Cardionerds: A Cardiology Podcast

The following question refers to Section 7.1 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by New York Medical College medical student and CardioNerds Intern Akiva Rosenzveig, answered first by Lahey Hospital and Medical Center internal medicine resident and CardioNerds Academy House Faculty Leader Dr. Ahmed Ghoneem, and then by expert faculty Dr. Clyde Yancy. Dr. Yancy is Professor of Medicine and Medical Social Sciences, Chief of Cardiology, and Vice Dean for Diversity and Inclusion at Northwestern University, and a member of the ACC/AHA Joint Committee on Clinical Practice Guidelines. The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #19 Ms. M is a 36-year-old G1P1 woman 6 months postpartum who was diagnosed with peripartum cardiomyopathy at the end of her pregnancy. She is presenting for a follow up visit today and notes that while her leg edema has resolved, she continues to have dyspnea when carrying her child up the stairs. She also describes significant difficulty sleeping, though denies orthopnea, and notes she is not participating in hobbies she had previously enjoyed. She is currently prescribed a regimen of sacubitril-valsartan, metoprolol succinate, spironolactone, and empagliflozin.  What are the next best steps? A Screen for depression B Counsel her to follow a strict low sodium diet with goal of < 1.5g Na daily C Recommend exercise therapy and refer to cardiac rehabilitation D A & C Answer #19 Explanation The correct answer is D – both A (screening for depression) and C (referring to cardiac rehabilitation) are appropriate at this time. Choice A is correct. Depression is a risk factor for poor self-care, rehospitalization, and all-cause mortality among patients with HF. Interventions that focus on improving HF self-care have been reported to be effective among patients with moderate/severe depression with reductions in hospitalization and mortality risk. Social isolation, frailty, and marginal health literacy have similarly been associated with poor HF self-care and worse outcomes in patients with HF. Therefore, in adults with HF, screening for depression, social isolation, frailty, and low health literacy as risk factors for poor self-care is reasonable to improve management (Class 2a, LOE B-NR).  Choice C is correct. In patients with HF, cardiac rehabilitation has a Class 2a recommendation (LOE B-NR) to improve functional capacity, exercise tolerance, and health-related QOL; exercise training (or regular physical activity) for those able to participate has a Class 1 recommendation (LOE A) to improve functional status, exercise performance, and QOL. Choice B is incorrect. For patients with stage C HF, avoiding excessive sodium intake is reasonable to reduce congestive symptoms (Class 2a, LOE C-LD). However, strict sodium restriction does not have strong supportive data and is not recommended. There are ongoing studies to better understand the impact of sodium restriction on clinical outcomes and quality of life. The AHA currently recommends a reduction of sodium intake to <2300 mg/d for general cardiovascular health promotion; however, there are no trials to support this level of restriction in patients with HF. Main Takeaway Depression is a risk factor for poor HF self-care and worse outcomes in pat...

CardioNerds (Daniel Ambinder) join Dr. Tomio Tran, Dr. Vid Yogeswaran, and Dr. Amanda Cai from the University of Washington for a break from the rain at the waterfront near Pike Place Market. They discuss the following case: A 46-year-old woman presents with cardiac arrest and was found to have cor triatriatum sinistrum (CTS). CTS is a rare congenital cardiac malformation in which the left atrium is divided by a fenestrated membrane, which can restrict blood flow and cause symptoms of congestive heart failure. Rarely, the condition can present in adulthood. To date, there have been no cases of sudden cardiac death attributed to CTS. Dr. Jill Steiner provides the E-CPR for this episode. Audio editing by CardioNerds Academy Intern, student doctor Akiva Rosenzveig. CardioNerds is collaborating with Radcliffe Cardiology and US Cardiology Review journal (USC) for a ‘call for cases’, with the intention to co-publish high impact cardiovascular case reports, subject to double-blind peer review. Case Reports that are accepted in USC journal and published as the version of record (VOR), will also be indexed in Scopus and the Directory of Open Access Journals (DOAJ). 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! Case Media - A Sinister Cause of Sudden Cardiac Death – University of Washington A 40-year-old woman with a history of recurrent exertional syncope had sudden loss of consciousness while kissing her partner. The patient received bystander CPR while 911 was called. EMS arrived within 10 minutes of the call and found the patient apneic and unresponsive. Initial rhythm check showed narrow complex tachycardia at a rate of 136 BPM. ROSC was eventually achieved. A 12-lead ECG showed that the patient was in atrial fibrillation with rapid ventricular rate. The patient was intubated and brought to the emergency department. The patient spontaneously converted to sinus rhythm en route to the hospital. In the emergency department, vital signs were remarkable for hypotension (76/64 mmHg) and sinus tachycardia (110 BPM). The physical exam was remarkable for an inability to follow commands. Laboratory data was remarkable for hypokalemia (2.5 mmol/L), transaminitis (AST 138 units/L, ALT 98 units/L), acidemia (pH 7.12), and hyperlactatemia (11.2 mmol/L). CT scan of the chest revealed a thin membrane within the left atrium. Transthoracic echocardiogram showed normal biventricular size and function, severe tricuspid regurgitation, pulmonary artery systolic pressure of 93 mmHg, and the presence of a membrane within the left atrium with a mean gradient of 25 mmHg between the proximal and distal left atrial chambers. Vasopressors and targeted temperature management were initiated. The patient was able to be re-warmed with eventual discontinuation of vasopressors, however she had ongoing encephalopathy and seizures concerning for hypoxic brain injury. There was discussion with the adult congenital heart disease team about next steps in management, however the patient was too sick to undergo any definitive treatment for the intracardiac membrane within the left atrium. The patient developed ventilator associated pneumonia and antibiotics were initiated. The patient ultimately developed  bradycardia and pulseless electrical activity; ROSC was unable to be achieved, resulting in death. Autopsy was remarkable for the presence of a fenestrated intracardiac membrane within the left atrium and lack of other apparent congenital heart defects. There was right ventricular hypertrophy and pulmonary artery intimal thickening with interstitial fibrosis suggestive of pulmonary hypertension. There were bilateral acute subsegmental pulmonary emboli present. The cause of death was declared to be arrhythmia in the setting of pulmonary hypertension and right s...

The following question refers to Section 6.3 of the 2021 ESC CV Prevention Guidelines. The question is asked by Dr. Christian Faaborg-Andersen, answered first by UCSD cardiology fellow Dr. Harpreet Bhatia, and then by expert faculty Dr. Jaideep Patel.Dr. Patel recently graduated from Virginia Commonwealth University cardiology fellowship and is now a preventive cardiologist at the Johns Hopkins Hospital.The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #24 A 65-year-old man with a history of ischemic stroke 6 months ago presents to cardiology clinic to establish care. An event monitor was negative for atrial fibrillation and TTE with agitated saline study was negative for a patent foramen ovale. Therefore, his ischemic stroke was presumed to be non-cardioembolic in origin. He is currently taking lisinopril 5 mg daily for hypertension (BP in clinic is 115/70) and atorvastatin 40 mg daily. He has no history of significant gastrointestinal or other bleeding. What do you recommend next?AStart apixaban 5 mg BIDBIncrease lisinopril to 10 mg dailyCStart aspirin 81 mg dailyDStart aspirin 81 mg daily and clopidogrel 75 mg dailyEStart aspirin 81 mg daily and ticagrelor 90 mg BID Answer #24 ExplanationThe correct answer is C – start aspirin 81mg daily.For the secondary prevention of non-cardioembolic ischemic stroke or TIA, anti-platelet therapy is recommended with aspirin only (75-150 mg/day), dipyridamole + aspirin (slightly superior to aspirin), or clopidogrel alone (slightly superior to aspirin) (Class I, LOE A).DAPT with aspirin and clopidogrel or aspirin and ticagrelor should be considered in the immediate period after a minor ischemic stroke or TIA (3 weeks after event, Class IIa), but not 6 months after an ischemic stroke. Dual antiplatelet therapy with aspirin and clopidogrel increases bleeding risk without a significant benefit over either agent alone. Dual antiplatelet therapy with aspirin and ticagrelor increases bleeding risk, but does not improve disability incidence.Oral anticoagulation would be recommended for a cardioembolic stroke, which does not fit the clinical picture.His BP is well controlled so increasing lisinopril is not necessary.Main TakeawayFor the secondary prevention of an ischemic stroke or TIA, anti-platelet therapy with aspirin, aspirin + dipyridamole, or clopidogrel alone is recommended.Guideline Loc.6.3, page 3296-3297 CardioNerds Decipher the Guidelines - 2021 ESC Prevention SeriesCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor RollCardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!

The following question refers to Sections 3.2, 4.1, 4.3, and 4.4 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by Texas Tech University medical student and CardioNerds Academy Intern Dr. Adriana Mares, answered first by Baylor University cardiology fellow and CardioNerds FIT Trialist Dr. Shiva Patlolla, and then by expert faculty Dr. Shelley Zieroth. Dr. Zieroth is an advanced heart failure and transplant cardiologist, Head of the Medical Heart Failure Program, the Winnipeg Regional Health Authority Cardiac Sciences Program, and an Associate Professor in the Section of Cardiology at the University of Manitoba. Dr. Zieroth is a past president of the Canadian Heart Failure Society. She is a steering committee member for PARAGLIE-HF and a PI Mentor for the CardioNerds Clinical Trials Program. The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #18 Ms. AH is a 48-year-old woman who presents with a 3-month history of progressively worsening exertional dyspnea and symmetric bilateral lower extremity edema. She has no history of recent upper respiratory symptoms or chest pain. She denies any tobacco, alcohol, or recreational drug use. There is no family history of premature CAD or HF. On exam, her blood pressure is 110/66 mmHg, heart rate is 112 bpm, and respiration rate is 18 breaths/min with oxygen saturation of 98% on ambient room air. She has jugular venous distention of about 12cm H2O, bibasilar crackles, an S3 heart sound, and bilateral lower extremity edema. Complete blood count, serum electrolytes, kidney function tests, liver chemistry tests, glucose level, iron studies, and lipid levels are unremarkable. An electrocardiogram shows sinus tachycardia with normal intervals and no conduction delays. A transthoracic echocardiogram demonstrates a left ventricular ejection fraction of 25%, normal right ventricular size and function, and no valvular abnormalities. Which of the following diagnostic tests has a Class I indication for further evaluation? A Cardiac catheterization B Referral for genetic counseling C Thyroid function studies D Cardiac MRI Answer #18 Explanation  The correct answer is C – thyroid function studies have a Class 1 indication for the evaluation of HF.  The common causes of HF include coronary artery disease, hypertension, and valvular heart disease. Other causes may include arrhythmia-associated, toxic, inflammatory, metabolic including both endocrinopathies and nutritional, infiltrative, genetic, stress induced, peripartum, and more. It is important to evaluate for the etiology of a given patient’s heart failure as diagnosis may have implications for treatment, counseling, and family members. For patients who are diagnosed with HF, laboratory evaluation should include complete blood count, urinalysis, serum electrolytes, blood urea nitrogen, serum creatinine, glucose, lipid profile, liver function tests, iron studies, and thyroid-stimulating hormone to optimize management (Class 1, LOR C-EO). These studies provide important information regarding comorbidities, suitability for and adverse effects of treatments, potential causes or confounders of HF, and severity and prognosis of HF.

CardioNerds (Amit Goyal and Daniel Ambinder), ACHD series co-chairs Dr. Dan Clark and Dr. Josh Saef, and ACHD FIT lead Dr. J.D. Serfas (Duke University) and Cardiology Fellow Dr. Victoria Thomas (Vanderbilt University) join ACHD experts Dr. Jamil Aboulhosn (Professor of Medicine at UCLA and the director of the Ahmanson/UCLA Adult Congenital Heart Disease Center) and Dr. Joanna Ghobrial, Medical and Interventional Director of the Adult Congenital Heart Disease Center at Cleveland Clinic. They discuss common ACHD pathologies that benefit from interventional cardiology procedures such as transcatheter pulmonic valve replacement (TPVR) and share new advancements in transcatheter approaches to correct sinus venosus defects. They end with a brief discussion on how to become an adult cardiology interventionalist that performs ACHD interventions. Episode notes were drafted by Dr. Victoria Thomas. Audio editing by CardioNerds Academy Intern, student doctor Akiva Rosenzveig.  The CardioNerds Adult Congenital Heart Disease (ACHD) series provides a comprehensive curriculum to dive deep into the labyrinthine world of congenital heart disease with the aim of empowering every CardioNerd to help improve the lives of people living with congenital heart disease. This series is multi-institutional collaborative project made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Josh Saef, Dr. Agnes Koczo, and Dr. Dan Clark. The CardioNerds Adult Congenital Heart Disease Series is developed in collaboration with the Adult Congenital Heart Association, The CHiP Network, and Heart University. See more Disclosures: None CardioNerds Adult Congenital Heart Disease PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls - ACHD: Interventional Cardiology The ductus arteriosus, which is formed from the distal portion of the left sixth arch, is key to fetal circulation because it allows blood to bypass Transcatheter pulmonic valve replacement (TPVR) is a treatment for many ACHD patients that can spare them repeat sternotomies. This is important as many ACHD patients hava already undergone multiple surgeries in their childhood.   Before any ACHD cardiology intervention, appropriate imaging (TEE, TTE, Cardiac MRI, Cardiac CTA, and/or 3D printing) is imperative to understanding the relevant anatomy and hemodynamics to guide procedural indication and planning.    As with other structural interventions, consider a SENTINEL device (cerebral embolic protection system) to provide embolic protection in procedures that could lead to debris/embolic dislodgement when appropriate. Sinus venosus defects can be repaired via a transcatheter approach with a covered stent in the superior vena cava (SVC).   Consider using 3D printing or 3D digital imaging when preparing for complex ACHD interventions.    Notes- ACHD: Interventional Cardiology 1. When considering a patient for TPVR there are 3 types of landing zones for pulmonic valves in ACHD patients:    Pulmonary conduits or homografts. These are typically seen in patients with TOF or prior Ross or Rastelli procedure. These may be calcified and stenotic and so pre-dilatation is often needed before valve replacement.   Bioprosthetic Valves. (Valve in Valve TPVR) Native outflow tract 2. What are some of the more severe complications to consider when talking to an ACHD patient about a TPVR?   Coronary artery compression Conduit rupture Vessel injury (including the pulmonary bed) Valve embolization Endocarditis 3. What are some of the hemodynamic measurements one would want to pay attention to in a patient with a Fontan heart?    You will see higher CVPs in patients with a Fontan palliation.

CardioNerds (Amit Goyal and Daniel Ambinder), ACHD series co-chairs Dr. Dan Clark and Dr. Josh Saef, and ACHD FIT lead Dr. J.D. Serfas (Duke University) and Cardiology Fellow Dr. Victoria Thomas (Vanderbilt University) join ACHD experts Dr. Jamil Aboulhosn (Professor of Medicine at UCLA and the director of the Ahmanson/UCLA Adult Congenital Heart Disease Center) and Dr. Joanna Ghobrial, Medical and Interventional Director of the Adult Congenital Heart Disease Center at Cleveland Clinic. They discuss common ACHD pathologies that benefit from interventional procedures such as transcatheter pulmonic valve replacement (TPVR) and share new advancements in transcatheter approaches to correct sinus venosus defects. They end with a brief discussion on how to become an adult cardiology interventionalist that performs ACHD interventions. Episode notes were drafted by Dr. Victoria Thomas. Audio editing by CardioNerds Academy Intern, student doctor Akiva Rosenzveig.  The CardioNerds Adult Congenital Heart Disease (ACHD) series provides a comprehensive curriculum to dive deep into the labyrinthine world of congenital heart disease with the aim of empowering every CardioNerd to help improve the lives of people living with congenital heart disease. This series is multi-institutional collaborative project made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Josh Saef, Dr. Agnes Koczo, and Dr. Dan Clark. The CardioNerds Adult Congenital Heart Disease Series is developed in collaboration with the Adult Congenital Heart Association, The CHiP Network, and Heart University. See more Disclosures: None CardioNerds Adult Congenital Heart Disease PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls - ACHD: Interventional Cardiology The ductus arteriosus, which is formed from the distal portion of the left sixth arch, is key to fetal circulation because it allows blood to bypass Transcatheter pulmonic valve replacement (TPVR) is a treatment for many ACHD patients that can spare them repeat sternotomies. This is important as many ACHD patients hava already undergone multiple surgeries in their childhood.   Before any ACHD cardiology intervention, appropriate imaging (TEE, TTE, Cardiac MRI, Cardiac CTA, and/or 3D printing) is imperative to understanding the relevant anatomy and hemodynamics to guide procedural indication and planning.    As with other structural interventions, consider a SENTINEL device (cerebral embolic protection system) to provide embolic protection in procedures that could lead to debris/embolic dislodgement when appropriate. Sinus venosus defects can be repaired via a transcatheter approach with a covered stent in the superior vena cava (SVC).   Consider using 3D printing or 3D digital imaging when preparing for complex ACHD interventions.    Notes- ACHD: Interventional Cardiology 1. When considering a patient for TPVR there are 3 types of landing zones for pulmonic valves in ACHD patients:    Pulmonary conduits or homografts. These are typically seen in patients with TOF or prior Ross or Rastelli procedure. These may be calcified and stenotic and so pre-dilatation is often needed before valve replacement.   Bioprosthetic Valves. (Valve in Valve TPVR) Native outflow tract 2. What are some of the more severe complications to consider when talking to an ACHD patient about a TPVR?   Coronary artery compression Conduit rupture Vessel injury (including the pulmonary bed) Valve embolization Endocarditis 3. What are some of the hemodynamic measurements one would want to pay attention to in a patient with a Fontan heart?    You will see higher CVPs in patients with a Fontan palliation.

The following question refers to Section 6.1 of the 2021 ESC CV Prevention Guidelines. The question is asked by Dr. Christian Faaborg-Andersen, answered first by Houston Methodist medicine resident Dr. Najah Khan, and then by expert faculty Dr. Eugenia Gianos.Dr. Gianos specializes in preventive cardiology, lipidology, cardiovascular imaging, and women’s heart disease; she is the director of Women s Heart Health at Lenox Hill Hospital and director of Cardiovascular Prevention for Northwell Health.The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #23 An asymptomatic 55-year-old man with no past medical history presents to clinic after having a cardiac CT as part of an executive physical. His coronary artery calcium (CAC) score was 200 and the coronary CTA demonstrated isolated 70% stenosis of the left circumflex coronary artery. He is asymptomatic and able to jog 2 miles daily without limitation. He was recently started on aspirin 81 mg daily and atorvastatin 40 mg daily by his primary care provider. His LDL is 50 mg/dL, HbA1c is 6.0%. His BP is 108/70. What would you recommend?AStop aspirin 81 mg daily as he has not had an ASCVD event or revascularizationBCardiac catheterization and stent placement in the left circumflexCIncrease atorvastatin to 80 mg dailyDStress testENo change in management Answer #23 Answer choicesAStop aspirin 81 mg daily as he has not had an ASCVD event or revascularizationBCardiac catheterization and stent placement in the left circumflexCIncrease atorvastatin to 80 mg dailyDStress testENo change in managementExplanationThe correct answer is E – no change in management.Though the patient has not had an ASCVD event or revascularization, low-dose aspirin may be considered with definite evidence of CAD on imaging (Class IIb, LOE C).He is asymptomatic and does not have high risk anatomy on CT (i.e., proximal LAD, left main disease, multivessel disease), so percutaneous coronary intervention or stress testing are not indicated.His LDL is well controlled, so increasing atorvastatin would not be appropriate at this time.Main TakeawayAspirin 75-100 md daily may be considered in the absence of MI or revascularization when there is definitive evidence of CAD on imaging (Class IIb, LOE C).Guideline Loc.Section 6.1 CardioNerds Decipher the Guidelines - 2021 ESC Prevention SeriesCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor RollCardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!

The following question refers to Section 5.1 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by Keck School of Medicine USC medical student & CardioNerds Intern Hirsh Elhence, answered first by Greater Baltimore Medical Center medicine resident / Johns Hopkins MPH student and CardioNerds Academy House Chief Dr. Alaa Diab, and then by expert faculty Dr. Biykem Bozkurt. Dr. Bozkurt is the Mary and Gordon Cain Chair, Professor of Medicine, Director of the Winters Center for Heart Failure Research, and an advanced heart failure and transplant cardiologist at Baylor College of Medicine in Houston, TX. She is former President of HFSA, former senior associate editor for Circulation, and current Editor-In-Chief of JACC Heart Failure. Dr. Bozkurt was the Vice Chair of the writing committee for the 2022 Heart Failure Guidelines. The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #17 A 63-year-old man with CAD s/p CABG 3 years prior, type 2 diabetes mellitus, hypertension, obesity, and tobacco use disorder presents for routine follow-up. His heart rate is 65 bpm and blood pressure is 125/70 mmHg. On physical exam, he is breathing comfortably with clear lungs, with normal jugular venous pulsations, a regular rate and rhythm without murmurs or gallops, and no peripheral edema. Medications include aspirin 81mg daily, atorvastatin 80mg daily, lisinopril 20mg daily, and metformin 1000mg BID. His latest hemoglobin A1C is 7.5% and recent NT-proBNP was normal. His latest transthoracic echocardiogram showed normal biventricular size and function. Which of the following would be a good addition to optimize his medical therapy? A DPP-4 inhibitor B Dihydropyridine calcium channel blocker C SGLT2 inhibitor D Furosemide Answer #17 Explanation The correct answer is C: SGLT2 inhibitor. This patient is at risk for HF (Stage A) given absence of signs or symptoms of heart failure but presence of coronary artery disease and several risk factors including diabetes, hypertension, obesity, and tobacco smoking. At this stage, the focus should be on risk factor modification and prevention of disease onset. Healthy lifestyle habits such as maintaining regular physical activity; normal weight, blood pressure, and blood glucose levels; healthy dietary patterns, and not smoking have been associated with a lower lifetime risk of developing HF. Multiple RCTs in patients with type 2 diabetes who have established CVD or are at high risk for CVD, have shown that SGLT2i prevent HF hospitalizations compared with placebo. The benefit for reducing HF hospitalizations in these trials predominantly reflects primary prevention of symptomatic HF, because only approximately 10% to 14% of participants in these trials had HF at baseline. As such, in patients with type 2 diabetes and either established CVD or at high cardiovascular risk, SGLT2i should be used to prevent hospitalizations for HF (Class 1, LOE A). The mechanisms for the improvement in HF events from SGLT2i have not been clearly elucidated but seem to be independent of glucose lowering. Proposed mechanisms include reductions in plasma volume, cardiac preload and afterload, alterations in cardiac metabolism, reduced arterial stiffness, and interaction with the Na+/H+ exchanger. SGLT2i are generally well tolerated,

The following question refers to Section 4.6 of the 2021 ESC CV Prevention Guidelines. The question is asked by Student Dr. Shivani Reddy, answered first by Johns Hopkins Cardiology Fellow Dr. Rick Ferraro, and then by expert faculty Dr. Eileen Handberg. Dr. Handberg is an Adult Nurse Practitioner, Professor of Medicine, and Director of the Cardiovascular Clinical Trials Program in the Division of Cardiovascular Medicine at the University of Florida. She has served as Chair of the Cardiovascular Team Section and the Board of Trustees with the ACC and is the President for the PCNA. The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association. Question #22 Mr. HC is a 50-year-old man presenting for a routine clinic visit. He is not sure the last time he had a lipid panel drawn, and would like one today, but ate lunch just prior to your appointment – a delicious plate of 50% fruits and vegetables, 25% lean meats, and 25% whole grains as you had previously recommended. True or False: Mr. HC should return another day to obtain a fasting lipid panel. TRUE FALSE Answer #22 Answer choices TRUE FALSE Explanation  This statement is False. A non-fasting lipid panel is appropriate for risk stratification and lipid evaluation in most patients per the ESC guidelines. While no level of evidence in provided in the ESC guidelines, this recommendation is consistent with AHA/ACC cholesterol guidelines, which have also largely moved away from fasting lipid panels for most patients and give a Class 1 (LOE B) recommendation to obtaining a fasting or nonfasting plasma lipid profile for ASCVD estimation and baseline LDL-C in adults 20 years of age or older. The ESC recommendation is based upon large trials showing that results of fasting and non-fasting panels are largely similar. This is similar to the AHA/ACC guidelines, which note non-fasting and fasting LDL-C change minimal over time following a normal meal, while HDL-C and tryiglycerides appear to have similar prognostic significance with cardiovascular outcomes in fasting or nonfasting states. A fasting lipid panel should be considered in those with hypertriglyceridemia, metabolic syndrome, and diabetes mellitus, as consumption of food or drink can have direct and immediate effects on TG and blood glucose values. Main Takeaway A non-fasting lipid panel is appropriate for the majority of patients undergoing lipid evaluation and cardiovascular risk stratification.  Guideline Loc. Section 4.6.1 CardioNerds Decipher the Guidelines - 2021 ESC Prevention Series CardioNerds Episode Page CardioNerds Academy Cardionerds Healy Honor Roll CardioNerds Journal Club Subscribe to The Heartbeat Newsletter! Check out CardioNerds SWAG! Become a CardioNerds Patron!

The following question refers to Sections 11.3 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by Western Michigan University medical student and CardioNerds Intern Shivani Reddy, answered first by Johns Hopkins Osler internal medicine resident and CardioNerds Academy Fellow Dr. Justin Brilliant, and then by expert faculty Dr. Harriette Van Spall. Dr. Van Spall is Associate Professor of Medicine, cardiologist, and Director of E-Health at McMaster University. Dr Van Spall is a Canadian Institutes of Health Research-funded clinical trialist and researcher with a focus on heart failure, health services, and health disparities. The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #16 Ms. Augustin is a 33 y/o G1P1 woman from Haiti who seeks counseling regarding family planning as she and her husband dream of a second child.  Her 1st pregnancy 12 months ago was complicated by pre-eclampsia and peripartum cardiomyopathy (LVEF 35%). Thankfully she delivered a healthy baby via C-section. She has no other past medical history and is currently on losartan 25 mg daily and metoprolol succinate 200 mg daily.  She has been asymptomatic. Which of the following statements is recommended to medically optimize Ms. Augustin prior to her 2nd pregnancy? A No medical optimization or preconception planning is needed as her 1st pregnancy resulted in a healthy infant. B Discontinue losartan and metoprolol with no other needed pregnancy planning  C Change her medication regimen, consider repeat TTE, and provide patient-centered counseling regarding risk of a future pregnancy D Continue losartan and metoprolol and advise against repeat pregnancy  Answer #16 Explanation The correct answer is C – change her medication regimen, consider repeat TTE, and provide patient-centered counseling regarding risk of a future pregnancy. Heart failure may complicate pregnancy either secondary to an existing pre-pregnancy cardiomyopathy or as a result of peripartum cardiomyopathy. In women with history of heart failure or cardiomyopathy, including previous peripartum cardiomyopathy, patient-centered counseling regarding contraception and the risks of cardiovascular deterioration during pregnancy should be provided (Class I, LOE C-LD) Peripartum cardiomyopathy (PPCM) is defined as systolic dysfunction, typically LVEF < 45%, often with LV dilation, occurring in late pregnancy or early postpartum with no other identifiable etiology. PPCM occurs worldwide, with the highest incidences in Haiti, Nigeria, and South Africa. Other clinical risk factors include maternal age > 30 years, African ancestry, multiparity, multigestation, preeclampsia/eclampsia, anemia, diabetes, obesity, and prolonged tocolysis.   The pathogenesis of peripartum cardiomyopathy is complex and it is likely a multifactorial process.  The combination of hemodynamic changes of pregnancy, inflammation of the myocardium, hormonal changes, genetic factors, and an autoimmune response have all been proposed as possible mechanisms and these may certainly be interrelated. While pregnancy is generally well-tolerated in women with cardiomyopathy and NYHA class I status pre-pregnancy, clinical deterioration can occur and so counseling a...