Cardionerds: A Cardiology Podcast

In this episode, CardioNerds (Amit Goyal), ACHD series co-chair,  Dr. Josh Saef (ACHD fellow at University of Pennsylvania) and episode lead fellow, Dr. Brynn Connor (Pediatric Cardiology fellow at Lucile Packard Children's Hospital at Stanford) are joined by Dr. Maan Jokhadar (Advanced heart failure and adult congenital heart disease specialist at Emory University) to discuss transposition of the great arteries. Audio editing by CardioNerds Academy Intern, Dr. Maryam Barkhordarian. For a brief review of the basic anatomy and physiology of D-TGA, check-out this great video by Dr. Maan Jokhadar! 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 Claim free CME for enjoying this episode! Disclosures: None Pearls • Notes • References • Guest Profiles • Production Team 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! https://www.youtube.com/watch?v=Ifu8nVtXT_c Pearls (1) In D-TGA following an atrial switch operation, the right ventricle IS the systemic ventricle! (2) Evaluation of systemic right ventricular function often requires use of both transthoracic echocardiography and cardiac MRI. (3) Use of medical heart failure therapies should be individualized, without any proven long-term mortality benefit and potential unique complications in this patient population (i.e. SA node dysfunction).  Show notes D-transposition of the great arteries (D-TGA) is one of the most common forms of cyanotic congenital heart disease presenting in the newborn period. Anatomically, d-transposition of the great arteries is characterized by atrioventricular concordance and ventriculoarterial discordance, such that the aorta arises from the morphologic right ventricle and pulmonary artery arises from the morphologic left ventricle. The resultant physiology is that of a parallel circulation, with deoxygenated blood recirculating in the systemic circulation (via the RA-RV) and oxygenated blood recirculating in the pulmonary circulation (via the LA-LV). At birth, this invariably results in cyanosis, with survival dependent upon adequate mixing of the two circulations via an atrial or ventricular level defect. Prior to surgical advances in the late 1950s, this lesion was uniformly fatal, with most infants dying before their first birthday. The subsequent development of the Senning and Mustard atrial-level repairs led to good immediate outcomes and improved long-term survival. However, following these “physiologic” types of repair, patients are far from cured, with several long-term established complications, including (1) dysfunction of the systemic right ventricle, (2) tricuspid regurgitation (the systemic atrioventricular valve), (3) atrial and ventricular arrhythmias, and (4) systemic and pulmonary venous baffles leaks and obstruction. These complications ultimately lead to substantial morbidity and premature mortality, with ACHD providers facing unique challenges in the medical and surgical management of this heterogenous patient population. 1. What are the basic anatomic features of d-transposition of the great arteries (d-TGA)?

CardioNerds (Amit Goyal and Daniel Ambinder) join Dr. Patrick Azcarate and Dr. Antoinette Birs from the University of California San Diego along with a guest host Dr. Christine Shen from Scripps Health for a hike along Torrey Pines. They discuss a case of a 30-year-old man with a history of malignant thymoma status post two partial lung resections and radiation for pleural/pulmonary metastasis, as well as a history of myasthenia gravis on rituximab, and Ig deficiency on IVIG presents with progressive exertional chest pain. We focus on the differential diagnosis of patients with a history of chest radiation exposure and dive into the complex management and surveillance for patients with radiation associated cardiac disease (RACD). The E-CPR is provided by Dr. Milind Desai (multimodality cardiovascular imaging expert, Director of Clinical Operations, Director of Center for HCM, Medical Director for Center for Aortic Diseases, and Medical Director for Center for Radiation Heart Disease at the Cleveland Clinic). Claim free CME just for enjoying this episode!  Disclosures: NoneJump to: Pearls - Notes - 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! Case Media TTE TTE TTE TTE AP Cranial Pre PCI LAO Caudal Pre PCI RAO Caudal Pre PCI RAO Cranial Pre PCI AP cranial Post PCI Episode Teaching Pearls - radiation associated cardiac disease Radiation-associated cardiac disease (RACD) is a heterogeneous disease that can manifest several years, or decades following radiation exposure to the chest and is associated with high morbidity and mortality. Given the non-specific or vague symptoms, one of the greatest challenges for this patient population may be diagnosing RACD which requires high clinical suspicion. In patients with a history of chest radiation, we should remember to ask three important questions: 1. What was the total dose of radiation given? 2. How long ago was radiation therapy administered? 3. Was the heart exposed?A cumulative dose of >30 Gray (Gy) chest radiation significantly increases the risk of RACD long-term, but cardiac damage can occur at even lower doses. Effects from chest radiation can take years to become clinically detectable. Screening for radiation induced coronary artery disease with stress testing should start 5 years following XRT and in low-risk patients (without risk factors for typical coronary artery disease) and continue at 5-year intervals, and 2-year intervals in high-risk patients. Valvular heart disease surveillance should begin 10 years post XRT and can be accomplished with echocardiogram. Regarding revascularization planning, a Heart Team approach is recommended. However, percutaneous intervention is preferred over bypass surgery in most cases. Notes - radiation associated cardiac disease 1. What is Radiation-Associated Cardiac disease (RACD)? A spectrum of disease that can affect any part of the heart and typically develops anywhere from 5 to 20 years after radiation. It may present with non-specific or vague symptoms. Manifestations include myocarditis, pericarditis (typically early in the course) and well as long term sequela such as myocardial fibrosis, valvular heart disease (regurgitation or stenosis), pericardial disease, vasculopathy (CAD), conduction system disease. Radiation may impact any tissue of the heart: Vascular: microvascular, coronary artery disease, macrovascular (ascending aorta) Valvular: has a longer latency ~10-20 years with the left sided valves being more commonly affected; Aorto-mitral curtain thickening/calcification is a hallmark of previous heart radiation and associated with higher mortality  Conduction: Sick sinus syndrome, AV nodal block,

Cardiogenic shock is a state of cardiac dysfunction leading to hemodynamic instability and end-organ hypoperfusion. At the bedside, clinicians take various data points – from history to physical exam to labs/imaging and invasive hemodynamics – to make an assessment of the etiology, severity and management of cardiogenic shock. Health systems have developed “Shock Teams” to collectively interpret this data to deliver the optimal care for each patient. In this episode, Dr. Mark Dela Cruz (Advanced Heart Failure and Transplant Fellow at University of Chicago), CardioNerds Critical Care Series Co-Chairs Dr. Mark Belkin (Advanced Heart Failure and Transplant Fellow at University of Chicago) and Dr. Karan Desai (General Cardiology Fellow at University of Maryland), and CardioNerds Co-Founder Dr. Daniel Ambinder (Structural Fellow at Johns Hopkins Hospital) join Dr. Anu Lala (Director of the AHFT Fellowship, Associate Professor of Medicine and Cardiology at Mount Sinai Hospital and Deputy Editor of the Journal of Cardiac Failure) on a Shock Team Call! Dr. Lala leads us in a discussion of the systematic bedside evaluation of cardiogenic shock, from understanding a patient’s physiology and their humanity, to manage their illness and make a rapid but thorough evaluation when on the Shock Call. Audio editing and episode introduction by CardioNerds Academy Intern, Hirsh Elhence. Claim free CME for enjoying this episode! Disclosures: None Pearls • Notes • References • Guest Profiles • Production Team CardioNerds Cardiac Critical Care PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls and Quotes - Shock Team Call The classic definition of cardiogenic shock was derived from studies of left ventricular dysfunction in the setting of acute myocardial infarction. With the advent of early primary percutaneous coronary intervention (PCI) and trends in cardiovascular disease risk factors, the prevalence of non-ischemic etiologies of cardiogenic shock (e.g., progression/exacerbation of chronic heart failure) has increased significantly.  The diagnosis of cardiogenic shock should be made by integrating key clinical features such as physical exam findings and objective laboratory and imaging data in an iterative fashion. Focused transthoracic echocardiography and invasive hemodynamics are helpful in further characterizing the type of shock and the etiology of cardiogenic shock. Early evaluation of right ventricular function is an important aspect of cardiogenic shock evaluation. Significant RV dysfunction portends poor prognosis, can necessitate more aggressive interventions, and defines the types of mechanical circulatory support necessary.  Classification systems for cardiogenic shock help to further characterize a patient’s illness severity. The INTERMACS and SCAI classification systems are particularly designed to allow for early identification of patients who would most benefit from more advanced interventions such as vasoactive medications or mechanical circulatory support.  Shock Team Calls improve mortality for patients in cardiogenic shock. By rapidly bringing together heart failure specialists, interventional cardiologists, cardiothoracic surgeons, and critical care physicians, appropriate interventions and contingencies can be discussed and quickly implemented without adding delays to patient care. Importantly, these calls should attempt to integrate patient goals of care in order to best serve our patients.  Show notes - Shock Team Call 1. What is the classic definition of cardiogenic shock? The classic definition of cardiogenic shock was initially derived from the Shock Trial published in 1999 (1). In this trial, cardiogenic shock was defined as shock due to left ventricular dysfunction occurring in the setting of acute myocardial infar...

In this episode, CardioNerds (Amit Goyal), Cardio-OB series co-chair and UT Southwestern cardiology fellow, Dr. Sonia Shah, and episode lead fellow, Dr. Laurie Femnou (UT Southwestern) are joined by Dr. Michael Luna (UT Southwestern) to discuss cardiovascular interventions during pregnancy. We discuss practical considerations for performing coronary angiography and valvular interventions in the pregnant patient, the timing and indication of procedures, and ways to minimize radiation exposure to both mom and baby. Audio editing by CardioNerds Academy Intern, Hirsh Elhence. 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 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! Pearls- Cardiac Interventions during Pregnancy Attempt should be made to manage pregnant patients with valvular disease with medical therapy, and cardiac interventions during pregnancy should be considered a last resort.Ideally, procedures in the gravid patient should be performed after 20 weeks gestation to minimize fetal risk. Specific ways to minimize radiation to the pregnant patient and fetus in the catheterization lab include: using an abdominal shield, radial access for coronary procedures, proper positioning of the C-arm to avoid extreme angulation, using collimation, and minimizing fluoroscopic time, frame rate, and use of cine-acquisition. When appropriate, intracoronary imaging modalities (ie. IVUS or OCT) should also be considered.Fetal monitoring should be performed during any cardiac intervention in the pregnant patientMultidisciplinary involvement and contingency planning are critical for the success of any high-risk cardiac intervention in the pregnant patient. Quatables - Cardiac Interventions during Pregnancy “Meetings including all providers— our cardiac surgical colleagues, cardiac anesthesiologists, and our obstetrics team—in the care of [pregnant] patients has to be had well ahead of a cardiac procedure to plan every detail.” Show notes - Cardiac Interventions during Pregnancy 1. What are special considerations for performing a balloon valvuloplasty in a pregnant patient with mitral stenosis?  In pregnant patients with severe mitral stenosis who cannot be adequately managed with medical therapy, percutaneous balloon mitral valvuloplasty (PMBV) is the treatment of choice given the high risk of morbidity and fetal loss with cardiac surgery.Ideally, procedures in the gravid patient should be performed after 20 weeks gestation to minimize risk to the fetus. Assessment of valve anatomy and consideration of the Wilkin’s score are especially important in pregnant patients to minimize the risk of peri-procedural complications.PBMV should performed at experienced centers with cardiac surgery and MFM available.Complications of PBMV are rare but include atrial perforation, cardiac tamponade, arrhythmias, emboli, mitral regurgitation, hypotension and maternal death. Mechanical support should be readily available and a delivery strategy in place in case there is sudden maternal or fetal deterioration. 2. What are ways to minimize radiation exposure in the catheterization lab to the pregnant patient and fetus? The general principle for imaging during pregnancy is similar to imaging for the general population, with the goal of radiation exposure being as low as reasonably achievable (ALARA). The mean radiation exposure to the unshielded abdomen is 1.

Dr. Michelle Kittleson, a leading expert in cardiology, discusses challenging cases of hypertrophic cardiomyopathy. Topics covered include advising patients with a family history of HCM, shared decision making in treatment options, use of implantable loop recorders, interpretation of imaging studies, and the global perspective in HCM patient care. Anticoagulation in HCM is also highlighted.

CardioNerds (Amit Goyal and Daniel Ambinder) join CardioNerds Ambassadors Dr. Pablo Sanchez (FIT, Stanford University) and Dr. Christine Shen (FIT, Scripps Clinic) for a discussion with Dr. Bob Harrington (Interventional Cardiologist, Professor of Medicine, and Chair of the Department of Medicine at Stanford University) about diversity and inclusion in the field of cardiology. This episode discusses Dr. Harrington’s broader approach to mentorship, sponsorship, and allyship; and particularly how (and why) he used his position as the president of the American Heart Association to advocate against all-male panels, or “manels.” Listen to the episode to learn the background and motivations behind his evidence-based efforts to make Cardiology a more inclusive field. Special message by California ACC State Chapter President, Dr. Jamal Rana. 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 - Diversity and Inclusion https://youtu.be/SnUadVRhH70 Quotables - Diversity and Inclusion “If senior men don’t change the field, it’s not going to change. We have the senior positions. We have to change it.”“You’re missing talent. You’re missing talent of the women who have decided not to go into Cardiology. I say to a lot of my male colleagues...don’t you care about the health of our specialty? Don’t you want the very best people going into it?”“How great is that--to open up an artery in the middle of the night?... What could be better than that?...Why would you not want to be a cardiologist? Frankly, maybe the field is not so friendly to women...And that bothers me greatly because I love the specialty.”“To those who have been given much, much is expected. That’s what people like me should do.”Dr. Bob Harrington Show notes - Diversity and Inclusion What are the gender disparities in the field of Cardiology? 45.8% of residents and fellows in ACGME-accredited programs are women. 14.9% of cardiologists are women. 8% of interventional cardiologists are women [1]. 30.6% of male faculty were full professors, while 15.9% of female faculty are full professors [2].Men are more likely to be influenced by positive attributes of a field, while women are more likely to be influenced by negative attributes [3].3% of percutaneous coronary interventions in the United States are performed by female operators [4]. What is mentorship, sponsorship, and allyship? A mentor provides advice and helps someone develop a skill.A sponsor is an advocate who helps someone secure career advancement opportunities.An ally partners with people, utilizing their power and influence to champion the rights of others [5].According to some studies, women report less sponsorship experiences than men. Additionally, in women it seems to translate less frequently into experiences that further their career (speaking engagements, serving on editorial boards, etc) [6].“I’m a mentor to a few people, I'm a sponsor to many, and I’m an ally to all.” - Dr.

CardioNerds (Amit Goyal and Daniel Ambinder), are joined by guest host Dr. Alex Pipilas (CardioNerds Ambassader, Boston University), and Cleveland Clinic fellows, Dr. Gary Parizher, Dr. Ambreen Ali, and Dr. Tiffany Dong. They discuss a case of an 18-year-old man with Autism Spectrum Disorder presented with advanced nonischemic dilated cardiomyopathy. Due to anxiety, he was unable to tolerate right heart catheterization, and the initial evaluation for advanced heart failure therapies was deferred. With assistance from a multidisciplinary team, catheterization was successful, and he underwent cardiac transplantation. Faculty experts, Dr. Richard Dane Meredith (Cardiovascular Imaging, Mission healthcare), Dr. Julie Niezgoda (Congenital Cardiac Anesthesiologist, CCF), and Dr. Ran Lee (Critical Care Cardiology and Advanced HF/Transplant Cardiologist, CCF) provide the E-CPR for this episode. Audio editing by CardioNerds Academy Intern, Dr. Leticia Helms. Claim free CME just for enjoying this episode!  Disclosures: NoneJump to: Pearls - Notes - 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! Case Media Episode Teaching Pearls - Heart Failure with Autism Spectrum Disorder Autism spectrum disorder should not be regarded as a contraindication to organ transplantation.Respect for patient discomfort with procedures, and efforts to mitigate that discomfort, are essential.A multidisciplinary team approach, especially one utilizing allied health support services, is important to provide care to adolescent patients with advanced organ dysfunction, particularly those with developmental disabilities. Notes - Heart Failure with Autism Spectrum Disorder Autism spectrum disorder (ASD) is a developmental disability characterized by impairments in social interaction and the presence of restricted, repetitive patterns of behaviors, interests, or activities (2). In 2016 the CDC estimated one in 54 children age 8 had ASD (3). Despite ASD’s prevalence, studies of organ transplantation in children and adolescents with developmental disabilities are lacking. Guidelines from the International Society for Heart Lung Transplantation indicate that heart transplantation cannot be recommended in patients suffering from severe cognitive-behavioral disabilities (4). However, the definition of “severe” is not clear, so the assessment of severity of a cognitive impairment, as well as whether the impairment constitutes a contraindication to organ transplantation, falls to healthcare providers on a case-by-case basis.             Cardiac transplantation in a patient with ASD has been documented previously (5). Nonetheless our case represents an important example of advocacy for lifesaving care in patients with developmental disability. Without any one component of the team taking care of our patient, including physicians and allied healthcare providers, he would have died of refractory cardiogenic shock. However, with individualized care and a multidisciplinary combined effort, his providers were able to overcome the obstacles posed by his ASD and deliver indicated interventions. References - Heart Failure with Autism Spectrum Disorder 1.  Baran, David A., et al. "SCAI clinical expert consensus statement on the classification of cardiogenic shock" Catheterization and Cardiovascular Interventions 94.1 (2019): 29-37. 2. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 5th edition. Arlington, VA: American Psychiatric Association, 2013. 3. Baio J, Wiggins L, Christensen D, et al. Prevalence of Autism Spectrum Disorder among children aged 8 years - Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2014. MMWR Surveillance Summaries 2018; 67:1-23. 4.

Pregnancy is a hypercoagulable state associated with increased risk of thromboembolism. Managing anticoagulation during pregnancy has implications for both the mother and the fetus. CardioNerd Amit Goyal joins Dr. Akanksha Agrawal (Cardiology Fellow at Emory University), Dr. Natalie Stokes (Cardiology Fellow at UPMC and Co-Chair of the Cardionerds Cardio-Ob series), and Dr. Katie Berlacher (Program Director of the Cardiovascular Disease Fellowship and Director of the Women’s Heart Program at UPMC) as they discuss the common indications for anticoagulation and their management before, during, and after pregnancy. In this episode, we focus on management of pregnant patients with mechanical valves and venous thromboembolism. Audio editing by CardioNerds Academy Intern, Dr. Maryam Barkhordarian. Pearls • Notes • References • Guest Profiles • Production Team 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! Pearls- Pregnancy and Anticoagulation Pregnancy is a hypercoagulable state. Pregnancy-associated VTE is a leading cause of maternal morbidity and mortality.The use of anticoagulation requires a balance between the risks and benefits to the mother and her fetus.The agent of choice for anticoagulation during pregnancy depends on the indication, pre-pregnancy dose of vitamin K antagonist (VKA), and the trimester of pregnancy. For instance, patients with mechanical heart valves, warfarin is generally recommended in the first trimester if the daily dose is less than 5 mg and as the first option for all patients with mechanical valves in the 2nd and 3rd trimester. Use of direct oral anticoagulants (DOACs) has not been systematically studied, they do cross the placenta and their safety remains untested.Warfarin crosses the placenta but is not found in breast milk. LMWH does not cross the placenta and is not found in breast milk. Thus, both these agents can be used by a lactating mother. Quatables - Pregnancy and Anticoagulation “[We] can’t highlight enough that good communication and documentation is vital in such situations” says Dr. Berlacher while discussing the role of a multidisciplinary team including cardiologists, obstetricians and fetal medicine physicians in taking care of a pregnant patient on anticoagulation. “What I love about cardio-obstetrics is that we really can help women in a time that is so important in their life…this is one of the most memorable times in their life..” says Dr. Berlacher when asked what makes your heart flutter about cardio-obstetrics. “Knowledge is power...not just for providers, but also for the patients” says Dr. Berlacher emphasizing the importance of clear communication between physicians and patients. Show notes - Pregnancy and Anticoagulation 1. What makes pregnancy a hypercoagulable state? Pregnancy is a hypercoagulable state associated with higher risk of thromboembolic phenomenon. The three components of Virchow’s triad: hypercoagulability, stasis, and endothelial injury are all present during pregnancy. This leads to a 5-fold increased risk of venous thromboembolism (VTE) during pregnancy that persists for 12 weeks postpartum. The risk for VTE seems to be highest in the first 6 weeks postpartum, with a higher prevalence of clot in the left lower extremity.There are additional risk factors for developing VTE in the postpartum period besides pregnancy itself, and this includes but is not limited to preeclampsia, emergent c-section, hypertension, smoking, and postpartum infection.Choosing anticoagulant therapies during pregnancy involves a fine balance between the risks and benefits to both the mother and fetus. A multidisciplinary team involving the obstetrician, cardiologist, and maternal-fetal medicine team is critical to guide anticoagulation in pregnanc...

The CardioNerds are thrilled to launch The Cardiac Critical Care Series! The series Co-Chairs – Dr. Mark Belkin (Advanced Heart Failure FIT, U Chicago), Dr. Yoav Karpenshif (FIT, U Penn), Dr. Eunice Dugan (CardioNerds Academy Chief Fellow and FIT, Cleveland Clinic), and Dr. Karan Desai (CardioNerds Academy Editor and FIT, U Maryland) - join CardioNerds Co-Founders, Amit Goyal and Daniel Ambinder to delve into high-yield topics in critical care cardiology. We kickstart this series with one of the early pioneers and national leaders in cardiac critical care – Dr. Jason Katz, Director of Cardiovascular Critical Care and Co-Director of Mechanical Circulatory Support and the CICU at Duke University Medical Center. In this episode, we learn about Dr. Katz’s career path and what motivated him to train in Critical Care Cardiology. He shares early struggles, notable changes in this field’s nascent period, and ongoing challenges in training and practice. We discuss collaboration with other cardiac and non-cardiac specialties and their importance in comprehensive care. Furthermore, we discuss how to advance critical care research, including the Critical Care Cardiology Trials Network and future randomized controlled trials to inform our practice and develop standardized protocols. In this small but rapidly growing field, we learn there is much to discover together. Audio editing by CardioNerds Academy Intern, Hirsh Elhence. Claim free CME for enjoying this episode! Disclosures: None Pearls • Notes • References • Guest Profiles • Production Team CardioNerds Cardiac Critical Care PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls and Quotes “I think it's really important not to be afraid of change in order to potentially succeed [...] it's okay to not entirely know what you want to do.” - Dr. Katz when sharing his non-direct career path in a novel field.“There is no greater team sport in cardiology than Cardiac Critical Care” and “I oftentimes think of the Critical Care Cardiologist as sort of the conductor that helps to orchestrate [the team]...” - Dr. Katz when discussing the importance of multidisciplinary teams and need to collaborate with other cardiac and non-cardiac sub-specialties.Many general surgical or medical residency/fellowship graduates are not comfortable caring for patients in the critical care setting. There is a need to revamp critical care training without significantly prolonging training time in order to complement and enhance our current workforce to care for complex, critically ill cardiac patients.“I don't think there's necessarily a one size fits all model, and I think we should be malleable or adaptable to the needs of our trainees and the needs of our patients.” - Dr. Katz when discussing training pathways in Critical Care Cardiology or combining Critical Care with other subspecialties like Interventional Cardiology or Advanced Heart Failure.Dr. Katz suggests that when choosing a Critical Care Cardiology training program: “consider geography, the flexibility of the curriculum, the overall fellowship and social experience, and the clinical setting. Everything that's really important to choosing a cardiology fellowship is more important in my mind than if they actually have a standardized, cardiac critical care pathway.” Show notes 1. What are some recent changes in the field of Critical Care Cardiology? Compared to even just a decade ago, there is a growing interest from medical students to young faculty in pursuing a career in critical care cardiology.At the same time there is evidence that the patient demographics in our CICUs are changing, including more multi-organ dysfunction and many non-cardiac diagnoses. In a recent paper from the Critical Care Cardiology Trials Network (CCCTN),

CardioNerds Tommy Das (Program Director of the CardioNerds Academy and cardiology fellow at Cleveland Clinic) and Rick Ferraro (Director of CardioNerds Journal Club and cardiology fellow at the Johns Hopkins Hospital) join Dr. Erin Michos (Associate Professor of Cardiology at the Johns Hopkins Hospital and Editor-In-Chief of the American Journal of Preventative Cardiology) for a discussion about the effect of DHA and EPA on triglycerides and why DHA/EPA combinations may have exhibited limited benefits in trials. This episode is part of the CardioNerds Lipids Series which is a comprehensive series lead by co-chairs Dr. Rick Ferraro and Dr. Tommy Das and is developed in collaboration with the American Society For Preventive Cardiology (ASPC). Relevant disclosures: 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! Pearls The best intervention for heart disease is prevention! The InterHeart trial showed that 9 modifiable risk factors (dyslipidemia, smoking, hypertension, diabetes, abdominal obesity, dietary patterns, physical activity, consumption of alcohol, and psychosocial factors) predict 90% of acute myocardial infarction. So many acute events can be prevented1.Atherosclerotic vascular disease events increase across a range of triglyceride levels, even from 50-200mg/dL. So even in a relatively normal range, lower triglycerides seem to be better. Over ¼ of US adults have triglycerides over 150.While 8% of US adults take fish oil supplements, multiple meta-analyses have failed to show any benefit to the use of dietary omega-3 supplementation2. Dietary supplements these are not meant for medical use and are not studied or regulated as such! Show notes 1. What are DHA and EPA? DHA, or docosahexaenoic acid, and EPA, or eicosapentaenoic acid, are n-3 polyunsaturated fatty acids, also known as omega-3 fatty acids. These compounds have been of considerable interest for over two decades given observed association of high dietary omega-3 fatty acid intake with reduced cardiovascular events3. As both are important omega-3 fatty acids, trials on the benefits of DHA and EPA have often focused on the two compounds in combination. 2. What was the GISSI-Prevenzione Trial and why was it Important? GISSI-Prevenzione trial (Lancet 1999), was one of the earliest trials to study DHA and EPA4. In this trial, the authors evaluated the effect of omega-3 supplementation as a combination pill of DHA and EPA on cardiovascular events and death in patients with recent myocardial infarction (the last three months). Over a 3.5-year follow-up period, participants treated with DHA/EPA combination experienced a significant reduction in death, nonfatal MI, and stroke.As this was an early trial, patients were largely not on statins, as these were not supported at the time of study initiation (Only 5% were on cholesterol-lowering medications at baseline, and only 45% were on cholesterol-lowering therapy at study completion). The benefits seen in this trial may not extend to modern practice with patients on contemporary background therapy.The trial participants were also not representative of our modern patients for a variety of other reasons. 85% of participants in the trial were men. 42.2% of patients in EPA/DHA arm were current smokers, and 35.4% were prior smokers. Only 14.2% of patients had diabetes and 14.7% with BMI >30.Notably, the decrease in triglycerides in this trial was only 3%, implying that triglyceride lowering did not entirely explain the benefit in cardiovascular events seen. 3. What about the data after the GISSI-Prevensione Trial? After this positive trial for DHA/EPA in combination, subsequent trial data in support of DHA/EPA has been less robust.