Cardionerds: A Cardiology Podcast

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144. Case Report: A Mother with Shortness of Breath – Pushing Against All Odds – Allegheny General Hospital Sep 05, 2021

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CardioNerds (Amit Goyal and Daniel Ambinder) join Dr. Kushani Gajjar and Dr. Mitha Naik from the Allegheny Health Network for a walk along the Three Rivers Trail in Pittsburgh. They discuss a case of young woman in her third trimester of pregnancy with a known history of pulmonary arterial hypertension. The management of pulmonary hypertension in pregnancy and RV failure in the context of pregnancy is described. The E-CPR segment is provided by Dr. Nandita Scott, Co-Director Corrigan Women's Heart Health Program and Cardiovascular Disease and Pregnancy Service at Massachusetts General Hospital. Special cameo appearance by Dr. Dani Crousillat. If you’re a current internal medicine resident, interested in the intersection between medical education, cardiovascular disease and digital media, consider applying to the CardioNerds Academy using this link. The deadline for this application is October 15th 2021. Learn more by visiting the CardioNerds Academy page. Claim free CME just for enjoying this episode! Disclosures: None Jump to: Patient summary - Case media - Case teaching - References CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Patient Summary - Pulmonary Hypertension in Pregnancy A 33-year-old woman in the third trimester of pregnancy, with a known history of untreated PAH in the setting of TKI therapy, presents with shortness of breath. She is found to have PA pressure greater than systemic pressure with PASP >130. We describe the management of PH and RV failure in the context of a pregnancy. The patient was admitted to the ICU where a multidisciplinary team was mobilized, involving high risk ob-gyn, maternal fetal medicine, critical care, anesthesiology, and advanced heart failure. They began pulmonary vasodilators including treprostinil, tadalafil and inhaled nitric oxide. They also added inotropic and vasopressor support for right ventricular dysfunction with her severe PAH. Fetal heart monitoring was performed. PAH also led to worsening of known chronic thrombocytopenia in the setting of CML. HELLP syndrome was ruled out. The patient had preterm rupture of membranes at 32 weeks of gestation and the team pursued assisted vaginal delivery to prevent vagal response. Following successful delivery, the patient elected to undergo intra-uterine device placement. Post-delivery, vasopressors and inotropes were weaned, and she was discharged on treprostinil, ambrisentan and tadalafil. Thankfully both the mother and baby returned healthy and well at 1 month follow up. Case Media - Pulmonary Hypertension in Pregnancy CMRCXRTTETTEClick to Enlarge Episode Teaching - Pulmonary Hypertension in Pregnancy Pearls - Pulmonary Hypertension in Pregnancy Pulmonary Hypertension is defined as a mean pulmonary arterial pressure (mPAP) of >20mmHg. There are 5 major types of pulmonary hypertension. Risk modifiers include symptom burden, exercise capacity, presence of pericardial effusion, RV function and hemodynamics.Multidisciplinary care teams are the key to achieving optimal pregnancy outcomes in patients with PH. It is critical to create a team of experts with experience in pulmonary hypertension and plan for constant communication before, during, and after pregnancy.Pregnant women who are already on PAH therapy outpatient should continue them during pregnancy (under the direction of PH experts) except for endothelin receptor blockers which fall in pregnancy category X.PH during pregnancy is associated with up to 38% maternal mortality rate as the right ventricle (RV) is often unable to handle the volume shifts and hemodynamic changes that occur during pregnancy, labor, and delivery.Patients with RV failure leading to low cardiac output and hypotension, like in this case, may benefit from vasopressors with the goal to maintain systemic blood pressure above pulmonary arterial pressures, preserving right coronary blood flow and preventing intracardiac shunting. Swan-guided management may be useful - to titrate inotropes and vasopressors, optimize pulmonary vasodilators and ensure that the patient is being adequately fluid-optimized to maintain a CVP of around 8-10. Notes - Pulmonary Hypertension in Pregnancy 1. What are the different types of pulmonary hypertension (PH)?The WHO separates PH into 5 groups: Group 1Pulmonary arterial hypertension (e.g., idiopathic, heritable [BMPR2], anorexigen associated, drug or toxin-associated, HIV, connective tissue disease associated, schistosomiasis, portal hypertension, congenital heart disease, etc) Group 2Pulmonary hypertension due to left sided heart disease (e.g., HFrEF, HFpEF, left-side valvular heart disease) Group 3Pulmonary hypertension due to lung disease or hypoxia: (e.g., COPD, ILD, OSA, hypoxia without lung disease such as high altitude, developmental lung disorders) Group 4PH due to pulmonary artery obstructions most commonly Chronic Thromboembolic Pulmonary Hypertension (CTEPH)Group 5Multifactorial causes such as hematologic disorders (chronic hemolytic anemia, as with myeloproliferative disorders), metabolic disorders (e.g., Gaucher disease, glycogen storage diseases, CKD), and systemic disorders (e.g., pulmonary Langerhans cell histiocytosis, neurofibromatosis, sarcoidosis) 2. What is the role of TTE and RHC in the workup of PH? Tyrosine kinase inhibitors are known to cause PAH and there should be a low threshold to do screening TTEs in these patients when there is concern for the development of PAH.Echocardiogram is essential in the evaluation of PH –for positing the presence of PH, evaluating the left heart and congenital defects for clues to PH etiology, and assessing the structural consequences of PH on the right heart. In addition to estimating the pulmonary artery systolic pressure (PASP) by measuring the tricuspid regurgitant jet, we can characterize RV and RA size, RV function, and RV wall thickness, which may help both support the diagnosis and gauge prognosis for PH. Further, we can evaluate for left-sided heart disease contributing to PH. The presence of a pericardial effusion is a poor prognostic sign in those with pulmonary hypertension. Notably, the PASP is not of prognostic value due both to inaccuracies in measurement and falling values in the context of severe PH with failing RV function; a such PASP should not be used to surveil patients with PH or monitor response to PH therapies. McLaughlin et al suggest using a checklist in the echocardiographic assessment of PH which includes the following1: ChecklistSalient pointsEstimated PASPTo calculate mean PAP, usually PA diastolic pressure needs to be assessed which often requires a PR jet which is both difficult to obtain and not often present.Evaluate RV size and functionSize: abnormal RV basal diameter >4.2 cm, wall thickness in subcostal view >5 mm Function: TAPSE (abnormal 20≤ 15≥ 31, 3, 4, 5Post-capillary> 20> 15 20> 15≥ 32, 5, multifactorial Furthermore, we can determine if a patient is “vasodilator responsive.” In the catheterization lab, a positive vasodilator response is defined as a decrease in mPAP ≥ 10 mmHg to an absolute value of ≤ 40 mmHg (without a decrease in cardiac output) with the use of inhaled nitric oxide or IV epoprostenol. If a patient has positive vasodilator test, calcium channel blockers can be initiated, however not all patients will be long term responders. We tend to do vasoreactivity testing in patients with PAH and not for other forms of PH (e.g., Pulmonary Veno-Occlusive Disease or Groups 2, 3, 4, or 5). 3. What are PAH-specific pharmacologic treatments? Remember that PAH is fundamentally a disease of increased pulmonary vascular resistance (PVR) causing elevated pulmonary pressures. The consequence of increased PVR includes increased RV afterload and hypoxemia and the subsequent clinical manifestations of PAH. Normally, the pulmonary vascular bed has a balance between vasodilators and vasoconstrictors that maintain a low-resistance, high-compliance state. This balance is disturbed in PAH and the goal of therapy is to “restore” balance between vasodilation and vasoconstriction.The management of PAH relies on 3 primary medication groups1: ...

143. Lipids: (Non)-Fasting LDL & Furious Lipid Lowering with Dr. Alison Bailey Sep 01, 2021

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CardioNerds Dr. Rick Ferraro, Director of the #CardsJC Journal Club and cardiology fellow at Johns Hopkins, and Dr. Tommy Das, Program Director of the CardioNerds Academy and cardiology fellow at Cleveland Clinic, learn all about the clinical application of the ASCVD primary and secondary prevention guidelines in terms of lifestyle modifications and lipid lowering strategies from Dr. Allison Bailey, Editor-in-Chief of the ACCEL Audio Journal and Advanced Heart Failure and Transplant Cardiologist at Centennial Heart. Dr. Baily was a co-author on the 2018 ACC/AHA Guideline on the Management of Blood Cholesterol. In this episode we will learn about the current guidelines for primary prevention of ASCVD, the evidence for specific dietary changes in improving cardiovascular outcomes, the current guidelines for secondary prevention of ASCVD, how successful are clinicians and patients in meeting LDL-C recommendations, and what the recent SAMSON trial teaches us about statin intolerance. If you're a current internal medicine resident, interested in the intersection between medical education, cardiovascular disease and digital media, consider applying to the CardioNerds Academy using this link. The deadline for this application is October 15th 2021. Learn more by visiting the CardioNerds Academy page. Relevant disclosure: None Pearls • Notes • References • Guest Profiles • Production Team CardioNerds Lipid Series PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Qoatables - Lipid Lowering with Dr. Alison Bailey “Lifestyle should be the first step and the last step of everything we do.” Pearls - Lipid Lowering with Dr. Alison Bailey In patients without established clinical ASCVD, the percent reduction in LDL-C is the strongest predictor of cardiovascular benefit. In patients with high LDL-C levels, a 50% reduction in LDL-C levels should be targeted.In high-risk patients with established clinical ASCVD, we should target a 50% reduction in LDL-C levels and an LDL-C level less of than

142. HF part 11: The Role of the Clinical Examination in Patients With Heart Failure – with Dr. Mark Drazner Aug 24, 2021

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CardioNerds Amit Goal, Daniel Ambinder, & Dr. Alex Pipilas (FIT, Boston University) discuss the clinical examination in patients with heart failure with Dr. Mark Drazner, professor of medicine, clinical chief of cardiology, and medical director of the LVAD and Cardiac Transplantation Program at UT Southwestern. In this pearl laden episode, they discuss how the exam can be used to non-invasively assess a patient's hemodynamic status, risk stratify and inform prognosis, and guide management. They also discuss ways to master the evaluation of the JVP and categorize patients based on their RA:PCWP ratio. Check out the CardioNerds Failure Heart Success Series Page for more heart success episodes and content! Relevant disclosures: None The CardioNerds Heart Success Series is developed in collaboration with the Heart Failure Society of America. The Heart Failure Society of America is a multidisciplinary organization working to improve and expand heart failure care through collaboration, education, research, innovation, and advocacy. Its members include physicians, scientists, nurses, nurse practitioners, and pharmacists. Learn more at hfsa.org. This episode is made possible with support from Panacea Financial. Panacea Financial is a national digital bank built for doctors by doctors. Visit panaceafinancial.com today to open your free account and join the growing community of physicians nationwide who expect more from their bank. Panacea Financial is a division of Primis, member FDIC. Pearls • Notes • References • Guest Profiles • Production Team CardioNerds Heart Success Series PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls - Clinical Examination in Heart Failure Begin hemodynamic assessment with the evaluation of congestion (“wet” vs “dry”) and perfusion (“cold” vs “warm”). In a 2x2 table, this breaks patients into 4 broad hemodynamic profilesThe most sensitive markers of congestion (PCWP > 30) are JVP >12 with an OR of 4.6 and the presence of orthopnea with an OR of 3.6“If you are cold, you are cold, if you are warm, you can still be cold”. Sensitivity for clinical markers of low cardiac index is very poor. Consider a low output state in patients with poor response to what are thought to be appropriate therapiesMost patients with acute on chronic heart failure have an RA:PCWP ratio of 1:2. These patients are the so called “concordant” phenotype. There are two other sub-phenotypes:The “RV equalizer group” have an elevated RA:PCWP ratioThe “RV compensated” group have a lower RA:PCWP ratioClinical congestion at the time of hospital admission as well as discharge portends a poor prognosis for patients with heart failure Show notes - Clinical Examination in Heart Failure Figure 1 1. What is the physical exam important in patients with heart failure? Important to view the physical exam as a diagnostic test with strengths and limitationsIt is a noninvasive way to assess hemodynamics and risk stratify patientsCan provide information on prognosisMay enhance the provider-patient relationship 2. How might we classify hemodynamics noninvasively? Framework begins with the “Stevenson” Classification, developed by Dr. Lynne StevensonClassifies patients along two axes: congestion and perfusionCongestion is the assessment of overall volume status and estimation of right and left sided filling pressures, broadly broken up into “wet” or “dry”:“Wet”, PCWP >15mmHg“Dry”, PCWP 2.2“Cold”, Cardiac index 12 predicts PCWP > 30 with an OR of 4.6 (Drazner, 2008).Rapidly developing ascites or edemaSquare wave test. The square wave test takes advantage of an abnormal response to Valsalva in patients with low systolic function and elevated filling pressures. In those with congestion, the MAP fails to fall with decrease in RV and LV preload from the Valsalva maneuver due to preexisting high filling pressures. This is likely the best evidence that the patient has elevated filling pressures and may help to identify patients with the discordant hemodynamic phenotypes.Symptoms:Orthopnea: one of the two most sensitive markers for congestion such that the presence of orthopnea predicts PCWP > 30 with an OR of 3.6 (Drazner, 2008).Bendopnea: the sensation of feeling breathless within 30 seconds of bending over. Bendopnea is associated with higher filling pressures and low cardiac index (Thibodeau JT T. A.-M., 2014), with increased risk of short term heart failure admission ( (Thibodeau JT J. B., 2017), and with elevated VE/VCO2 (more advanced HF marker from CPET) (Dominguez-Rodriguez A, 2016). Relief of bendopnea during hospitalization is associated with greater fall in median NT-proBNP.The following are less helpful for identifying patients with acute on chronic HFRales have a low sensitivity and specificity for acute on chronic decompensated heart failure. If rales are present in chronic HF patients, consider looking for pulmonary pathology. This doesn’t apply for patients with acute MI or flash pulmonary edema.Weight may be misleading as heart failure is a cachexia promoting illness such that variation in weight may not be referred to fluid status alone. Volume overload often leads to appetite changes and weight loss as well as fluid retention which together can lead to net negligible weight change. Additionally once patients are euvolemic and clinically improved, they might gain true caloric weight which makes tracking “dry weights” difficult. Weight may be helpful over the short term i.e with a report of 10lbs of weight gain within the past week + significant stigmata of overload. With these considerations, we must be cautious regarding targeting a fixed “dry” weight over long periods of time given true changes in body weight.Adjunctive data may help adjudicate the bedside assessment of congestion:Prognosis is better with down trending natriuretic peptides but no data clearly suggests benefit from tailoring therapy based on these levels.Echo parameters such as the PASP, mitral inflow pattern, and IVC size may be helpful in the right context.Implantable PA sensors (i.e. CardioMems) may be helpful. A large RCT looking at this, Guide-HF, trial is still enrolling. 4. What are some tips & tricks for measuring the JVP? We are not looking for venous structure, but rather referred pulsating waves, which are usually better seen than felt.Look on both sides of the neck!Carotid vs Jugular vein – if you compress BELOW the pulsation and it goes away then it is a VENOUS pulsation. If not, then it is likely carotid. Venous pulsation (not carotid pulsation) will change in height as you adjust the degree of patient’If unable to see the pulsation, sit the patient upright and assess. It may be too high to see when recumbentCan use the EJ if it is respirophasic. If it isn’t then the high level could be due to a valve in the vein in which case we need to be cautious with interpretation. 5. What is the connection of the JVP (i.e estimated RA pressure) to left sided filling pressures (i.e PCWP/LVEDP) (Drazner 2008)? The RAP:PCWP ratio is ~1:2 (“concordant”) in 70-75% of patients in acute on chronic heart failure from ESCAPE trial data. Importantly, this relationship does not hold in all groups of patients including those with acute MI or other conditions which may cause discordance between right- and left-sided filling pressures like primary pulmonary hypertension, significant valvular disease, etc.This relationship does not hold ~25-30% of the time, where the RAP and PCWP are “discordant.” The two sub-phenotypes to think about are: Right/left equalizers: high RAP:PCWP ratio (ratio ~≥ 2:3). Clinically, a high JVP may overestimate the overall fluid status. They may run into hypotension and worsening renal function because left sided pressures are lower than you would estimate by the JVP. These tend to be sicker patients with a generally worse prognosis (Grodin JL, 2015).Compensated RV group: low RAP:PCWP ratio (ratio ~≤ 1:3). In contrast to the right/left equalizers, those with a “compensated RV” may have a JVP which underestimates the overall fluid status since the RAP is lower for a given PCWP. Consider this phenotype in those with classic left sided HF symptoms despite a relatively low or normal JVP.There are no clear clinical makers to identify patients who are in the discordant phenotypes but if the clinical course is not what you expect, consider exploring if a patient’s hemodynamics fall within these discordant phenotypes.If a patient has had a RHC in the past, you can use their previous RA:PCWP ratio to estimate left sided filling pressures with JVP during subsequent encountersThere is some data to suggest that a given patient us unlikely to move from one extreme to another, at least over a short period of time (i.e move from right/left equalizers to compensated RV ect)More likely, a patient may move from extremes to the middle with either progression of disease or improvement 6. What is the role of the clinical exam in the assessment of perfusion: “Warm” or “Cold”? “If they are cold, they are cold. If they are warm, they still may be cold.” In other words, the sensitivity of the clinical evaluation is poor for the diagnosis of poor perfusion, but the specificity is high....

141. Narratives in Cardiology: Empowerment & Growing Together as Women in EP with Dr. Kamala Tamirisa – Texas Chapter Aug 17, 2021

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In the PA.ACC – CardioNerds Narratives in Cardiology episode, CardioNerd Amit Goyal joins Dr. Miranda Merrill (FIT, Oregon Health & Science University), Dr. Stephanie Fuentes Rojas (FIT, Houston Methodist Hospital), and Dr. Natasha Cuk (FIT, Cedars-Sinai Medical Center) for a discussion with Dr. Kamala Tamirisa (Clinical Cardiac Electrophysiologist, Texas Cardiac Arrhythmia, National ACC Women in Cardiology Leadership Council Member and Co-Chair for ACC Women in Cardiology Advocacy Work Group, and current co-chair of the Texas Chapter ACC EP section) about gender equity and women in cardiology and electrophysiology. This episode focuses on the experiences of women in cardiology across the spectrum of training, from medical school, fellowship, through the procedural field of electrophysiology, to local and national leadership and beyond. Listen to the episode to learn about the factors which have led to Dr. Tamirisa’s success as a private practice electrophysiologist incorporating leadership roles in medical education and national organizations. Closing remarks by Texas ACC chapter governor, Dr. Kenneth Shaffer. Episode script was developed by Dr. Miranda Merrill and episode notes were developed by Dr. Natasha Cuk. The PA-ACC & CardioNerds Narratives in Cardiology is a multimedia educational series jointly developed by the Pennsylvania Chapter ACC, the ACC Fellows in Training Section, and the CardioNerds Platform with the goal to promote diversity, equity, and inclusion in cardiology. In this series, we host inspiring faculty and fellows from various ACC chapters to discuss their areas of expertise and their individual narratives. Join us for these captivating conversations as we celebrate our differences and share our joy for practicing cardiovascular medicine. We thank our project mentors Dr. Katie Berlacher and Dr. Nosheen Reza. Video Version • Notes • References • Production Team Claim free CME just for enjoying this episode! There are no relevant disclosures for this episode. The PA-ACC & CardioNerds Narratives in Cardiology PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Video version - Women in EP https://youtu.be/e7Cjv4vPXqg Quotables - Women in EP “The exciting part today is to see three women who are interested in EP… like RBG said, when all EP physicians are women, that’s the day we’re going to celebrate” 07:15 “There's nothing (more) exciting… than EP, just that technology, the marriage between analytical thinking, tactile, touch, with a deductive logic.” 09:18 “Multiple studies have documented sex disparities in cardiovascular care… (Historically) women and minorities did not receive implantable cardioverter defibrillators or even BiV (biventricular) pacers… a potential driver for these disparities in cardiovascular disease is lack of diversity in the workforce. Very simple.” 19:28 “I still want to wear my lipstick. I still want to wear my heels. I want to do my hair. I still want to be a proceduralist and that's okay. Make room.” 28:00 Show notes - Women in EP While this episode and the following notes are specific to women in electrophysiology, these same basic principles apply to fostering a more inclusive and welcoming environment in other subspecialties for all persons regardless of sex, gender, race, ethnicity, IMG status, and the other factors which make us different from one another and which enrich our workforce. 1. Why choose electrophysiology? An EP career is unique – it combines the biology, physiology, and procedural skills learned in residency and fellowship training with engineering, mathematic, and imaging principles learned and refined in advanced EP fellowship.1EPs work in a spectrum of settings and with a spectrum of modalities: inpatient, outpatient clinic, EP lab and with fluoroscopy, echocardiography (including intracardiac echo), 3D mapping systems, intracardiac EGMs, surface EKGs. Bedside medicine is still key to this field.Curative procedures performed in EP have a meaningful impact on patients’ quality and quantity of life1 and life saving devices such as implantable cardioverter defibrillators have profound impacts on mortality with a number needed to treat to save one life between 3-27 for both primary and secondary prevention indications from multiple randomized controlled trials.2If you LOVE EKGs, find yourself dissecting telemetry strips, and bonding with your mentors over EKG analysis, then EP is the field for you!40% of the 130 clinical cardiac electrophysiology fellowship positions in the U.S. remain unfilled and there is a decline in the number of fellows choosing EP for advanced training over the last 5 years. Early exposure to internal medicine residents and first year cardiology fellows to the field will allow time for exploration and may help direct more trainees with an interest to this career.1 2. What are some opportunities for an electrophysiologist in private practice? Private practice can facilitate a certain level of independence and flexibility including directing choices both large and small such as which devices and tools are used, how the lab is set up, or even the ability to build an entirely new ablation program.Leadership is inherent to private practice, especially in EP - there are opportunities everywhere!Private practice facilitates close, longitudinal relationships with patients.Understanding the finances is important – take time to learn about this from mentors not just in EP but in other fields of medicine or even outside of medicine.Community initiatives can be a fulfilling aspect in addition to procedures, patient care, and leadership opportunities. Dr. Tamirisa earned a Healthcare Heroes Award for Northwest Ohio in 2017 for making an impact on community wellbeing, domestic violence/impact on cardiovascular disease, and health of minority women and was nominated for the Thomas Jefferson Award for the Northwest Ohio region in 2016 for her contribution to women's empowerment in the community. 3. Why and how should we promote diversity within electrophysiology? Women physicians across subspecialties are more likely to provide patient centered communication and may provide improved outcomes for certain patient populations.3,4Diversity drives innovation, which is why drawing more women and underrepresented minorities to EP will advance the field.5Women are “unicorns” in the procedural subspecialties of cardiology.6 Their representation is not growing at the same rate as in other parts of medicine; only 7-10% of EPs currently in practice are women and there remains limited visibility in leadership roles for women at the national level.1,7,8How can we address barriers to entry into the field? Dr. Tamirisa makes several suggestions in her EP lab digest article and in the podcast.1Adjust work and training environments so that they are more inclusive to women and URiM.Address sexual harassment and discrimination on the basis of sex, gender, race, ethnicity, and other factors which make us different and enrich our field.9Advocate for work-life integration for all, including flexible (full- and part-time) work schedules such as 4 day-a-week schedules.Acknowledge and respond to family planning concerns given that childbearing age may overlap with the training period: limit radiation exposure, protect research and family leave time, provide access to lactation areas, and consider reduced or flexible training schedules (such as 2.5 years/30 months of cardiology fellowship and 18 months of EP training). 4. Mentorship in Electrophysiology and Empowering Women to Succeed Mentorship in EP for women can and should be from both women and men! Initiatives such as social media hashtags #HeforShe and #TakeAWomanToTheCathLab and official speaking opportunities eliminating “manels” at national conferences are creating a more inclusive field.10Tips for mentors:Be kind always.Listen to your mentees – even without offering advice, just listening can lead to profound insights.Show your flaws – shattering the illusion of a perfect career or trajectory can help your foster confidence and the ability to tackle obstacles.Be open, vulnerable, and honest (both as a mentor and mentee!)Be inclusive with your projects.Understand the microaggressions that women and underrepresented minorities face in training and their careers. Help them with tools to address those issues including microresistance response strategies.11,12Engage and share your creative endeavors! Dr. Tamirisa writes poetry and journals as her outlet.13 References Tamirisa KP. The Importance of Choosing Cardiac Electrophysiology as a Career: Thoughts on the EP Fellow Shortage. EP Lab Digest. 2020;20(2). https://www.hmpgloballearningnetwork.com/site/eplab/importance-choosing-cardiac-electrophysiology-career-thoughts-ep-fellow-shortage 2. Al-Jefairi N, Burri H. Relevance of guideline-based ICD indications to clinical practice. Indian Heart J. 2014;66 Suppl 1:S82-87. https://www.ncbi.nlm.nih.gov/pubmed/24568834 3. Roter DL, Hall JA. Physician gender and patient-centered communication: a critical review of empirical research. Annu Rev Public Health. 2004;25:497-519. https://www.ncbi.nlm.nih.gov/pubmed/15015932 4. Tsugawa Y, Jena AB, Figueroa JF, Orav EJ, Blumenthal DM, Jha AK. Comparison of Hospital Mortality and Readmission Rates for Medicare Patients Treated by Male vs Female Physicians. JAMA Intern Med. 2017;177(2):206-213. https://www.ncbi.nlm.nih.gov/pubmed/27992617 5. Welson-Rossman T. Healthcare Needs More Diverse Experts To Guide Innovation. ForbesWomen. 2021. https://www.forbes.com/sites/traceywelsonrossman/2021/02/09/healthcare-needs-more-diverse-experts-to-guide-innovation/?sh=358d5b2769e6 6. The Unicorns: Women in Cardiac Electrophysiology

140. Lipids: LDL, Cardiovascular Events, & Disparities in Care with Dr. Keith Ferdinand Jul 30, 2021

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CardioNerds Dr. Rick Ferraro, Director of the #CardsJC Journal Club and cardiology fellow at Johns Hopkins and Dr. Tommy Das, Program Director of the CardioNerds Academy and cardiology fellow at Cleveland Clinic join Academy fellow and episode lead Dr. Julie Power, chief fellow at the University of Minnesota to learn all about the link between LDL-C and cardiovascular events and disparities in care from Dr. Keith Ferdinand, Professor of Medicine and Chair in Preventative Cardiology at Tulane University School of Medicine. As we’ve learned in prior episodes, LDL-C plays a key role in lipid pathophysiology. But how does it lead to cardiovascular events? LDL-C directly leads to plaque expansion and deposition in the arterial intima. Increasing levels of LDL-C are directly related to worsening plaque burden, a principle exhibited powerfully by the dose-dependent nature of coronary atherosclerosis in patients with underlying mutations leading to LDL-C elevation, such as familial hypercholesterolemia. Importantly, the treatment of atherosclerosis and implementation of lipid-lowering therapies are not uniform, with significant disparities throughout the community. The message is clear: Reducing LDL-C is of paramount significance in the prevention and treatment of coronary atherosclerosis and ensuring equitable access to care is critical to addressing the societal burden of cardiovascular disease and improving the health of our communities. There is no CME associated with this episode. To get free CME from other CardioNerds episodes, please visit VCU Health here. Relevant disclosure: Dr. Ferdinand reported severing as a consultant for Medtronic, Amgen, and Novartis. Pearls • Quotables • Notes • References • Guest Profiles • Production Team CardioNerds Lipid Series PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls - LDL, Cardiovascular Events, & Disparities in Care LDL-C is a major stimulant for the initiation and progression of atherosclerosis.The lower the LDL-C level, the greater the clinical benefit in both primary and secondary ASCVD prevention.Our healthcare systems continue to have major disparities in access to quality care and it is essential to reduce barriers to cardiovascular wellness for all communities.Lowering LDL-C in individuals at high cardiovascular risk, especially in those with familial hypercholesterolemia, prevents ASCVD events. Quotables - LDL, Cardiovascular Events, & Disparities in Care “Empower patients to be partners in their care” Dr. Keith Ferdinand Show notes - LDL, Cardiovascular Events, & Disparities in Care 1. What is the link between LDL-C and cardiovascular events? LDL-C is a major stimulant for the initiation and progression of atherosclerosis. The key events in the initiation of ASCVD are the retention and accumulation of cholesterol-rich lipoproteins within the arterial intima at sites with a predilection for plaque formation. As serum levels of LDL-C increase, the probability of intimal retention of LDL leading to the development of atherosclerotic plaque increases in a dose-dependent manner [4].The WOSCOPS trial demonstrated genes associated with lower LDL-C levels are also associated with a three-fold reduction in the risk of cardiovascular disease per unit reduction in LDL-C [4].The Emerging Risk Factors Collaboration (ERFC) and Prospective Studies Collaboration reported plasma LDL-C was associated with increased risk of non-fatal MI or CHD death [4].Statins uniformly reduce atherosclerotic risk across varying levels of baseline LDL-C and are first line therapy for primary and secondary prevention of ASCVD.In high-risk individuals and secondary prevention populations, AHA/ACC guidelines recommend 50% reductions in LDL-C, regardless of baseline, to 190. FH should be considered in adults with LDL-C levels > 190 mg/dL or total cholesterol levels > 310 mg/dL [5].Homozygous FH is a much rarer condition, with an extreme phenotype characterized by untreated plasma LDL-C levels above >400 from birth and almost universal development of ASCVD and xanthomas in childhood or early adolescence. Statins can be started as early as 8-10 years of age. PCSK-9 inhibitors may also be used. LDL apheresis is also a common treatment option [5].To learn more about personalized ASCVD risk assessment and FH, enjoy CardioNerds Episode #98: Personalized Risk Assessment for Cardiovascular Prevention with Dr. Amit Khera. 3. What is the interaction of LDL-C with other ASCVD risk factors? There are numerous risk factors for ASCVD: hypertension, diabetes mellitus, tobacco smoking, and more. Patients with more risk factors have a higher absolute rate of ASCVD in comparison with persons with fewer risk factors [4].However, reduction in LDL-C is associated with the same proportional risk reduction of ASCVD, regardless of the presence or absence of these other risk factors [4].Statin therapy reduces vascular event rates, including major coronary events, stroke, and coronary revascularization by 15-25% for each 1 mmol/L reduction in LDL-C [8]. 4. How do we best support the cholesterol management and cardiovascular health needs of underserved and low-resource communities? We must recognize and work together to address CV health disparities from both the individual and population levels.Reduced adherence to statin therapy among eligible patients is associated with increased mortality. Minority patients, those with low income, and those with barriers to health literacy have been found to be less likely to adhere to statins, signaling important disparities that must be addressed further. The reasons are likely multifactorial and require a multipronged approach to address.Team care delivered in nontraditional locations shows promise, but the cost-effectiveness and sustainability of these approaches need to be studied further [13].Barriers to treatment in low-resource communities exist at multiple levels: educational opportunities, environment, limited access to healthy food options, access to healthcare providers, transport to healthcare facility organization and practice settings where care occurs, and governmental health policy. Focus is needed on developing cross-sectional partnerships to target multiple barriers [13, 16]Programs need early-stage investigators committed to disparities research to bridge these findings to clinical practice and formulation of health policy.To learn about the use of community based participatory research to meaningfully engage and empower the community in addressing these barriers, enjoy CardioNerds Episode #131 with Dr. LaPrincess Brewer and Dr. Norrisa Haynes.To learn about strategies to engage minority patients in clinical trials, enjoy CardioNerds Episode #135 with Dr. Clyde Yancy. 5. What are some other benefits and consequences of lowering LDL-C? Intensive LDL-C lowering is associated with a greater reduction of all-cause mortality in addition to CV mortality [9].LDL-C lowering has exhibited protective effects against cerebrovascular events.The ODYSSEY trial in 2019 demonstrated that PCSK-9 therapy decreased the risk of stroke in patients with recent ACS and dyslipidemia; however, this was regardless of LDL-C levels achieved.There is no evidence for an increased risk of cognitive impairment (PROSPER trial) or hemorrhagic stroke with lower LDL-C levels. References - LDL, Cardiovascular Events, & Disparities in Care Baigent C, Blackwell L, Emberson J, et al. Efficacy and Safety of More Intensive Lowering of LDL Cholesterol: A Meta-Analysis of Data from 170,000 Participants in 26 Randomised Trials. Lancet. 2010; 376: 1670–81.Damask A, Steg PG, Schwartz GG et al. Patients With High Genome-Wide Polygenic Risk Scores for Coronary Artery Disease May Receive Greater Clinical Benefit From Alirocumab Treatment in the ODYSSEY OUTCOMES Trial. Circulation. 2020 Feb 25;141(8):624-636.Duran EK, Aday AW, Cook NR, et al. Triglyceride-Rich Lipoprotein Cholesterol, Small Dense LDL Cholesterol, and Incident Cardiovascular Disease. J Am Coll Cardiol. 2020 May 5; 75(17):2122-2135.Ference BA, Yoo W, Alesh I, et al. Effect of Long-Term Exposure to Lower Low-Density Lipoprotein Cholesterol Beginning Early in Life on the Risk of Coronary Heart Disease: a Mendelian Randomization Analysis. Journal of the American College of Cardiology. 2012; 60: 2631-9.Goldberg AC, Hopkins PN, Toth PP, et al. Familial Hypercholesterolemia: Screening, Diagnosis and Management of Pediatric and Adult Patients: Clinical Gu

139. Narratives in Cardiology: International Medical Graduates in the Cardiology Workforce with Dr. William Zoghbi Jul 26, 2021

Show notes

CardioNerds (Amit Goyal and Daniel Ambinder) join fellow lead, Dr. Giselle A. Suero-Abreu (FIT, Massachusets General Hospital), Dr. Isadora Sande Mathias (FIT, Houston Methodist and CardioNerds Academy Fellow), and Dr. Victor Nauffal (FIT, Brigham and Women's Hospital) for a discussion with Dr. William Zoghbi (Chair, Department of Cardiology, Houston Methodist Hospital, Methodist DeBakey Heart & Vascular Center, Past President, the American College of Cardiology) about international medical graduates in the cardiology workforce. This episode focuses on the narratives of international medical graduates (IMGs) who make important contributions to the US medical workforce and scientific innovation. Listen to the episode to learn the state of IMGs in the US physician workforce and the field of Cardiology, an overview of factors that influence IMG selection when applying to residency and fellowship training programs in the US, the impact of recent changes in licensing exams and immigration restrictions, and how to address challenges and support IMGs throughout their medical careers. Audio editing by CardioNerds Academy Intern, Dr. Leticia Helms. Claim free CME just for enjoying this episode! Disclosures: None Cardionerds Narratives in Cardiology PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll Subscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Show notes 1. What is the definition of an international medical graduate (IMGs)? International medical graduates (IMGs) are physicians who who graduated from a medical school outside the United States, regardless of nationality. This group of foreign-trained physicians include US-IMGs (US citizens) and non-US IMGs (non-US citizens). Nearly 80% of IMGs are born abroad [1]. In a paper senior authored by Dr. Zoghbi, IMGs in the US physician workforce are described as “the multicultural, multiethnic, open-minded, and plural fabric that has defined American medicine and contributed to its success over the years” [2]. 2. Why are IMGs important? IMGs are an integral part of the U.S. healthcare system. They constitute about 25% of the physician workforce and, since 2010, the number of IMGs in practice has grown by nearly 18% [1, 3]. IMGs play a critical role in addressing healthcare inequities across the US, comprising a significant proportion of physicians in high-need rural and underserved urban areas [1, 3, 4]. IMGs contribute to the diversity and cultural competence in the US physician workforce with 98% of them speaking two or more languages fluently. They help patients overcome linguistic and cultural barriers that can interfere with their care [5]. Learn more about Diversity and inclusion (Episode 95) and Latinx representation in cardiology (Episode 129). Racial and ethnic concordance between physicians and their patients results in improved healthcare outcomes, and IMGs are essential in matching the needs of the increasingly diverse US population [6]. Many IMGs pursue the opportunity to train in the best academic programs in the US and return as leaders to serve their country. This becomes an avenue for international collaboration to help patients and contribute to research, innovation, and education. 3. What is the state of the IMG workforce in Cardiology? IMGs in cardiology serve as an important source of cardiac care in the United States. Data from the 2020 Physician Specialty Data Report from the Association of American Medical Colleges (AAMC) [7] showed that: Among active US physicians, IMGs comprise 31% of general cardiologists, 46% of interventional cardiologists, and 26% of pediatric cardiologists.Among ACGME trainees, IMGs constitute 38% of fellows in cardiovascular disease, 53% in interventional cardiology, and 20% in pediatric cardiology.Many IMGs have non-immigrant visas, including the J-1 Visitor Exchange visa, and pursue visa waivers at the end of their training. This provides an important source of care to patients in rural and underserved urban areas but can also pose restrictions that affect the career choices and post-training employment opportunities of these physicians [4, 8].For example, only a third of visa waiver positions can go to specialists, creating difficulty for highly trained cardiovascular subspecialists who are IMGs (such as interventionalists and electrophysiologists) who sometimes have limited options to find a job that matches their training when integrating into the US cardiology workforce [4]. 4. What are some challenges IMGs face? IMGs face a series of barriers when entering US residency programs, during their training experiences, and upon the transition into practice [2, 4, 8-11]. There are disparities and biases concerning IMGs during the residency and fellowship match process. For instance, data from the 2020 NRMP Program Director survey showed that 36% of program directors would “seldom” interview a non-US IMG and 18% would “never” do so. When ranking non-US IMGs, 37% of program directors would “seldom” and 21% would “never” do so [12]. These numbers have remained similar over recent years. Over the past few years, changes related to licensing exams, immigration policies, and the COVID-19 pandemic have impacted the recruitment and integration of IMGs into the US physician workforce [2, 8, 11] Nearly 15,000 IMGs in active clinical practice in the US are awaiting permanent residency status. This limits their ability to work to the fullest capacity and capability, especially during public health emergencies [13]. Understanding the challenges faced by IMGs can inform efforts to strengthen support and guidance for this resilient and hard-working group of physicians. 5. How can we support IMGs throughout their medical careers? There are many opportunities for addressing the professional and personal challenges faced by IMGs and supporting their integration throughout their medical careers (Table 1) [4, 5, 10, 11]. Discussion among program leadership at different institutions can help administrators learn from each other’s experiences regarding the recruitment and retention of IMGs and may help reduce barriers. Major medical organizations and the cardiology community can help address immigration and licensure policies affecting IMGs during training and when transitioning to the cardiology workforce in the US [2, 4, 13]. Incorporating diversity and inclusion efforts into the mission of organizations is paramount to ensuring professional satisfaction and success for IMGs as academic faculty. Advocacy, mentorship, and sponsorship enable IMGs to contribute to their highest potential in their medical careers in the US and internationally. Figure 1. Arjun et al [10]Table 1. (Zaidi, Z. et al) [5] CardioNerds Narratives in Cardiology The CardioNerds Narratives in Cardiology series features cardiovascular faculty representing diverse backgrounds, subspecialties, career stages, and career paths. Discussing why these faculty chose careers in cardiology and their passion for their work are essential components to inspiring interest in the field. Each talk will feature a cardiology faculty from an underrepresented group, within at least one of several domains: gender, race, ethnicity, religion, national origin, international graduate status, disadvantaged backgrounds, etc. Featured faculty will also represent a variety of practice settings, academic ranks, subspecialties (e.g. clinical cardiology, interventional cardiology, electrophysiology, etc), and career paths (e.g. division chief, journal editor, society leadership, industry consultant, etc). Faculty will be interviewed by fellows-in-training for a two-part discussion that will focus on: 1) Faculty's content area of expertise2) Faculty's personal and professional narrative As part of their narrative, faculty will discuss their unique path to cardiology and their current professional role with particular attention to challenges, successes, and advice for junior trainees. Specific topics will be guided by values relevant to trainees, including issues related to mentorship, work-life integration, and family planning. To help guide this important initiative, the CardioNerds Narratives Council was founded to provide mentorship and guidance in producing the Narratives series with regards to guests and content. The CardioNerds Narratives Council members include: Dr. Pamela Douglas, Dr. Nosheen Reza, Dr. Martha Gulati, Dr. Quinn Capers, IV, Dr. Ann Marie Navar, Dr. Ki Park, Dr. Bob Harrington, Dr. Sharonne Hayes, and Dr. Michelle Albert. The Narratives Council includes three FIT advisors who will lead the CardioNerds’ diversity and inclusion efforts, including the current project: Dr. Zarina Sharalaya, Dr. Norrisa Haynes, and Dr. Pablo Sanchez. Guest Profiles - Physician Scientists Women Electrophysiology Dr. William A. Zoghbi Dr. William A. Zoghbi, a renowned cardiology, echocardiography and cardiac imaging expert, has developed noninvasive heart function and valve disorder evaluation techniques. As a result, Dr. Zoghbi has overseen national and international heart valve evaluation guideline development.He built his reputation on his ischemic heart disease, myocardial function and hibernation research, as well as his development of echocardiographic techniques to evaluate valvular dynamics and measure valvular regurgitation. Dr. Zoghbi has authored more than 300 publications and lectured at every major cardiology conference worldwide. Dr. Giselle Alexandra Suero Abreu Dr. Giselle Alexandra Suero Abreu is a cardiology fellow at Massachusetts General Hospital. She was born and raised in Dominican Republic where she received her M.D. from the Instituto Tecnológico de Santo Domingo (INTEC). During medical school,...

138. Lifelong Advocacy for Women’s Cardiovascular Health with Dr. Sharonne Hayes and Dr. Nanette Wenger Jul 21, 2021

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CardioNerds Cardio-OB series co-chairs University of Texas Southwestern Cardiology Fellow, Dr. Sonia Shah (FIT, University of Texas Southwestern) and Dr. Natalie Stokes, (FIT, University of Pittsburgh) join Dr. Nanette Wenger, Professor of Medicine in the Division of Cardiology at the Emory University School of Medicine and a consultant to the Emory Heart and Vascular Center and Dr. Sharonne Hayes, Professor of Internal Medicine and Cardiovascular Diseases and founder of the Women’s Heart Clinic at Mayo Clinic for an in depth discussion about lifelong advocacy for women's cardiovascular health. Audio editing by CardioNerds Academy Intern, Dr. Leticia Helms. CardioNerds Cardio-Obstetrics Series PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Guest Profiles - Advocacy for Women's Cardiovascular Health Dr. Nanette Wenger Dr. Nanette Wenger is Professor of Medicine in the Division of Cardiology at the Emory University School of Medicine. Dr. Wenger received her medical degree from Harvard Medical School in 1954 as one of their first female graduates followed by training at Mount Sinai Hospital where she was the first female to be chief resident in the cardiology department. She is among the first physicians to focus on heart disease in women with an expertise in cardiac rehabilitation and geriatric medicine.Dr. Wenger has received numerous awards including the Distinguished Achievement Award from the Scientific Councils of the American Heart Association and its Women in Cardiology Mentoring Award, the James D. Bruce Memorial Award of the American College of Physicians for distinguished contributions in preventive medicine, the Gold Heart Award, the highest award of the American Heart Association, a Lifetime Achievement Award in 2009 and the Inaugural Bernadine Healy Leadership in Women’s CV Disease Distinguished Award, American College of Cardiology. She chaired the U.S. National Heart, Lung, and Blood Institute Conference on Cardiovascular Health and Disease in Women, is a Past President of the Society of Geriatric Cardiology and is past Chair, Board of Directors of the Society for Women’s Health Research. Dr. Wenger serves on the editorial boards of numerous professional journals and is a sought-after lecturer for issues related to heart disease in women, heart disease in the elderly, cardiac rehabilitation, coronary prevention, and contemporary cardiac care. She is listed in Best Doctors in America. Dr. Sharonne N. Hayes Sharonne N. Hayes, M.D., studies cardiovascular disease and prevention, with a focus on sex and gender differences and conditions that uniquely or predominantly affect women. With a clinical base in the Women's Heart Clinic, Dr. Hayes and her research team utilize novel recruitment methods, social media and online communities, DNA profiling, and sex-specific evaluations to better understand several cardiovascular conditions. A major area of focus is spontaneous coronary artery dissection (SCAD), an uncommon and under-recognized cause of acute coronary syndrome (heart attack) that occurs predominantly in young women. Dr. Hayes also studies the diagnosis and treatment of nonobstructive (microvascular) coronary artery disease and chest pain syndromes and the subsequent risk of arrhythmias and other cardiac conditions in women who have had hypertension, diabetes or preeclampsia during a pregnancy. With the Pericardial Disease Study Group, Dr. Hayes is assessing the optimal management of pericarditis. Additionally, Dr. Hayes is involved in several research initiatives aimed at addressing health equity and reducing health disparities. Through partnerships with national professional women- and minority-serving organizations, Dr. Hayes assesses barriers faced by women and minorities that prevent or deter them from participating in research studies. Through surveys and national databases, Dr. Hayes is also studying the professional development of women and minorities in the health science professions, including the effects of pregnancy and childbearing during training, and evaluating disparities in academic promotion. CardioNerds Cardioobstetrics Production Team Natalie Stokes, MDSonia Shah, MDAmit Goyal, MDDaniel Ambinder, MD

137. WomenHeart Champions: Patients As Support and Advocates for Women With Heart Disease Jul 19, 2021

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In this special CardioOB series patient perspective episode, CardioNerds (Amit Goyal and Daniel Ambinder), join three incredible WomenHeart Champions, Ms. Porothea Dennis, Ms. Brandie Taylor, and Ms. Ellen Robin in the presence of two legendary leaders in cardiovascular medicine, Dr. Nanette Wenger and Dr. Sharonne Hayes. In addition to this episode being featured on our Cardio-Obstetrics topic page, you can also find this episode in our Patient and Family Perspective collection which features several moving and meaningful patient and family stories that remind us of why we do what we do. Special message by Ms. Celina Gorre, CEO of WomenHeart. Audio editing by CardioNerds Academy Intern, Dr. Leticia Helms. The CardioNerds Cardio-Obstetrics series is a comprehensive series led by series co-chairs Dr. Natalie Stokes CardioNerds ambassador from UPMC and Dr. Sonia Shah CardioNerds ambassador from UTSW, and produced in collaboration with WomenHeart. There is no CME for this episode. Relevant disclosures: None. CardioNerds Cardio-Obstetrics Series PageCardionerds Patient and Family Perspective PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Why Cardio-Obstetrics❓ Because it’s important, and relevant to anyone taking care of women who are, may become, or have been pregnant as cardiovascular disease is the #1 cause of pregnancy-related death. In order to raise awareness we’ve put together an fun, sometimes sobering, but comprehensive curriculum, so get ready, because this CardioNerds Cardio-Obstetrics cruise will dock at several ports along the way: ✔normal pregnancy physiology, ✔hypertensive disorders, ✔arrhythmia, ✔valvular heart disease, ✔anticoagulation, ✔pulmonary hypertension, ✔congestive heart failure, ✔aortopathies, ✔coronary artery disease, ✔critical care, ✔4th trimester, ✔Racial disparities in care, ✔interventional considerations, ✔patient perspectives including from womenheart champions, and more! CardioNerds Cardioobstetrics Production Team Natalie Stokes, MDSonia Shah, MDAmit Goyal, MDDaniel Ambinder, MD

136. ACC 2021 Prevention Highlights – ADAPTABLE and STRENGTH Trials Jul 16, 2021

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Join CardioNerds for a great discussion about key ACC 2021 Prevention highlights featuring the ADAPTABLE and STRENGTH trials. This episode is produced in collaboration with the American College of Cardiology Prevention of Cardiovascular Disease Council with mentorship from the Council’s Chair Dr. Eugene Yang (University of Washington Medical Center) who provides a message at the end of the episode. First, Dr. Amit Goyal and Council Representative Dr. Mahmoud Al Rifai (FIT, Baylor College of Medicine) discuss the implications of the ADAPTABLE Trial with Dr. Gina Lundberg (Emory University School of Medicine). Then Dr. Tommy Das (FIT, Cleveland Clinic), Dr. Rick Ferraro (FIT, Johns Hopkins) and Council Representative Dr. Anum Saeed (FIT, University of Pittsburgh Medical Center) discuss the results of the STRENGTH trial’s secondary analysis with Dr. Steven Nissen (Cleveland Clinic). Disclosures: Dr Nissen reported grants from AstraZeneca during the conduct of the STRENGTH trial Cardionerds Cardiovascular Prevention PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll Subscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Show notes ADAPTABLE Trial The ADAPTABLE trial is a randomized open label pragmatic trial comparing two doses of aspirin (325 mg vs. 81 mg) for the secondary prevention of cardiovascular disease. The trial employed a range of innovative and low-cost methods to simplify the identification, recruitment, and follow-up of patients. The primary effectiveness outcome was a composite of death from any cause, hospitalization for myocardial infarction, or hospitalization for stroke. The primary safety outcome was hospitalization for major bleeding. A total of 15,076 patients were followed for a median of 26.2 months. The primary effectiveness and safety outcomes were not significantly different between the two groups. Together with Dr. Lundberg we discuss design and methodological issues related to the trial and applicability to clinical practice. ASA 81 mg is as effective as ASA 325 mg for reducing cardiovascular events ASA 325 mg does not cause more bleeding episodes than ASA 81 mg ASA dosing should be based on a clinician-patient risk discussion incorporating patients’ risk profile and their values and preferences Future trials should ensure adequate representation of women and race/ethnic minorities The results of the present trial suggest that either dose of ASA (81 mg or 325 mg) would be adequate to lower patients’ risk of death or atherosclerotic cardiovascular events with similar risk of bleeding. ASA dosing should be based on patient values and preferences and clinician judgement as the effectiveness and safety profile of these two regiments appears to be equivalent on the basis of the present trial. STRENGTH Trial, Secondary Analysis Whether omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) reduce cardiovascular risk has been long debated. Data have largely remained inconclusive with several previous trials, particularly the VITAL and ASCEND, showing no significant cardiovascular benefit DHA and EPA supplementation. However, the REDUCE-IT and the JELIS trials showed cardiovascular benefit with higher dose of purified EPA compared to placebo. Meanwhile, the STRENGTH trial did not show any difference in CVD outcomes in treatment groups using a combined EPA/DHA formulation. In this episode, we discuss a secondary anaylsis from the STRENGTH trial entitled “Association Between Achieved ω-3 Fatty Acid Levels and Major Adverse Cardiovascular Outcomes in Patients With High Cardiovascular Risk” presented at the ACC 2021 addressing the effects of carboxylic acid formulation of EPA/DHA (omega-3 CA) compared with placebo among patients with dyslipidemia and high cardiovascular risk. This analysis showed that there was no added clinical benefit or harm in those who achieved the highest tertiles of EPA and DHA. “It is very important to use a neutral comparator as a placebo and this is what we aimed to do in the STRENGTH trial by using corn oil as the placebo against EPA/DHA... you can only optimally interpret a clinical trial in the context of a neutral placebo.” The STRENGTH trial used carboxylic acid derivative which is better absorbed than other ester formulations used in other studies and its absorption is independent of food. The EPA concentration in the blood reached adequate levels (even up to 268% in the pooled analysis) in this study however, there was only a ~39% increase in DHA even though a formulation of both EPA and DHA was used. Reasons for this remain to be uncovered. Three most recent trials including REDUCE-IT, STRENGTH and OMEMI trial have all consistently showed an increase in atrial fibrillation with omega-3 FA use. The incidence is small but not trivial. Mechanistically, we do not know the reason for this. Opportunity to do further studies studying the effects of Omega-3FA on atherosclerotic disease itself and its progression or reduction remains wide open. Guest Profiles Dr. Eugene Yang Dr. Yang is medical director of the UW Medicine Eastside Specialty Center and a UW professor of medicine. He has particular expertise in the diagnosis and treatment of coronary artery disease, valvular heart disease, peripheral vascular disease, congestive heart failure, cardiac arrhythmias, hypertension and lipid disorders. He is especially interested in the primary and secondary prevention of heart disease through aggressive risk-factor modification and lifestyle change. He also conducts research on new cholesterol-lowering therapies and appropriate treatment options for patients with coronary artery disease. Dr. Yang received his bachelor’s and master’s degrees from Stanford University and his medical degree from the University of Pennsylvania School of Medicine. He completed his internal medicine residency and fellowships in cardiovascular disease and advanced cardiac imaging at Stanford University School of Medicine. Prior to joining the faculty at UW Medicine, he was a clinical instructor and physician-scientist at Stanford. Dr. Yang has been on the faculty at UW Medicine since 2007 and is actively involved with the teaching of medical students, residents and fellows. He is a fellow of the American College of Cardiology and is board certified in internal medicine and cardiovascular disease. Dr. Yang's personal interests include food, wine, golf, travel, and watching soccer. Dr. Gina Lundberg Gina Price Lundberg MD FACC FAHA is an Associate Professor of Medicine at Emory University School of Medicine and has served as the Clinical Director of the Emory Women’s Heart Center since it was founded in 2013. She is a Preventive Cardiologist and specializes in heart disease in women, lipid abnormalities and cardiovascular risk reduction. She founded the first women’s heart prevention program in the state of Georgia in 1998. Dr Lundberg’s service at Emory University includes improving outcomes for women with cardiovascular disease but also improving gender equity for women in cardiology and encouraging more women to choose cardiology for their careers. She attended the Medical College of Georgia at Augusta University and trained in Internal Medicine at Atlanta Medical Center. Her cardiology fellowship was at Rush University in Chicago. She is active with the ACC, AHA, and NLA. She is the Chair-elect for the ACC Women in Cardiology Leadership Council and is the co-chair for the WIC Communications and Social Media Committee. She is the Co-chair for the NLA Social Media and Communications committee and the co-Chair for NLA DE&I Committee. She serves on the AHA Clinical Cardiology Communications and Social Media committee and the AHA Familial Hypercholesterolemia and Hyperlipidemia working group. And she serves as the Social Media Supervisor for JACC Case Reports. Dr. Steven Nissen Steven Nissen, MD, is Chief Academic Officer, Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute, and holds the Lewis and Patricia Dickey Chair in Cardiovascular Medicine. Dr. Nissen has more than 35 years of experience as a physician. He is world-renowned for his work as a cardiologist, patient advocate and researcher. Equally as significant is his pioneering work in IVUS technology and its use in patients with atherosclerosis. Dr. Nissen has written more than 400 journal articles and 60 book chapters, including many published in the New England Journal of Medicine and the Journal of the American Medical Association. In recent years, he has also written on the subject of drug safety and was the author of manuscripts highlighting concerns about medications such as Vioxx™, Avandia™, and muraglitazar. He is heavily involved with the American College of Cardiology (ACC), serving as President from March 2006 to March 2007, a member of the ACC Executive Committee from 2004 to 2008, and spending 10 years as a member of the organization’s Board of Trustees. In addition, Dr. Nissen has served several terms on the Program Committee for the ACC Annual Scientific Sessions. In his leisure time, Dr. Nissen likes to bicycle whenever possible. He is also an advanced amateur photographer. Dr. Mahmoud Al Rifai Dr. Mahmoud Al Rifai earned his medical degree from American University of Beirutand M.P.H. from Johns Hopkins Bloomberg School of Public Health. He completed his internal medicine residency training at University of Kansas – Wichita where he also completed a chief residency year. His career interests include academic cardiology, imaging, risk prediction, cardiovascular disease prevention and his hobbies include tennis, healthy lifestyle, reading, and coffee making. Dr. Anum Saeed Dr. Anum Saeed is a Clinical Instructor/Postdoctoral Associate at th

135. Narratives in Cardiology: Underrepresentation in Clinical Trials & Guidelines with Dr. Clyde Yancy – Illinois Chapter Jul 12, 2021

Show notes

CardioNerds (Amit Goyal and Daniel Ambinder), Dr. Victoria Thomas (Cardionerds Ambassador, Vanderbilt University Medical Center), and Dr. Quentin Youmans, cardiology fellow at Northwestern Medicine Bluhm Cardiovascular Institute, join Dr. Clyde Yancy, Vice Dean for Diversity and Inclusion and Chief of Cardiology in the Department of Medicine at Northwestern for an important discussion about underrepresentation in clinical trials and guidelines. This episode was recorded during a live event hosted by the ACC Illinois Chapter. Listen in to hear why diversity matters in clinical trials, how we can recruit more minorities in representation in CV trials and so much more! Stay tuned for a message by chapter Governor, Dr. Annabelle Volgman. The PA-ACC & CardioNerds Narratives in Cardiology is a multimedia educational series jointly developed by the Pennsylvania Chapter ACC, the ACC Fellows in Training Section, and the CardioNerds Platform with the goal to promote diversity, equity, and inclusion in cardiology. In this series, we host inspiring faculty and fellows from various ACC chapters to discuss their areas of expertise and their individual narratives. Join us for these captivating conversations as we celebrate our differences and share our joy for practicing cardiovascular medicine. We thank our project mentors Dr. Katie Berlacher and Dr. Nosheen Reza. Audio editing by CardioNerds Academy Intern, Dr. Gurleen Kaur. Video Version • Notes • References • Production Team Claim free CME just for enjoying this episode! There are no relevant disclosures for this episode. The PA-ACC & CardioNerds Narratives in Cardiology PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Video version https://youtu.be/5gGqWysdCT0 Show notes 1. Why does diversity matter in clinical trials? Having clinical trial enrollment being representative of the general population in which we practice is essential for the generalizability of the trial results.Representative populations matter so we can say to patients, “yes, there were patients that think like you and look like you in the trial.” We can confidently tell them how patients within the trial have done. This is important when we are trying to narrow health disparities to provide confidence and comfort to our patients.Advocacy for health equity is important but not enough. We need data or evidence to support why a change in our behaviors and clinical practice is needed. An evidence base that reflects and includes all our patients is key to bridging health disparities.In medicine, the case for diversity also includes to better serve diverse patients, to promote health equity, to provide diverse mentors at all levels, to bring different points of view to debates and problem solving, to better engage our communities, and to include investigators with a broad range of perspectives in their scholarly activities. (1) 2. How do we recruit more minorities in representation in cardiovascular trials? We need more advocates for diversity in trials in the room when the conversations about trial designs are being made. This is why diversity of leadership is important.There needs to be an intentional approach for every clinical trial to recruit people that are likely to be candidates for enrollment.Stop asking patients to come “downtown” but instead go to their town or their communities. Meet them where they are.Always make sure you are providing some additional advantage or opportunity for the patients you have recruited into your trials. Don’t make it a one-way street. Allow patients to feel that they are getting the best care and generate trust with them.To gain trust, try to get a sense of what is happening in your patient’s life. Find 2-3 minutes to ask them to give a mini biography of their lives. This goes for routine clinical care as well as conducting trials! 3. What advice do you share with people who are underrepresented in medicine, and who may potentially face racism or sexism? You have two choices when people promote division and hatred. You can choose to be angry, or you can choose to not let others’ poor decisions or thoughts define you.Your best tool as UIM is to control yourself and to be successful.Remember that your uniqueness can make a difference in the lives of so many others. It can help you execute making a large impact for so many more people. 4. How do we recruit more diversity in medicine or cardiology in general? One strategy is to establish new medical school(s) at Historically Black Colleges or Universities (HBCUs). HBCUs recognize broad talent, refine that talent, and propel that talent to success.The current 4 medical schools in part aligned with HBCUs and serving Black medical students represent 2.6% of total medical schools yet account for 15% of all Black medical students. (2)We must stop looking at diversity as a “representativeness” cause. We should all be striving for excellence. To achieve this, we need diversity of thought, diversity of ideas, and diversity of execution. This will not be accomplished if we continue all have the same “skin”.There must be intentionality for diverse leadership. There needs to be diversity in the C-suite of hospitals and the Dean’s executive committee of medical schools. Diversity in medicine will follow suit when there is a diverse thought process in those rooms that affect the future. 5. How has structural racism affected studies and guidelines? There has been a system in medicine early on in our country that intentionally separated people as a function of race such as the “Jim Crow experience”. This disabled many opportunities for certain groups of people.Physicians must recognize there are still residual consequences of the Jim Crow experience that have allowed for a “cultural set point” that continues to be operative today. (3)The “cultural set point” has allowed many generations to become acculturated subconsciously to believe there are distinct differences between people and then behave accordingly that leads to effect of how one may practice medicine. 6. How do we combat structural racism within cardiology or medicine? If you are trying to incite culture change, something abrupt likely will need to happen. You must embrace and enjoy the need for change.CardioNerds and the new generation of physicians have the license to be architects of the future in medicine. We have the power to change the culture as we practice and develop new studies and guidelines.Consider a positive disruptive change when making new ideas for the future in medicine to battle social injustices within medicine.We must fundamentally change the way we do things to change our already known processes. 7. Should there be race or gender-based guidelines or socioeconomic status guidelines? The first step is recognizing this is a complex issue and when one is developing a trial there needs to be a thoughtful conversation.We do need more data in the study of racial and gender differences.We still need race and gender-based research – not race/gender-based research looking for a different biology, but research trying to unravel where do we see these differences that are otherwise inexplicable, with the exception of bias. (4) 8. How to get your peers and patients to trust you to advocate and promote diversity, equity, and inclusion? Per Dr. Yancy you need 3 traits to become a strong and effective advocate: Competency: to strive to be best physician you can be and to give the best care you can. You need your voice to be respected.Civility: be able to stand in a room where there is a difference of opinions and hold yourself appropriate. Manage to have eye contact, manage your emotions, because remember if you allow people to make you angry and show it then they have won.Compassion: show people that you genuinely care. Remember you may have had opportunities that your patients or colleagues may never have had. Also remember to go back to evidence! The evidence is there to promote for more diversity within the physician workforce. This in turn leads to diversity of thought, ideation, and execution which help improve clinical trial subject representation.Remind people that in the 2019-2020 academic year, 21,863 first-year medical students were enrolled in the US, of whom 1,626 were Black—a number that has been stagnant since 1978. References Douglas, P. S., Williams, K. A., & Walsh, M. N. (2017). Diversity matters.Association of American Medical Colleges. Facts: Applicants, Matriculants, Enrollment, Graduates, MD-PhD, and Residency Applicants Data. Published 2020. Accessed December 3, 2020. https://www.aamc.org/data-reports/students-residents/report/factsYancy, C. W. (2020). COVID-19 and African Americans. Jama, 323(19), 1891-1892.Ioannidis, J. P., Powe, N. R., & Yancy, C. (2021). Recalibrating the use of race in medical research. JAMA, 325(7), 623-624.Steinecke A, Terrell C. Progress for whose future? the impact of the Flexner Report on medical education for racial and ethnic minority physicians in the United States. Acad Med. 2010;85(2):236-245. Production Team Dr. Gurleen KaurAmit Goyal, MDDaniel Ambinder, MD

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