards to the primary endpoint of cardiovascular death, myocardial infarction, hospitalization for unstable angina and heart failure as well as with regards to the secondary endpoints of cardiovascular death or myocardial infarction. The probability of at least a 10% benefit of an invasive strategy on all cause mortality was < 10, based on pre-specified Bayesian analysis. The ISCHEMIA trial concluded that patients with stable CAD and moderate to severe ischemia had significant durable improvements in angina control and quality of life with an invasive strategy if they had angina occurring daily/weekly or monthly. Shared decision-making should be done to ensure alignment of treatment with patients’ goals and preferences for patients with angina. However, in patients without angina, an invasive strategy led to minimal symptom improvement or quality of life benefits as compared with a conservative strategy. An early invasive strategy was not associated with a significant reduction in clinical events.
Imaging of Valvular Heart Disease
There was also an enlightening session on the role of cardiac imaging in the assessment of tricuspid valvular heart disease with a focus on severe secondary tricuspid regurgitation as well as congenital Ebstein’s anomaly of the tricuspid valve. The preoperative risk factors for significant post op tricuspid regurgitation that were noted were (a) preoperative tricuspid regurgitation of 2+ or more (b) atrial fibrillation and (c) huge left atrium9. Mitral valve surgery as well as double valve surgery including the aortic and mitral valve were associated factors for the development of late significant tricuspid regurgitation after left sided valve surgery10. Mild to moderate progressive functional tricuspid regurgitation with tricuspid valve annular dilation of >40 mm or > 21 mm/m2 by 2D echocardiography has a class IIa indication for tricuspid valve repair at time of left sided valve surgery. In addition any symptomatic severe functional tricuspid regurgitation at the time of left sided valve surgery has a class I indication for tricuspid valve repair or replacement11.
Ebstein’s anomaly involving the tricuspid valve accounts for <1% of congenital heart disease. The tricuspid valve malformation is often complex and typically involves the tricuspid valve leaflets, the chordal apparatus and the myocardium of the right ventricle. The severity of tricuspid valve leaflet displacement on echocardiography has been identified as an independent predictor of cardiac mortality in patients with Ebstein’s anomaly12.
Primary tricuspid regurgitation may also result from lesions of the tricuspid valve apparatus itself such as in endocarditis, congenital disease or from mechanical trauma to the leaflets, annulus and/or chordae. Echocardiography remains the primary imaging modality to diagnose the etiology and severity of tricuspid valve disease. Features on echocardiography that may indicate significant tricuspid regurgitation includes tricuspid valve annular dilation of >40 mm or > 21 mm/m2, tethering distance >0.76 cm, tethering area >1.63 cm2 and right ventricular end systolic area of > 20 cm213. However, CMR and Cardiac CT are useful in some cases. CMR is considered the gold standard for the quantification of tricuspid regurgitation, quantification of right ventricular volumes, evaluation of right ventricular function, assessment of fibrosis and occasionally assessment of the etiology. Limitations for CMR includes presence of cardiac devices, arrhythmias, claustrophobia and renal failure (gadolinium). In special situations tricuspid regurgitation can be complex. 3D echocardiography provides useful information and it is sometimes necessary to assess tricuspid regurgitation with multimodality imaging as Cardiac CT can provide information about the anatomical regurgitant orifice area. Additionally, CMR and Cardiac CT can provide information about the dimensions of the tricuspid valve annular diameter, right heart volumes and function as well as vascular assessment13. In the presence of significant tricuspid regurgitation, tricuspid valve repair should be performed whenever possible.
Multimodality imaging of Aortic Diseases
There was also an excellent session dedicated to the multi modality imaging with CT and MRI of acute and chronic aortic diseases such as aortic intramural hematoma, aortic aneurysms, aortic dissection and endovascular repair of the aorta (TEVAR) planning for aortic repair. 4D flow MRI was also discussed with regards to TEVAR planning.
With regards to aortic aneurysms, type B aortic dissection should be considered a chronic disease with complex pathophysiology with up to 75% of patients developing an aortic aneurysm14. Hemodynamic forces are believed to play a central role in this pathophysiology.
In the presence of type B intramural hematoma, tiny intimal disruptions/fenestrations (TID) does not confer poor prognosis as the risk of aorta related events are similar when compared to patient without TID. 14% of these patients progress to focal intimal disruption in a recent meta analysis15. Focal intimal disruptions and ulcer like projections may cause large communications in intramural aortic hematoma with >3mm connection with the aortic lumen and are typically absent on the initial study. Limited intimal tears of the aorta although rare are an unquestionable cause of acute aortic syndromes and is considered a variant of aortic dissection. It is predominantly seen in type A intramural hematoma with an aneurysmal aorta and patients are older than patients with classic aortic dissection. Limited intimal tears can be seen on state of the art CT angiography and 3D volume rendering can make lesions more conspicuous.
Quality Cardiac Imaging
The last day of AHA 2019 was kicked off with an inspiring and informative session that discussed Quality in Cardiac Imaging that was led by several leaders in the field which included Dr. Pamela Douglas and Dr. Leslee Shaw. Dr. Ritu Sachdeva discussed strategies to maximize imaging information and outcomes by facilitating implementation by removing barriers and incentivizing schemes. She also discussed designing strategies to keep up with the pace of technology through improving quality, promoting innovation and research and focusing on adequate training in cardiac imaging. It was also mentioned that achieving excellence in imaging has to include collaboration between providers, professional societies, patients, payers and industry. The focus should move from “Volume Driven Healthcare” to “Value Driven Healthcare”.
The future of Cardiac Imaging in a value based healthcare system has to include definitions of the cardiovascular imager of the future, ensure robust innovation and research and maximizing imaging information and improving outcomes. This was outlined in the “Future of Cardiac Imaging Think Tank” article by Dr. Pamela Douglas16.
AHA Presidential Address
The AHA Opening session was a very energetic, encouraging and enlightening session. This session was opened by wonderful performances by Broadway’s Hamilton cast of actors. The Presidential address by Dr. Robert Harrington (Figure 1) was encouraging as he spoke on the importance of increasing diversity in the cardiology workforce as well as improving gender equality in the cardiology field.
AHA Women in Cardiology (WIC) Committee Events
- Professional Development: There were many Women in Cardiology Professional Development sessions that covered a wide range of topics such as “Volunteerism to Advance Your Career” with Drs. Stacy Rosen and Michelle Albert, “Negotiations” with Drs. Sandra Lewis and Linda GIllam, “Time Management” with Drs. Toniya Singh and Gina Lundberg, “Self-Advocacy” with Drs. Elaine Tseng and Linda Shore, “Sponsor vs. Mentor” with Dr. Emelia Benjamin and “Around the World with Go Red for Women”. These sessions were held in the Women in Science and Medicine Lounge in the expo hall and were very engaging and well attended sessions.
WIC Networking Luncheon:
The AHA Women in Cardiology networking luncheon was an excellent session that provided an opportunity to network with other colleagues and AHA leadership. This session also hosted an excellent panel of speakers led by Dr. Laxmi Mehta who spoke on the topic of “Physician Burnout” and how to address this issue in Medicine. The other panel of speakers included Dr. Minnow Walsh who discussed the “Increased demand of the aging population and decreased supply of clinicians causing burnout – what can be done?”, Dr. Athena Poppas discussed “What can Cardiology leaders and Chiefs of Cardiology do to help decrease the stress from the clinical workload and increase career satisfaction?”, Dr. Sandy Lewis discussed “Legislative advocacy to decrease physician burnout – what can organizations do?” and Dr. Sherry Ann Brown discussed “What can cardiologists do to decrease their stress levels?” and she also discussed “What can fellowship program directors do to help fellows decrease burnout?” The attendees at the luncheon also added their own experiences relevant to this topic and also shared words of wisdom and advice.
The All Council Reception and Clinical Cardiology Council Dinner:
The All Council reception was very well attended with standing room only. It was also very lively with performance by the members from the Mummers Philadelphia group. This reception led into the Clinical Cardiology Council Dinner and during the dinner there were several awards given as well as recognition of the new Fellows of the American Heart Association. Dr. Sharon Reimold was the recipient of the AHA Women in Cardiology Mentoring Award.
The AHA WIC Networking dinner hosted by University of Pennsylvania:
The AHA Women in Cardiology committee was very grateful to the University of Pennsylvania led by Dr. Monika Sanghavi who hosted a wonderful dinner that provided an opportunity for Women in Cardiology fellows in training (FIT) to network with several Women in Cardiology leaders in the field. We appreciated pearls of wisdom from leaders such as Dr. Nanette Wenger, Dr. Sharonne Hayes, Dr. Minnow Walsh, Dr. Andrea Russo, Dr. Martha Gulati and Dr. Annabelle Volgmann. This was the second annual WIC event at the AHA Scientific meeting and we are hoping to continue this at future AHA Scientific meetings as these events have been very well received by our Women in Cardiology FITs.
AHA 2019 was an educational, engaging and exciting meeting where new scientific data relevant to Cardiology practice was presented. The event also offered many opportunities for networking with many leaders in the field. I look forward to the American Heart Association Scientific meeting in November 2020 in the beautiful city of Dallas, Texas.
- Petersen JW, Johnson BD, Kip KE, Anderson RD, Handberg EM, et al. (2014) TIMI Frame Count and Adverse Events in Women with No Obstructive Coronary Disease: A Pilot Study from the NHLBI-Sponsored Women’s Ischemia Syndrome Evaluation (WISE). PLoS ONE 9(5): e96630. doi:10.1371/journal.pone. 0096630
- Banning AP, De Maria GL.Measuring coronary microvascular function: is it finally ready for prime time? Eur Heart J. 2019 Jul 21;40(28):2360-2362. doi: 10.1093/eurheartj/ehz426. No abstract available. PMID: 31236565
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Renée P. Bullock-Palmer, MD is a board certified Cardiologist who specializes in and has a passion for Cardiac Imaging as well as Cardiovascular health in women. She is the Director of Non Invasive Cardiac Imaging as well as the Director of the Women’s Heart Center at Deborah Heart and Lung Center in Browns Mills, New Jersey. She serves on several committees in the American Society of Nuclear Cardiology (ASNC), American Society of Echocardiography (ASE), the Society of Cardiovascular Computed Tomography (SCCT) as well as the American Heart Association (AHA). She’s also the founding Chair of the Women in Cardiology section of the New Jersey chapter of the American College of Cardiology (NJACC). @RBP0612