Cardionerds: A Cardiology Podcast

CardioNerds (Amit Goyal & Carine Hamo) discuss the past, present, and future of Women's Heart Health & Women in Cardiology with Dr. Nanette Wenger, Professor of Medicine in the Division of Cardiology at the Emory University School of Medicine. Dr. Wenger is a true leader in the field of women’s heart health and a strong proponent for women in cardiology and medicine. Her passion, dedication, and advocacy have inspired countless trainees to carry this torch and continue to build on her truly impactful work. Special introduction by Dr. Martha Gulati. This is a special encore in recognition of the Go Red campaign and celebration of women's health. Collect free CME/MOC credit for enjoying this episode!  Episode graphic by Dr. Carine Hamo The Cardionerds CV prevention series  includes in-depth deep dives on so many prevention topics including the ABCs of prevention, approach to obesity, hypertension, diabetes mellitus and anti-diabetes agents, personalized risk and genetic risk assessments, hyperlipidemia, women’s cardiovascular prevention, coronary calcium scoring and so much more! CardioNerds Prevention PageCardioNerds Women's Cardiovascular Health PageCardioNerds Episode PageSubscribe to our newsletter- The Heartbeat CardioNerds AcademyCardionerds Healy Honor RollCheck out CardioNerds SWAG!Become a CardioNerds Patron! This episode initially ran as part of the CardioNerds Prevention Series which we produced in collaboration with the American Society for Preventive Cardiology! The ASPC is an incredible resource for learning, networking, and promoting the ideals of cardiovascular prevention! Cardionerds Cardiovascular Prevention Series References and Links 1. Wenger NK (2005) Women in cardiology: The US experience. Heart. 2. Douglas PS, Rzeszut AK, Noel Bairey Merz C, Duvernoy CS, Lewis SJ, Walsh MN, Gillam L (2018) Career preferences and perceptions of cardiology among us internal medicine trainees factors influencing cardiology career choice. JAMA Cardiol. 3. Wenger NK, Speroff L, Packard B (1993) Cardiovascular Health and Disease in Women. N Engl J Med. 4. Burgess S, Shaw E, Zaman S (2019) Women in Cardiology. Circulation. Meet Dr. 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. Carine Hamo, MDAmit Goyal, MD

CardioNerd Amit Goyal is joined by Dr. Erika Hutt (Cleveland Clinic general cardiology fellow), Dr. Aldo Schenone (Brigham and Women’s advanced cardiovascular imaging fellow), and Dr. Wael Jaber (Cleveland Clinic cardiovascular imaging staff and co-founder of Cardiac Imaging Agora) to discuss nuclear and complimentary multimodality cardiovascular imaging for the evaluation of coronary ischemia. Show notes were created by Dr. Hussain Khalid (University of Florida general cardiology fellow and CardioNerds Academy fellow in House Thomas). To learn more about multimodality cardiovascular imaging, check out Cardiac Imaging Agora!  Collect free CME/MOC credit for enjoying this episode!  CardioNerds Multimodality Cardiovascular Imaging PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll Subscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Show Notes & Take Home Pearls Five Take Home Pearls 1. We can broadly differentiate non-invasive testing into two different categories—functional and anatomical. Functional tests allow us to delineate the functional consequence of coronary disease rather than directly characterizing the burden of disease. Anatomical tests such as coronary CTA, on the other hand, allow us to directly visualize obstructive epicardial disease. 2. In general PET imaging provides higher quality images than SPECT imaging for a variety of reasons, including a higher “keV” of energy in PET radiotracers 3. If using a SPECT camera, we should use cameras that have attenuation correction. Without attenuation correction, the specificity of a SPECT camera drops to 50-60%. 4. In evaluating ischemic heart disease, cardiac nuclear imaging can provide a wide range of information including myocardial perfusion (rest and stress), ejection fraction assessment (rest and stress), absolute myocardial blood flow with quantitative flow reserve in all coronary territories (PET), assessment of myocardial viability (PET), and calcium score with CT attenuation correction. 5. To select the best non-invasive test, we should consider a variety of factors such as pretest probability of obstructive epicardial disease, patient-specific factors (e.g., ability to exercise) and whether a functional or an anatomical test will provide the best answer for our clinical question. Detailed Show Notes What are the basic non-invasive testing categories for evaluation of coronary artery disease?  We have a variety of different non-invasive testing modalities that can be broadly separated into functional tests and anatomical tests.  The basic principle underlying functional stress testing is to induce ischemia or coronary vasodilation (discussed below), followed by a functional assessment by different techniques (e.g., EKG, echocardiography, radionuclide imaging) to detect flow-limiting obstructive coronary artery disease. These tests delineate the functional consequence of the coronary disease, rather than directly characterizing the burden of disease itself.  Functional tests can also allow us to assess the nature of a patient’s symptoms. For example, by having a patient exercise on a treadmill we can evaluate whether we can reproduce a patient’s chest pain syndrome. Anatomical tests allow us to visualize the presence of obstructive epicardial disease. For example, obtaining a Coronary Computed Tomography Angiography (CCTA) for a patient with chest pain would allow you to directly visualize possible obstructive epicardial disease.   How do we induce ischemia for functional stress testing?  To induce ischemia (and/or coronary vasodilation), we have many different stressors that can be broadly separated into exercise stressors and pharmacologic stressors. Treadmill exercise via standardized protocols is the most common method for inducing ischemia and has the advantage of assessing functional capacity,

CardioNerds (Carine Hamo, Amit Goyal and Daniel Ambinder) discuss personalized risk assessment for cardiovascular prevention with Dr. Amit Khera, the immediate past president for the American Society for Preventive Cardiology and Director of the Preventive Cardiology and Professor of Medicine at the University of Texas, Southwestern Medical School in Dallas, Texas. They dive into an illuminating discussion about traditional and next generation personalization of risk assessment which covers the need for personalization, traditional risk stratification, applying risk enhancing factors for decision making, biomarkers, familial hypercholesterolemia, and the use of -Omics. This episode is the 13th and final part of our in-depth prevention series produced in collaboration with the American Society for Preventive Cardiology! Stay tuned for a bonus segment at the end of the episodeas we talk to Dr. Ankur Kalra, interventionist at the Cleveland Clinic, Podcast host of Parallax by Ankur Kalra, and founder of the non-profit startup, makeadent.org for a discussion about the CHAI (Cardiovascular Health in Asian Indians) Collaborative, an initiative that aims to identify genetic markers of heightened atherosclerosis in South Asians. Episode graphic by Dr. Carine Hamo 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 Coming soon! Cardionerds Cardiovascular Prevention Series The Cardionerds CV prevention series  includes in-depth deep dives on so many prevention topics including the ABCs of prevention, approach to obesity, hypertension, diabetes mellitus and anti-diabetes agents, personalized risk and genetic risk assessments, hyperlipidemia, women’s cardiovascular prevention, coronary calcium scoring and so much more! We are truly honored to be producing the Cardionerds CVD Prevention Series in collaboration with the American Society for Preventive Cardiology! The ASPC is an incredible resource for learning, networking, and promoting the ideals of cardiovascular prevention! This series is kicked off by a message from Dr. Amit Khera, President of the American Society for Preventive Cardiology and President of the SouthWest Affiliate of the American Heart Association. Guest Profiles Amit Khera, MD, MSc, FACC, FAHA, FASPC Dr. Amit Khera is Professor of Medicine at the University of Texas, Southwestern Medical School in Dallas, Texas where he serves as Director of the Preventive Cardiology, and holder of the Dallas Heart Ball Chair in Hypertension and Heart Disease.  He is also currently President of the American Society for Preventive Cardiology and President of the SouthWest Affiliate of the American Heart Association. His clinical and research interests include the primary and secondary prevention of coronary artery disease, focusing on risk assessment and risk factor modification in those with premature and familial disease. Dr. Khera received his undergraduate degree in American History from the University of Pennsylvania, with magna cum laude honors. He obtained his medical degree from Baylor College of Medicine where he served as class president and was inducted into the Alpha Omega Alpha honor medical society. He completed an Internal Medicine Residency at Brigham and Women’s Hospital, Harvard Medical School, followed by a Cardiology Fellowship at the University of Texas, Southwestern Medical Center. He also completed his Masters degree in Epidemiology at the Harvard School of Public Health. He has published over 150 publications in the field of preventive cardiology and has served on numerous local and national committee and leadership roles for the American Heart Association, American College of Cardiology, and American Society for Preventive Cardiology.

CardioNerds (Amit Goyal and Daniel Ambinder) are joined by Cleveland Clinic cardiology fellow Dr. Gregory Ogunnowo to discuss hypertension with Dr. Luke Laffin, cardiology faculty in the division of Preventive Cardiology and Rehabilitation and Medical Director of Cardiac Rehabilitation at the Cleveland Clinic. Part 2 of this discussion covers the evaluation for secondary causes of HTN, approach to resistant HTN, interventional anti-hypertensive procedures, and a note on cardiac rehabilitation. Part 1 covered the definition of hypertension, correct measurement of blood pressure, nonpharmacologic HTN management, initial choice of BP agents, and hypertensive disorders of pregnancy. Episode graphic by Dr. Carine Hamo 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 Coming soon! Cardionerds Cardiovascular Prevention Series The Cardionerds CV prevention series  includes in-depth deep dives on so many prevention topics including the ABCs of prevention, approach to obesity, hypertension, diabetes mellitus and anti-diabetes agents, personalized risk and genetic risk assessments, hyperlipidemia, women’s cardiovascular prevention, coronary calcium scoring and so much more! We are truly honored to be producing the Cardionerds CVD Prevention Series in collaboration with the American Society for Preventive Cardiology! The ASPC is an incredible resource for learning, networking, and promoting the ideals of cardiovascular prevention! This series is kicked off by a message from Dr. Amit Khera, President of the American Society for Preventive Cardiology and President of the SouthWest Affiliate of the American Heart Association. Guest Profiles Dr. Luke Laffin, serves as cardiology faculty in the division of Preventive Cardiology and Medical Director of Cardiac Rehabilitation at the Cleveland Clinic. Dr. Laffin attended medical school at Vanderbilt University School of Medicine. He trained in internal medicine and cardiology at the University of Chicago where he completed a dedicated fellowship in hypertensive diseases. He is a clinical specialist in hypertension designated by the American Society of Hypertension – which has now merged with the AHA. Dr. Gregory Ogunnowo is a cardiology fellow at the Cleveland Clinic. He completed medical school at the University of South Carolina School of Medicine in Columbia, South Carolina. He went on to complete internal medicine residency at Washington University School of Medicine in St. Louis where he stayed on as faculty in the Department of Hospital Medicine for a year prior to pursing fellowship. His interests include outcomes research in interventional cardiology and medical education In his spare time, Greg enjoys traveling, exercising, and experiencing new cultures through their food. When he’s not in the hospital, you can find Greg planning a trip with close friends and family. References and Links Coming soon! Luke Laffin MDGreg Ogunnowo, MDAmit Goyal, MDDaniel Ambinder, MD

CardioNerds (Amit Goyal and Daniel Ambinder) are joined by Cleveland Clinic cardiology fellow Dr. Gregory Ogunnowo to discuss hypertension with Dr. Luke Laffin, cardiology faculty in the division of Preventive Cardiology and Rehabilitation and Medical Director of Cardiac Rehabilitation at the Cleveland Clinic. Part 1 of this discussion covers the definition of hypertension, correct measurement of blood pressure, nonpharmacologic HTN management, initial choice of BP agents, and hypertensive disorders of pregnancy. Be sure to follow-up with Part 2 to learn about evaluation for secondary causes of HTN, approach to resistant HTN, interventional anti-hypertensive procedures, and a note on cardiac rehabilitation. Episode Graphic by Dr. Carine Hamo 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 Coming soon! Cardionerds Cardiovascular Prevention Series The Cardionerds CV prevention series  includes in-depth deep dives on so many prevention topics including the ABCs of prevention, approach to obesity, hypertension, diabetes mellitus and anti-diabetes agents, personalized risk and genetic risk assessments, hyperlipidemia, women’s cardiovascular prevention, coronary calcium scoring and so much more! We are truly honored to be producing the Cardionerds CVD Prevention Series in collaboration with the American Society for Preventive Cardiology! The ASPC is an incredible resource for learning, networking, and promoting the ideals of cardiovascular prevention! This series is kicked off by a message from Dr. Amit Khera, President of the American Society for Preventive Cardiology and President of the SouthWest Affiliate of the American Heart Association. Guest Profiles Dr. Luke Laffin, serves as cardiology faculty in the division of Preventive Cardiology and Medical Director of Cardiac Rehabilitation at the Cleveland Clinic. Dr. Laffin attended medical school at Vanderbilt University School of Medicine. He trained in internal medicine and cardiology at the University of Chicago where he completed a dedicated fellowship in hypertensive diseases. He is a clinical specialist in hypertension designated by the American Society of Hypertension – which has now merged with the AHA. Dr. Gregory Ogunnowo is a cardiology fellow at the Cleveland Clinic. He completed medical school at the University of South Carolina School of Medicine in Columbia, South Carolina. He went on to complete internal medicine residency at Washington University School of Medicine in St. Louis where he stayed on as faculty in the Department of Hospital Medicine for a year prior to pursing fellowship. His interests include outcomes research in interventional cardiology and medical education In his spare time, Greg enjoys traveling, exercising, and experiencing new cultures through their food. When he’s not in the hospital, you can find Greg planning a trip with close friends and family. References and Links Coming soon! Luke Laffin MDGreg Ogunnowo, MDAmit Goyal, MDDaniel Ambinder, MD

CardioNerds (Amit Goyal and Daniel Ambinder) introduce the CardioNerds Narratives in Cardiology Series which will feature the stories of amazing cardiovascular faculty and trainees representing diverse backgrounds, subspecialties, career stages, and career paths. To kick this series off, Dr. Pamela Douglas, who heads the Diversity and Inclusion task force for the American College of Cardiology, provides valuable insights in the field and shares her personal story. We are joined by the CardioNerds Narratives #FIT Advisors, Dr. Zarina Sharalaya, Dr. Norrisa Haynes and Dr. Pablo Sanchez for this very important discussion. Special messages by: Dr. Vanessa Blumer, Dr. Robert Harrington, Dr. Richard Chazal, Dr. Nosheen Reza, Dr. Neha Pagidipati, Dr. Mary Norine (Minnow) Walsh, Dr. Melissa Daubert, Dr. Gerald Bloomfield, Dr. Angela Lowenstern, Dr. Ralph Brindis, Dr. Michael Valentine, Dr. Anna Lisa Crowley, Dr. Malissa Wood and Dr. Geoffrey Ginsberg. 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 What is "Diversity" & "Inclusion"?Facets of diversity are all aspects of human differences. These include gender, race, ethnicity, age, physical ability, gender identity, national origin, language, religion, sexual orientation, socioeconomic status, and more.Inclusion is making everyone feel welcomed and included.Inclusion requires having a culture & environment where everyone can thrive regardless of background differences. This inclusive culture fosters respect & belonging in which we hear, appreciate, & value everyone and their perspectives.Inclusive organizations work with individuals to recognize and eliminate both explicit and implicit biases. They may do this with intentional efforts like professional & skills development as well as addressing awareness, education, and policy. Diversity measures representation by counting the presence of varying identities and characteristics. But Diversity itself is not the final goal.Diversity is the metric while Inclusion is the goal. For now, while representation is so disparate among certain groups, diversity is an important metric. It’s hard to be truly inclusive with such professional inequities. “Ultimately what we want is for people to belong. So not just be asked to the dance and sitting around and staring at everybody else but really feeling like you can go out on that dance floor and dance, like nobody's watching and it's fine because this is your  community.” - Pamela Douglas Why is achieving diversity important?Diversity is a virtue in and of itself. But more than that, diverse groups make better decisions, are more innovative, are better at problem solving, and have an expanded talent pool.Cardiovascular medicine benefits from having a diverse workforce. Science performed by diverse groups has greater scientific novelty and produces higher impact papers in higher impact journals. Is there a link between professional diversity and healthcare inequities?YES!Physician diversity reduces healthcare disparities and improves healthcare quality.Physicians who train in diverse environments are more culturally competent when treating underrepresented groups.Underrepresented physicians are more likely to serve underrepresented populations.Underrepresented patients are more likely to follow the recommendations of physicians who look like them. This enhanced trust is critical to an effective patient-physician relationship. In the context of clinical trials and guidelines, underrepresented physician scientists help diversify our clinical trial participants, resulting in a more robust and representative evidence base.  How are we doing in cardiology with respect to diversity?There have been improvements but we have a long way to go.Women comprise 43% of internal medicine resident physician...

CardioNerds (Amit Goyal & Karan Desai) join University of Illinois at Chicago cardiology fellows (Brody Slostad, Kavin Arasar, and Mary Rodriguez-Ziccardi) for a cup of tea from atop Hancock Tower! They discuss an illuminating case of altered mental status & electrical instability due to digitalis poisoning. Program director Dr. Alex Auseon and APD Dr. Mayank Kansal provide the E-CPR and a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Tommy Das with mentorship from University of Maryland cardiology fellow Karan Desai.   Jump to: Patient summary - Case media - Case teaching - References Episode graphic by Dr. Carine Hamo CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor RollSubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Check out CardioNerds SWAG! Cardiology Programs Twitter Group created by Dr. Nosheen Reza Patient Summary A woman in her late 80s with history of systemic arterial hypertension and dementia presented with 2 weeks of nausea, vomiting, confusion, and yellow-tinted vision. When she presented to the hospital, initial history was limited as her caregiver was unaware of her medications and medical history. An initial ECG showed isorhythmic A-V dissociation and scooping ST segments laterally. Given her clinical history, this raised the suspicion for Digoxin toxicity, and a serum digoxin level was significantly elevated. However, this was not a home medication for the patient, nor did she have access to it! Listen to the episode now as the UIC Cardionerds masterfully take us through this case that would surely stump Dr. House!   Case Media through the Differential ABCDEFClick to Enlarge A. Initial ECGB. CXR- Patchy opacities of the left lower lobe consistent with pulmonary edema and/or aspiration​ pneumonia.C. Repeat ECG: AF with AV block, persistent scooped T waves​D. Post arrest ECG: Flutter/fib with AV block, VERY LONG PAUSES up to 6 secondsE. ECG post TVP: A flutter, slow V response (pacing picking up), intrinsic ventricular rate 20-40, PM set to 50 bpmF. Most recent ECG: Normal sinus rhythm TTE Episode Schematics & Teaching The CardioNerds 5! – 5 major takeaways from the #CNCR case 1) This episode featured a challenging case of digitalis toxicity. Cardionerds, what is the mechanism of action of cardiac glycosides?   Cardiac Glycosides (such as digoxin, digitalis, and oubain), inhibit the myocardial Na/K ATPase pump. This leads to an increased concentration of intracellular sodium, which then drives the influx of calcium into cardiac myocytes via the Na/Ca exchanger. This increase in intracellular calcium leads to further calcium release from the sarcoplasmic reticulum making even more calcium available to bind to troponin, increasing contractility. In addition to their effect on inotropy, cardiac glycosides increase vagal tone, reducing SA node activity and slowing conduction through the AV node by increasing the refractory period  2) The first published account of digitalis to treat heart failure dates back to the 18th century, when botanist and physician William Withering published "An account of the Foxglove and some of its medical uses with practical remarks on dropsy, and other diseases". A lot has changed over the years; what are some of the uses of digoxin in the modern day?   The DIG trial (1997) demonstrated a reduction in hospitalizations in patients with HFrEF treated with digoxin. However, no impact on mortality was shown. A major limitation from randomized trials of digoxin is the lack of contemporary background HF treatment (e.g., ARNI, SGLT2i, MRA, Device Therapy). Thus, its role in modern HFrEF management is typically limited to reducing hospitalizations in patients with persistent NYHA Class III or IV symptoms despite maximally tolerated guideline-directed medical therapy Digoxi...

CardioNerds (Carine Hamo, Amit Goyal, and Daniel Ambinder) discuss the obesity epidemic and how it relates to the cardiovascular system with Dr. Chiadi Ndumele, cardiologist and epidemiologist at The Johns Hopkins Hospital and chairs the obesity subcommittee of the American Heart Association (AHA). They cover obesity definitions, epidemiology, strengths and limitations of different biometrics, including BMI, impact on myocardial structure and function, and current pharmacologic & surgical options for weight loss. They also discuss the practical approach to addressing obesity with patients. This episode was produced by Dr. Carine Hamo. Show notes & references by Dr. Daniel Ambinder. Episode graphic by Dr. Carine Hamo Cardionerds Cardiovascular Prevention PageCardioNerds Episode PageSubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron! Show notes 1. What is obesity and how do we define it at the personal and population level?  Obesity is when there is an excess and often dysfunctional adipose tissue that contributes to morbidity and to premature mortality The metric used to define obesity is Body Mass Index (BMI), defined as a person's weight in kilograms divided by the square of the person's height in meters (kg/m2) See WHO BMI classification below 2. What is the current epidemiology of obesity and are there certain populations that are affected more than others?  Rates of obesity are climbing. Currently, around 70% of the population meets criteria for being either overweight or obese and ~40% are at the level of obesity. Minorities such as African Americans, Native Americans, and Latinos have higher rates of obesity. Higher rates of obesity are also seen in groups with lower socioeconomic status. Certain populations, such as Southeast Asians, tend to develop severe metabolic consequences of obesity such as insulin resistance and cardiovascular consequences with less excess weight than other populations. Adult weight is very important but weight history (long standing obesity) plays a role as well when it comes to cardiovascular risk associated with obesity.    3. Currently the WHO classifies obesity based on BMI. What are the limitations to using BMI as a measure of obesity? Are their benefits to measuring waist circumference instead?  BMI is a far from a perfect measure but it correlates nicely at the population level with cardiovascular events and premature mortality BMI is more accessible than a direct quantitative or functional measure of adipose tissue   A major limitation of BMI is that it does not reflect body composition. Body composition is very important in understanding risk associated with obesity. For example, football players may fall into the category of grade 1 obesity if just using BMI to classify their weight status. Waist circumference (WC) is a good way of getting a sense of body composition. Abdominal obesity is most closely linked to insulin resistance and various metabolic consequences such as diabetes, hypertension, and inflammation. This is why WC is incorporated into the metabolic syndrome construct. Adding WC measurements to the BMI measurements, particularly for individuals in the overweight and grade 1 obesity group (BMI 25-29.9, and 30-34.9) provides significant prognostic information about the development of cardiovascular disease.  4. How do obesity and metabolic syndrome impact myocardial structure and function? How does obesity and increased adiposity fit into the larger scheme of metabolic risk and metabolic syndrome?  Obesity is independently associated with myocardial remodeling and with increased heart failure risk. This contrasts with coronary heart disease (CAD) and stroke. For CAD and stroke, most associations with obesity are largely mediated by diabetes, hypertension and dyslipidemia. However, in heart failure, there is a strong unexplained association that remains after you consider those associated ...

CardioNerds (Amit Goyal and Daniel Ambinder) discuss diabetes mellitus with Dr. Dennis Bruemmer. This is a must-listen for anyone engaged in the case of the cardiovascular patient. Given the alarming obesity epidemic, we anticipate a rising worldwide tide of diabetes mellitus and ensuing cardiovascular disease. Here we discuss the epidemiology and approach to diabetes management, with emphasis on what CardioNerds need to know. Dr. Bruemmer is board-certified in both cardiology and endocrinology, and is the director of the Center for Cardiometabolic Health in the section of Preventive Cardiology and Rehabilitation at the Cleveland Clinic. Episode graphic by Dr. Carine Hamo Cardionerds Cardiovascular Prevention PageCardioNerds Episode PageSubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron! Show notes Why should CardioNerds pay attention to diabetes mellitus (DM)? As a cardiovascular risk equivalent, DM is a key CVD risk factor, associated with a 2-4 fold increased risk. 70% of ACS patients have DM. Cardiologists will see more patient with DM given the rising prevalence of obesity, subsequent diabetes and ensuing CVD.  Only 6% of patients with DM and cardiovascular disease (CVD) get appropriate care for DM and CVD. Historically, hypoglycemic agents improved microvascular outcomes (retinopathy, nephropathy, neuropathy), but not macrovascular outcomes (MI, CVA, PAD). However, this has changed with the advent of mandatory cardiovascular safety trials with positive data for GLP1 agonists and SGLT2 inhibitors! There aren't enough endocrinologists! They only see ~5% of DM patients. In 2012 the US generated 280 endocrinologists versus  100 million patient with DM or pre-DM. Primary care physicians are key allies in the care of these patients.  So as CardioNerds, let's get over this therapeutic inertia and take ownership of our patients' DM as we already do for their HTN and HLD; in collaboration with a multidisciplinary team including the PCP, dietician, pharmacist, DM educators, +/- behavioral therapist, +/- endocrinologist, +/- metabolic surgeon.  What is your global approach to the patient with DM? Optimize the non-DM CVD risk factors with lifestyle intervention and medical management: CVD risk factors are very common in patients with DM (sedentary lifestyle, unhealthy weight, HTN, HLD).  The Steno-2 Study (Gaede et al., NEJM 2008) showed that in patients with T2DM & microalbuminuria, intensive intervention with multiple drug combinations and behavioral modification was better with regards to: vascular complications, death from any cause, and death from CV causes.     Emphasize a healthy lifestyle -  use a patient-centered approach with motivational interviewing and shared decision making, provide education, set realistic goals, identify barriers (socioeconomic, etc), engage family and a multidisciplinary team (nutritionist, exercise physiologist), utilize behavioral interventions. Pharmacologic intervention - medical weight loss for BMI > 27 and DM (enjoy upcoming Ndumele episode), anti-HTN (enjoy upcoming Laffin episode), and anti-HLD (enjoy the Navar-Shah episode). NOTE that statins have been shown to have a small effect on increasing incident or worsening DM, but the effect size is small and overcome by the benefit in whom statins are indicated.                Treat the Hyperglycemia itself! Let's discuss this deeper…  What is your approach to non-insulin DM management? First-line agents: US guidelines: in addition to lifestyle intervention, start with metformin as the first line agent. European guidelines: now give preference to GLP1 agonists and SGLT2 inhibitors in patients with or at risk for cardiovascular disease. Sulfonylureas: increase pancreatic insulin secretion. Dr. Bruemmer feels they obsolete for the preventive cardiologist from the standpoints of safety, efficacy, and cardiovascular disease. There is no efficacy data past 4 years and no cardiovasc...

The CardioNerds (Carine Hamo and Daniel Ambinder) discuss aspirin as primary prevention, Vitamin D, Calcium, and omega 3 fatty acids supplementation with Dr. Erin Michos, director of women's cardiovascular health and the associate director of preventive cardiology with Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease. We are also joined by Dr. Michos' mentees, Dr. Rick Ferraro, Dr. Andi Shahu, and student doctor Sunyoung (Sarah) Jang for a discussion about mentorship and career development. This episode was produced by Dr. Rick Ferraro and Dr. Carine Hamo. Show notes & references by Dr. Amit Goyal. Episode graphic by Dr. Carine Hamo Cardionerds Cardiovascular Prevention PageCardioNerds Episode PageSubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron! Show notes - Aspirin, Vitamin D, Calcium & Omega 3 Fatty Acids Supplementation What is the role of aspirin for primary ASCVD prevention?  The Conundrum: ASCVD event rates are much lower in the primary prevention than in the secondary prevention population, BUT the bleeding rates are comparable. So in the primary prevention patients, the bleeding risk is just as high, but the propensity for benefit is lower. The Question: Does low dose aspirin have a place in the primary prevention of ASCVD events. The Data: ARRIVE Trial: in moderate risk nondiabetic patients without prior ASCVD events, there was no different in the composite ASCVD end point, but there was an increased risk of bleeding (mostly mild GI bleeding). Thus, in the moderate risk patients --> primary prevention aspirin has an unfavorable risk-benefit profile. The benefit in a higher risk (>10-20% estimated 10-yr risk) remains unclear.  ASCEND Trial: In men and women age ≥ 40yrs with diabetes without prior ASCVD events, there was a modest benefit (NNT = 59 patients for 10 years to prevent 1 major ASCVD event) counterbalanced by a similar magnitude of harm (NNH = 77 patients for 10 years to cause 1 major bleeding event). Thus, in adults with diabetes --> primary prevention aspirin had a neutral risk-benefit profile. ASPREE Trial: in elderly patients (≥ 70 years; ≥ 65 years for Hispanic or Black patients) without prior ASCVD events, there was no difference in ASCVD events but there was a significant increase in bleeding events (NNH = 42 patients for 10 years to cause 1 major bleeding event). The trial was stopped early due to futility. Interestingly, there was higher all-cause mortality driven primarily by cancer. Importantly, patients had to have a life expectancy longer than 5 years and those with dementia, substantial physical disability, or high estimated bleeding risk were excluded. Thus, in elderly patients --> primary prevention aspirin led to overall harm.  The Recommendations: There was insufficient evidence to recommend a specific risk threshold for starting primary prevention aspirin. This may be due to more widespread contemporary prevention strategies like lifestyle management, tobacco cessation, statin use, better blood pressure control, etc.  Individualize the decision based on the totality of evidence for an individual's risk of ASCVD events versus bleeding events. Notably, those with higher ASCVD risk generally also have a higher bleeding risk.           Class IIB: Low-dose aspirin (75-100 mg orally daily) might be considered for the primary prevention of ASCVD among select adults 40 to 70 years of age who are at higher ASCVD risk but not at increased bleeding risk. There may be a role for primary prevention aspirin in select adults with a high estimated ASCVD risk and low bleeding risk. CAC score ≥ 100 may help identify those might benefit from primary prevention aspirin.           As always, shared decision making remains           crucial. Class III: Low-dose aspirin (75-100 mg orally daily) should not be administered on a routine basis for the primary prevention of ASCVD among adults >70 years of age.