Cardionerds: A Cardiology Podcast

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, which has prognostic information. Supine bicycle is another common exercise modality that is utilized.  There are also several pharmacologic stressors that vary in their mechanisms of action. Dobutamine is a synthetic catecholamine that stimulates myocardial beta-1 and beta-2 receptors to increase heart rate, contractility, and consequently myocardial oxygen demand with a small decrease in systemic vascular resistance.    Adenosine and adenosine derivatives (e.g. regadenoson) induce coronary vasodilation and take advantage of differences in coronary flow reserve. With obstructive coronary lesions, the vessels distal to the obstruction are already dilated at baseline and have little flow reserve. Adenosine (and its derivatives) induce vasodilation and increase flow in normal coronary beds, but much less so in areas supplied by an obstructive lesion. Consequently, we can see disparate radiotracer uptake that correlates with different coronary territories.   Once we’ve induced ischemia, we can assess it via electrocardiogram (EKG) alone or in conjunction with an imaging modality such as echocardiography, MRI, or nuclear imaging — such as Single Photon Emission Computed Tomography (SPECT) or Positron Emission Tomography (PET).    What is the difference between SPECT and PET imaging quality? What are the advantages of using PET imaging?  SPECT and PET imaging both use gamma cameras that detect gamma rays produced by the injected radionuclide tracer. SPECT utilizes a single-crystal camera to acquire multiple 2D images to be reconstructed into a 3D image, while PET imaging utilizes a multi-crystal camera which can detect more counts (e.g., quantification of radioactivity).   SPECT studies usually use Technetium-based tracers which have nuclei that emit 140 keV of energy. PET studies usually use Rubidium or Ammonia which have nuclei that emit around 510 keV of energy. Either of these studies can also use Thallium which have nuclei that emit 68 keV of energy. In general, the higher the “keV”, the better the image quality. So, using thallium may result in poorer quality images and is not recommended as a first-line agent.   Rubidium has a half-life of 76 seconds and Ammonia has a half-life of 10 minutes—so it is possible to do an exercise stress test if using Ammonia but not with using Rubidium!  Because the radiotracers used for PET imaging have higher “keV” than those used in SPECT imaging, PET image quality is generally better with a higher resolution.  If using a SPECT camera, you should use a camera that has attenuation correction. Attenuation artifact can occur when you have tissue such as breast or diaphragm that overlies the myocardium and decreases the intensity/strength of signal prior to reaching the myocardium. This can result in the false appearance of a myocardial perfusion defect in that region. Without attenuation correction, the specificity of a SPECT camera drops to 50-60%.   In addition to improved spatial resolution and higher quality images resulting from using radiotracers with higher “keV”, PET cameras also do not require physical collimation. This allows for even further increase in spatial resolution and image quality.   A collimator is a piece of lead with holes that absorb and stop most photons except for those that arrive almost perpendicular to the detector face. This allows the camera to accurately localize the radiotracer in the patient’s body over the organ of interest. Overall, PET has better sensitivity, specificity, and better accuracy to diagnose 50% and 70% lesions than SPECT!   However, maintaining PET scanners comes at increased cost compared to SPECT.  What diagnostic information can cardiac nuclear imaging provide us? What are some unique uses of nuclear imaging?  In the evaluation of coronary disease, some diagnostic information provided by SPECT and PET imaging include:  Assessment of myocardial perfusion and blood flow at both rest and stress  Ejection fraction assessment at both rest and stress  Quantitative flow reserve in all coronary territories (PET)  Assessment of myocardial viability (PET)  Prognostication  Calcium Score with CT Attenuation Correction  If using CT for attenuation correction, you should also use it for calcium score. A high coronary calcium score can change management—there is also data that shows that just showing patients the plaque on CT imaging can improve outcomes!   There are many uses of nuclear imaging, and novel uses are continuously being described. In addition to its use in noninvasive stress testing and ischemic heart disease, we can also use it to assess etiology of cardiomyopathies:   In patients with suspected cardiac sarcoidosis, fluorodeoxgylocse(FDG)-PET imaging with Rubidium can be utilized to detect sarcoid and prognosticate. Enjoy the upcoming discussion about sarcoidosis imaging as well as the CNCR from the University of Chicago!   Nuclear scintigraphy with 99m-Technetium pyrophosphate can be used to assess for cardiac amyloidosis. Stay tuned for more on this as part of the amyloidosis imaging discussion.   FDG PET and whole-body-white blood cell scan can be used to help evaluate for prosthetic valve endocarditis or LVAD-associated infections, which we will also discuss later in this imaging series!  FDG-PET can help evaluate and differentiate aortopathies in patients presenting with chest pain  Many novel uses of nuclear stress testing are being described for patients admitted to the cardiac intensive care unit (CICU).   CT imaging and MRI require significant patient cooperation. MRI additionally is sometimes limited by patient compatibility issues. A full PET study can be done in 20-25 minutes, however, independent of renal and hepatic function.   In patients admitted to the CICU with an intra-aortic balloon pump (IABP), exercise can be simulated by reducing the IABP support ratio from 1:1 to 1:3. A PET stress test can then be conducted using this “exercise” to evaluate for myocardial ischemia.  How do you select the best non-invasive test?  A variety of factors play a role in this decision. To begin, you can start with the picking whether a functional test or an anatomical test is best to answer your clinical question.  Are you trying to identify the nature of a patient’s symptoms for a possible underlying cardiac etiology? Perhaps a functional test is best.   Are you trying to rule out obstructive epicardial disease? Perhaps an anatomical test is best.   In many instances functional and anatomical tests provide complimentary information. And if the patient has had multiple prior non-invasive testing of the same modality with equivocal answers to the clinical question, it may be more helpful to switch to a different modality.  Many imaging and individual patient factors affect the selection for the best non-invasive test. For instance:  Patient factors/comorbidities such as kidney disease, liver disease, devices, metallic implants, ability to exercise, baseline abnormal ECG or TTE, and patient cooperation issues affect the selection for the best non-invasive test.  Cost-effectiveness of the study and radiation exposure should be a consideration.  If the patient has a low pretest probability of obstructive CAD, perhaps testing is not needed, or you could consider an anatomical test such as a Coronary CTA  If the patient has a low-intermediate pretest probability of obstructive CAD, one could consider obtaining CCTA anatomical testing in addition to an exercise tolerance test (ETT) with or without imaging as this has been shown to provide higher diagnostic ability and affects management. Rather than have premature closure when obstructive epicardial disease is ruled out, we can assess for nonobstructive plaque that warrants initiation of aggressive lifestyle and risk factor modifications.  If the patient has a significant cardiovascular disease history (e.g. multiple prior stents or bypass surgery) but lower suspicion of symptomatic coronary ischemia, perhaps functional testing such as stress MRI, nuclear stress test, or stress echocardiogram is preferred.  If the patient has a high pretest probability of obstructive epicardial disease, perhaps it is best to skip a non-invasive test and proceed straight to an invasive test.  Do note that patients with angina who do not have obstructive epicardial stenoses on anatomical testing may have coronary microvascular disease which is still important to diagnose given important therapeutic and prognostic implications. More on this in the next episode!   Below is a depiction of the how effective the different non-invasive modalities are to rule in or rule out significant coronary artery disease in stable CAD patients. It is based on follow-up invasive coronary angiography or FFR assessment, stratified by pretest probability. Notably, stress ECG requires a relatively lower pretest probability to rule out obstructive CAD and relatively higher pretest probability to rule in CAD. CCTA does not perform as well as functional imaging techniques in ability to rule-in and rule out FFR-significant CAD when comparing it to its ability to rule in and rule out significant CAD by invasive coronary angiography.  Guest Profiles Wael Jaber, MD Wael Jaber, MD, is a staff cardiologist in the Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, at the Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute at Cleveland Clinic. Dr. Jaber specializes in cardiac imaging (both nuclear cardiology and echocardiography) and valvular heart disease. Dr. Jaber attended college at the American University in Beirut, graduating with a Bachelor of Science in biology. He then went on at the American University to receive his medical degree while making the Dean’s honor list. He completed his residency in internal medicine at the St. Luke’s-Roosevelt Hospital Center at Columbia University College of Physicians and Surgeons, where he also completed fellowships in cardiovascular medicine and nuclear cardiology. Dr. Jaber is currently is the Medical Director of the Nuclear Lab and of the Cardiovascular Imaging Core Laboratory in C5Research. He is fluent in English, French and Arabic. He is the author of Nuclear Cardiology review: A Self-Assessment Tool and cofounder of Cardiac Imaging Agora. Dr. Aldo L Schenone Dr. Aldo L Schenone is one of the current Chief Non-Invasive Cardiovascular Imaging Fellows at the Brigham and Women’s Hospital. He completed medical school at the University of Carabobo in Valencia, Venezuela, and then completed both his Internal Medicine residency and Cardiology fellowship at the Cleveland Clinic where he also served as a Chief Internal Medicine Resident. Dr. Erica Hutt Dr. Erika Hutt @erikahuttce is a cardiology fellow at the Cleveland Clinic. Erika was born and raised in Costa Rica, where she received her MD degree at Universidad de Costa Rica. She then decided to pursue further medical training in the United States, with the goal of becoming a cardiologist. She completed her residency training at Cleveland Clinic and went on to fellowship at the same institution. Her passions include infiltrative heart disease, atrial fibrillation, valvular heart disease and echocardiography among many. She is looking forward to a career in advanced cardiovascular imaging. References and Links Pitman AG, Kalff V, Van Every B, Risa B, Barnden LR, Kelly MJ. Contributions of subdiaphragmatic activity, attenuation, and diaphragmatic motion to inferior wall artifact in attenuation-corrected Tc-99m myocardial perfusion SPECT. J Nucl Cardiol. 2005;12:401–9.  Heller GV, Bateman TM, Johnson LL, Cullom SJ, Case JA, Galt JR, et al. Clinical value of attenuation correction in stress-only Tc-99m sestamibi SPECT imaging. J Nucl Cardiol. 2004;11:273–81.  Maddahi J, Packard RR. Cardiac PET perfusion tracers: current status and future directions. Semin Nucl Med. 2014;44(5):333-343. doi:10.1053/j.semnuclmed.2014.06.011  van Dalen JA, Visser EP, Vogel WV, Corstens FH, Oyen WJ. Impact of Ge-68/Ga-68-based versus CT-based attenuation correction on PET. Med Phys. 2007 Mar;34(3):889-97. doi: 10.1118/1.2437283.  Parker MW, Iskandar A, Limone B, Perugini A, Kim H, Jones C, Calamari B, Coleman CI, Heller GV. Diagnostic accuracy of cardiac positron emission tomography versus single photon emission computed tomography for coronary artery disease: a bivariate meta-analysis. Circ Cardiovasc Imaging. 2012 Nov;5(6):700-7. doi: 10.1161/CIRCIMAGING.112.978270. Epub 2012 Oct 10.   Mettler FA, Guiberteau MJ. Essentials of nuclear medicine imaging. 6th ed. Philadelphia, PA: Elsevier/Saunders; 2012.  SCOT-HEART Investigators, Newby DE, Adamson PD, Berry C, Boon NA, Dweck MR, Flather M, Forbes J, Hunter A, Lewis S, MacLean S, Mills NL, Norrie J, Roditi G, Shah ASV, Timmis AD, van Beek EJR, Williams MC. Coronary CT Angiography and 5-Year Risk of Myocardial Infarction. N Engl J Med. 2018 Sep 6;379(10):924-933. doi: 10.1056/NEJMoa1805971. Epub 2018 Aug 25.  Juhani Knuuti, Haitham Ballo, Luis Eduardo Juarez-Orozco, Antti Saraste, Philippe Kolh, Anne Wilhelmina Saskia Rutjes, Peter Jüni, Stephan Windecker, Jeroen J Bax, William Wijns, The performance of non-invasive tests to rule-in and rule-out significant coronary artery stenosis in patients with stable angina: a meta-analysis focused on post-test disease probability, European Heart Journal, Volume 39, Issue 35, 14 September 2018, Pages 3322–3330, https://doi.org/10.1093/eurheartj/ehy267  Jaber W, Gimelli A. Cardiac Imaging Agora. https://www.cardiacimagingagora.com/list  Wael Jaber, MD Dr. Aldo L Schenone Dr. Erika Hutt Dr. Hussain Khalid Amit Goyal, MD

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.  He is currently Digital Strategies Editor and an Associate Editor for the journal Circulation.  Dr. Khera has been named Best Doctor in Dallas and Texas SuperDoctor every year since 2014 and was previously the Program Director for the Cardiology Fellowship at UT Southwestern from 2011-2019.  References and Links Coming soon! Amit Khera, M.D. Carine Hamo, MD Amit Goyal, MD Daniel 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 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 MD Greg Ogunnowo, MD Amit Goyal, MD Daniel 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 MD Greg Ogunnowo, MD Amit Goyal, MD Daniel 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 physicians by only 22% of general cardiology fellows and even lower proportions within procedural fields. Underrepresented minorities–specifically Blacks, Hispanics, and Native Americans–make up about 32% of the US population but only 13% of general cardiology fellows. Benchmarks for other racial and ethnic groups and for other facets of diversity like socioeconomic status, sexual orientation, gender identity, IMG status, and others are even less clear. Inequities amplify in advanced career and leadership positions.  Only 11%, 9%, 11%, and 24% of Asian, black, Hispanic, and white women, respectively, are full professors compared with 21%, 18%, 19%, and 36% of Asian, black, Hispanic, and white men, respectively (Albert 2018). In the top 40 ranked cardiology programs, there are no female cardiology chiefs (Albert 2018). There were no women editors-in-chief for US general cardiology journals between 1998 and 2018 and only 1 woman editor-in-chief for a general European cardiology journal (Balasubramanian et al., 2020). Such benchmarks are helpful for measuring representation, but remember the ultimate goal is Inclusion. We want to be more holistic in our approach to Inclusion. Let’s focus on competency and quality. Given the benefits of a diverse workforce discussed above, Diversity itself is a competency. If someone brings a different background & perspective, they are valuable to the group, just as someone else with specific leadership and interpersonal skills.  How do we create a more diverse Cardiology? This requires a multi-pronged approach that spans deep pipeline projects through to career ascension. We must deliberately address implicit bias and both systemic racism & sexism. Among other efforts (detailed below), we have to create a welcoming environment, showcase a culture conducive to work-life integration, and ensure equity in compensation, opportunities, and promotion.  According to a survey of internal medicine trainees, the top perceptions of cardiology careers were adverse job conditions, interference with family life, and lack of diversity. Women and those residents who had already chosen noncardiology careers more strongly valued work-life balance and had more negative perceptions of cardiology than men or future cardiologists. Compared with men, women trainees placed greater value on stable hours, family friendliness, female friendliness, and positive role models (Douglas et al., 2018). Understanding these perceptions was a key motivator for the CardioNerds Narratives in Cardiology series! The CardioNerds “Narratives in Cardiology” series will feature cardiovascular faculty representing diverse backgrounds, subspecialties, career stages, and career paths. The faculty will be interviewed by fellows-in-training (FITs) to discuss both their clinical expertise and their individual career narratives with the goals of showcasing diversity within the profession, inspiring interest in the field, and demonstrating the more positive culture of modern cardiology. See the ACC’s approach below (Figure 1 – Poppas et al., 2020) and  the approach by Albert 2018 (Figure 2). Show notes updated as of 12.30.2020 Figure 1 Figure 2 Click to enlarge. (Figure 1 – Poppas et al., 2020, Figure 2 – Albert 2018. CardioNerds Narratives in Cardiology The CardioNerds Narratives in Cardiology series features cardiovascular faculty representing diverse backgrounds, subspecialties, career stages, and career paths. Discussing why these faculty chose careers in cardiology and their passion for their work are essential components to inspiring interest in the field. Each talk will feature a cardiology faculty from an underrepresented group, within at least one of several domains: gender, race, ethnicity, religion, national origin, international graduate status, disadvantaged backgrounds, etc. Featured faculty will also represent a variety of practice settings, academic ranks, subspecialties (e.g. clinical cardiology, interventional cardiology, electrophysiology, etc), and career paths (e.g. division chief, journal editor, society leadership, industry consultant, etc). Faculty will be interviewed by fellows-in-training for a two-part discussion that will focus on: 1) Faculty’s content area of expertise2) Faculty’s personal and professional narrative As part of their narrative, faculty  will discuss their unique path to cardiology and their current professional role with particular attention to challenges, successes, and advice for junior trainees. Specific topics will be guided by values relevant to trainees, including issues related to mentorship, work-life integration, and family planning. To help guide this important initiative, the CardioNerds Narratives Council was founded to provide mentorship and guidance in producing the Narratives series with regards to guests and content. The CardioNerds Narratives Council members include: Dr. Pamela Douglas, Dr. Nosheen Reza, Dr. Martha Gulati, Dr. Quinn Capers, IV, Dr. Ann Marie Navar, Dr. Ki Park, Dr. Bob Harrington, Dr. Sharonne Hayes, and Dr. Michelle Albert. The Narratives Council includes three FIT advisors who will lead the CardioNerds’ diversity and inclusion efforts, including the current project: Dr. Zarina Sharalaya, Dr. Norrisa Haynes, and Dr. Pablo Sanchez. Guest Profiles Dr. Pamela Douglas Pamela S Douglas MD is the Ursula Geller Professor of Research in Cardiovascular Diseases in the Department of Medicine at Duke University. She has led several landmark and pivotal multicenter randomized clinical trials and outcomes research studies funded by government, professional societies, and industry. She is renowned for her scientific and policy work in improving the quality and appropriateness of imaging in clinical care, clinical trials, and registries and through development and dissemination of national standards for imaging quality, utilization, informatics, and analysis. Dr Douglas helped to establish several important specialty areas including heart disease in women, sports cardiology, and cardio-oncology. Dr. Douglas’ wealth of experience includes authorship of over 500 peer reviewed manuscripts and 30 practice guidelines, service as the President of the American College of Cardiology, President of the American Society of Echocardiography, and Chief of Cardiology at both the University of Wisconsin-Madison and Duke University. She has also previously served on the faculties of the University of Pennsylvania and Harvard University. She has served on the External Advisory Council of the National Heart, Lung and Blood Institute and the Scientific Advisory Boards of the National Space Biomedical Institute and the Patient Advocate Foundation. Dr. Zarina Sharalaya Dr. Zarina Sharalaya is an interventional cardiology fellow at the Cleveland Clinic. She completed medical school at The Ohio State University and then completed her residency at The University of North Carolina Chapel Hill. She moved back to her home state of Ohio to do general cardiology fellowship at The Cleveland Clinic. Zarina has been very involved with the Ohio ACC and this year has served as co-chair of the FIT Council. She is passionate about the Women in Cardiology initiative has been able to help formulate the first WIC chapter for Ohio ACC. She enjoys traveling, music, and spending time with her husband and new puppy Zuma. Dr. Norrisa Haynes Dr. Norrisa Haynes is a senior cardiology fellow at the University of Pennsylvania (UPenn). She attended Yale University for her undergraduate studies where she received a Bachelor of Science (BS) in Molecular and Cellular Biology. She went on to complete her medical school and internal medicine training at Columbia University College of Physicians and Surgeons. During medical school, she received a Master of Public Health (MPH) from Harvard University. After residency, she worked for Partners in Health (PIH) in Haiti for 2 years at Hôpital Universitaire de Mirebalais (HUM) as a junior attending. During those two years, she also worked as a Harvard Medical School instructor and Brigham hospitalist. After spending 2 years in Haiti, she started cardiology fellowship at UPenn. She is interested in imaging and is currently obtaining a Master of Science in Health Policy (MSHP). Dr. Haynes is a member of the ACC/AHA joint guidelines committee and is a member of UPenn’s Women in Cardiology group (WIC). Dr. Haynes also serves the fellow representative to the board of the Association of Black Cardiologists (ABC). Dr. Pablo Sanchez Dr. Pablo Sanchez is a cardiology fellow at Stanford University Medical Center. He completed medical school The University of Arizona, in Tucson. He completed Internal Medicine training at Brigham & Women’s Hospital, and served as Chief Resident from 2018-2019. He is devoted to furthering diversity and inclusion, and passionate about using compelling and effective methods to aid medical education. His clinical and research interests encompass critical care cardiology, end-stage heart failure, respiratory failure and ARDS. He plans to pursue further training in critical care medicine. Outside of medicine, his time revolves around his wife/family, friends, Latin American music and mambo/salsa dancing. References 1. Albert MA. #Me-Who anatomy of scholastic, leadership, and social isolation of underrepresented minority women in academic medicine. Circulation. 2018;138(5):451-454. doi:10.1161/CIRCULATIONAHA.118.035057 2. Douglas PS, Rzeszut AK, Noel Bairey Merz C, et al. Career preferences and perceptions of cardiology among us internal medicine trainees factors influencing cardiology career choice. JAMA Cardiol. 2018;3(8):682-691. doi:10.1001/jamacardio.2018.1279 3. Douglas PS, Williams KA, Walsh MN. Diversity Matters. J Am Coll Cardiol. 2017;70(12):1525-1529. doi:10.1016/j.jacc.2017.08.003 4. Damp JB, Cullen MW, Soukoulis V, et al. Program Directors Survey on Diversity in Cardiovascular Training Programs. J Am Coll Cardiol. 2020;76(10):1215-1222. doi:10.1016/j.jacc.2020.07.020 5. Poppas A, Albert MA, Douglas PS, Capers Q. Diversity and Inclusion: Central to ACC’s Mission, Vision, and Values. J Am Coll Cardiol. 2020;76(12):1494-1497. doi:10.1016/j.jacc.2020.08.019 6. Mehta LS, Fisher K, Rzeszut AK, et al. Current Demographic Status of Cardiologists in the United States. JAMA Cardiol. 2019;4(10):1029-1033. doi:10.1001/jamacardio.2019.3247 7. Balasubramanian S, Saberi S, Yu S, Duvernoy CS, Day SM, Agarwal PP. Women representation among cardiology journal editorial boards. Circulation. 2020. doi:10.1161/CIRCULATIONAHA.119.042909 Amit Goyal, MD Daniel Ambinder, MD

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 A B C D E F Click 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  Digoxin can also be used for acute or chronic rate control in atrial fibrillation, and may be particularly useful in patients with RVR refractory to beta blockers/calcium channel blockers or in those patients who cannot tolerate these agents due to hypotension. Notably, data from the ARISTOTLE trial (2018) showed a significant mortality increase was seen in patients with a digoxin level ≥1.2 ng/ml, while no increase in mortality was seen with levels <0.9 ng/ml.   Recent data from the small, randomized RATE-AF trial showed no difference in quality of life and similar heart rate control in older patients with permanent atrial fibrillation and heart failure symptoms. Thus, while the therapeutic window may be limited, there remains a role for digoxin in the treatment of HFrEF, Afib, or both.  3) While digoxin can be given in HFrEF and/or AF, its use is limited by its side-effects and potential toxicity. What are the clinical manifestations of digitalis toxicity?   Arrhythmia: Digitalis toxicity can cause virtually any atrial or ventricular arrhythmia. More to come in take-away #4!  GI: Acute toxicity is associated with nausea, vomiting, abdominal pain. Meanwhile, chronic toxicity can be more subtle with less pronounced nausea, anorexia and weight loss developing over weeks to months.   Neuro: Alterations in color vision (chromatopsia), particularly seeing a yellow hue, can be specific for digitalis poisoning. Headache, fatigue, lethargy and altered mental status can also occur.   4) Lets dig a little deeper into digoxin induced arrhythmias; why is digoxin so arrhythmogenic, and what are the most common electrical manifestations?   By inhibiting the  Na/K ATPase pump, digoxin increases intracellular sodium and calcium levels, as well as extracellular potassium. These electrolytes shifts, in addition to the increased parasympathetic activity, lead to Digoxin’s arrhythmogenicity.   Generally, younger patients develop bradyarrythmias due to increased vagal tone, while older patients who may have pre-existing cardiac disease are more likely to develop tachyarrythmias.   Influx of calcium into the cardiac myocyte leads to delayed afterdepolarizations in phase 4 of the ventricular action potential, which can trigger ventricular tachycardia.   Digoxin also increases atrial pacemaker cell automaticity, leading to an increase in atrial arrythmias. This occurs via an increase in the slope of phase 4 of the pacemaker action potential (decreasing the time to depolarization), lowering the depolarization threshold, and increasing the resting potential.  While ectopic atrial tachycardia with AV block and bidirectional VT are associated with digoxin toxicity, virtually any arrhythmia can be seen in digitalis toxicity. However, atrial fibrillation and flutter are less likely to be induced by digoxin toxicity.   5) Now that we’ve established all the effects and side-effects of digoxin, lets wrap up with some points on treating cardiac glycoside toxicity!  The mainstay of therapy for acute and/or severe digoxin toxicity is digoxin-specific antibody (Fab) fragments. Empiric treatment for adults with imminent cardiac arrest or ingestion of an unknown amount of digoxin consists of 10 vials, with each vial binding approximately 0.5mg of digoxin.   Indications for Fab fragments aside from acute overdose include:  Hemodynamically unstable arrythmias  Hyperkalemia  Evidence of end-organ damage from hypoperfusion  Notably, the serum digoxin concentration alone does not dictate Fab fragment treatment. Additionally, in patients with severe renal impairment, Fab fragments may be ineffective and may provide a false sense of benefit. The manifestations of digoxin toxicity may improve initially in these patients given Fab; however, recurrent toxicity can occur weeks later as digoxin moves from peripheral tissues.   While other cardiac glycosides have cross-reactivity with digoxin and can be treated with Fab fragments, dosing can be challenging due to lack of correlation between serum digoxin level and cardiac glycoside activity.  Potassium homeostasis in digoxin toxicity is nuanced. Hyperkalemia, as a result of Na-K ATPase inhibition, is a predictor of mortality in acute toxicity. After Fab fragments are given, hyperkalemia is often rapidly corrected, and over-aggressive treatment of hyperkalemia in the setting of acute toxicity may ultimately lead to hypokalemia once Fab fragments are given.   References Digitalis Investigation Group (1997). The effect of digoxin on mortality and morbidity in patients with heart failure. The New England journal of medicine, 336(8), 525–533.  Lopes, R. D., Rordorf, R., De Ferrari, G. M., et al. (2018). Digoxin and Mortality in Patients With Atrial Fibrillation. Journal of the American College of Cardiology, 71(10), 1063–1074.   Chen, J. Y., Liu, P. Y., Chen, J. H., & Lin, L. J. (2004). Safety of transvenous temporary cardiac pacing in patients with accidental digoxin overdose and symptomatic bradycardia. Cardiology, 102(3), 152–155.  Taboulet, P., Baud, F. J., Bismuth, C., & Vicaut, E. (1993). Acute digitalis intoxication–is pacing still appropriate?. Journal of toxicology. Clinical toxicology, 31(2), 261–273.   The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus. We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director. CardioNerds Case Reports: Recruitment Edition Series Production Team Bibin Varghese, MD Rick Ferraro, MD Tommy Das, MD Eunice Dugan, MD Evelyn Song, MD Colin Blumenthal, MD Karan Desai, MD Amit Goyal, MD Daniel Ambinder, MD

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 conditions.  The independent association of obesity with heart failure pertains almost exclusively to heart failure with preserved ejection fraction (HFpEF) and not heart failure with reduced ejection fraction (HFrEF).  The mechanism for this independent association is not well understood and is an area of active research. In mice that are predisposed to obesity have several inflammatory processes that occur locally in the myocardium and systemically that likely contribute to cardiac risk. At the local level, lipotoxicity occurs within the myocardium as it does in nonalcoholic fatty liver disease. At the systemic level, adipose tissue releases adipokines and cytokines that are linked to myocardial damage, injury, and fibrosis.  There is a spectrum of metabolic risk among individuals with excess weight. And when obesity is associated with metabolic syndrome in individuals, the risk for cardiovascular disease markedly rises.    4. What are some core tenants of addressing obesity when working with patients when it comes to exercise and diet?          A core tenant of discussing obesity with patients is to discuss it! Obesity is generally under-addressed and under-discussed.  Motivation by being positive about risk reduction with a healthier lifestyle can be very effective.  Help patients “take time to invest in themselves”. Having them put items on the calendar that include exercise activities, such as taking a walk or going to the gym, can be a useful strategy for patients who are particularly busy with work or school.  Stress reduction is an important component to diet and exercise.  Smaller activities, a brisk walk or taking the stairs at work can help reduce the activation energy required for exercise and can make exercise feel more attainable to patients.  Meal planning and meal timing are both very important aspects to counseling for patients when it comes to healthy eating.  5. What are some tips and tricks on broaching the subject of obesity with patients given the sensitivity of the subject.  It is important to check biases in this space. Obesity should not be considered an individual failing when there is a systemic and societal based issue. We need to think of obesity as a multi-factorial disease that has a behavioral component but also has a more complex societal and biological contribution as well.  Approaching the patient with a plan for partnership of management of obesity as a disease, like other diseases such as hypertension and diabetes can be very helpful.  Patients want to lose weight, it just becomes very challenging for a variety matters.  The weight of the clinician can have an impact as to the discussion of weight in the clinic. For example, clinicians with a higher weight than the patient tend to avoid discussing obesity during clinic visits. Clinicians who have healthy weight statuses can used stigmatizing language when counseling patients.  Appreciate that weight management can be challenging and there’ll be stops and starts but there can be great outcomes with long-term partnerships with patients.  6. What are the current pharmacologic options for weight loss and when should these agents be considered?  Pharmacological agents should be considered once physical activity and social stressors are addressed. Pharmacological therapy can be a nice adjunct to lifestyle modification, particularly when BMI remains above 30 or when BMI remains >27 with comorbidities.  There are a variety of agents such as Orlistat, Liraglutide, Phentermine, Topiramate, and Bupropion.  These medications are generally underutilized due to cost and side effects.  Some agents have cannot be used long term which may limit their use.  The only agent that has been related to cardiovascular risk reduction is Liraglutide.  7. What do we know about the role of bariatric surgery in cardiovascular disease prevention and does weight loss through bariatric surgery provide differential benefit over other forms of weight loss?  Bariatric surgery is probably the most powerful weapon in our obesity arsenal.  There are two major subtypes of bariatric surgery. There is a restrictive subtype, such as a sleeve gastrectomy, and a malabsoptive subtype, such as a gastric bypass surgery. The Roux-en-Y gastric bypass has both the malabsorptive and restrictive components.  There is prospective data that shows that bariatric surgery is associated with more weight loss than lifestyle modifications. Bariatric surgery is also shown to be associated with a reduction in comorbidities like hypertension, diabetes and dyslipidemia.  Bariatric surgery is also associated with a reduction in pathophysiological processes like inflammation and endothelial dysfunction.  Prospective studies with matched data, such as the Swedish Obesity study cohort, bariatric surgery has been associated with a reduced risk in cardiovascular disease events and a markedly improved survival. There have been significant risk reductions in heart failure as well.  Most cardiovascular disease reductions seen with bariatric surgery occur through the profound weight loss that occurs after surgery.  Risk calculators such as https://riskcalc.org/BariatricSurgeryComplications/ can help guide clinicians and patients when considering bariatric surgery.  BMI WHO Classification Below 18.5 Underweight 18.5-24.9  Normal weight 25.0-29.9 Pre-obesity 30.0-34.9 Obesity class I 35.0-39.9 Obesity class 2 > 40.0 Obesity class 3 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. Chiadi Ndumele is an Assistant Professor in the Department of Medicine at Johns Hopkins University. Dr. Ndumele graduated from Harvard University School of Medicine. He completed his Internal Medicine training at Brigham and Women’s Hospital, where he also served as Chief Medical Resident. He was Chief Cardiology Fellow at Johns Hopkins University. During fellowship training, Dr. Ndumele received an MHS and Ph.D. in Epidemiology at Johns Hopkins Bloomberg School of Public Health. Dr. Ndumele’s research has been supported by career development awards from the NHLBI and Robert Wood Johnson Foundation, a Catalyst Award from Johns Hopkins, an R01 from the NHLBI and an AHA Strategically Focused Research Network Grant. He has received national recognition for his work, including a Young Physician-Scientist Award from the American Society of Clinical Investigation. He has national leadership roles including Chair of the Obesity Subcommittee of the American Heart Association (AHA) and Editorial Board membership on the journals Circulation and Circulation Research. Dr. Ndumele’s research focuses on mechanisms linking adiposity to CVD and strategies to improve prediction and prevention. References and Links Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: A report of the American College of cardiology/American Heart Association task force on practice guidelines and the obesity society. Circulation. 2014;129(25 SUPPL. 1):102-138. doi:10.1161/01.cir.0000437739.71477.ee Yu Z, Grams ME, Ndumele CE, et al. Association Between Midlife Obesity and Kidney Function Trajectories: The Atherosclerosis Risk in Communities (ARIC) Study. Am J Kidney Dis. September 2020. doi:10.1053/j.ajkd.2020.07.025 Kaze AD, Musani SK, Bidulescu A, et al. Plasma Adipokines and Glycemic Progression Among African Americans: Findings from the Jackson Heart Study. Diabet Med. November 2020. doi:10.1111/dme.14465 Cohen LP, Vittinghoff E, Pletcher MJ, et al. Association of Midlife Cardiovascular Risk Factors with Risk of Heart Failure Subtypes Later in Life. J Card Fail. November 2020. doi:10.1016/j.cardfail.2020.11.008 Khera R, Pandey A, Ayers CR, et al. Performance of the Pooled Cohort Equations to Estimate Atherosclerotic Cardiovascular Disease Risk by Body Mass Index. JAMA Netw open. 2020;3(10):e2023242. doi:10.1001/jamanetworkopen.2020.23242 Fliotsos M, Zhao D, Rao VN, et al. Body Mass Index From Early-, Mid-, and Older-Adulthood and Risk of Heart Failure and Atherosclerotic Cardiovascular Disease: MESA. doi:10.1161/JAHA.118.009599 Mann JFE, Nauck MA, Nissen SE, et al. Liraglutide and cardiovascular outcomes in type 2 diabetes. Drug Ther Bull. 2016;54(9):101. doi:10.1056/nejmoa1603827 Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric Surgery versus Intensive Medical Therapy for Diabetes — 5-Year Outcomes. N Engl J Med. 2017;376(7):641-651. doi:10.1056/nejmoa1600869 Aminian A, Zajichek A, Arterburn DE, et al. Association of Metabolic Surgery with Major Adverse Cardiovascular Outcomes in Patients with Type 2 Diabetes and Obesity. JAMA – J Am Med Assoc. 2019;322(13):1271-1282. doi:10.1001/jama.2019.14231 https://riskcalc.org/BariatricSurgeryComplications/ Chiadi Ndumele, MD Carine Hamo, MD Amit Goyal, MD Daniel Ambinder, MD

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 cardiovascular benefit. In contrast data suggests increase all-cause mortality and possibly MACE events. Low cost may make these more affordable for some patients.   Thiazolidinediones (aka: “glitazones”): increase insulin sensitivity, the primary defect in T2DM. Rosiglitazone is discouraged due to adverse cardiovascular outcomes. Pioglitazone has better data, especially in those who’ve had a stroke or TIA (IRIS Trial, NEJM 2016). They may have a role in those for whom other classes are contraindicated or cost-prohibitive.   DPP4 Inhibitors: increase incretin levels (GLP-1 and GIP) which inhibit glucagon release, increase insulin secretion, and delay gastric emptying. They do not cause hypoglycemia or weight gain. These have a very modest glycemic effect and have no CV benefit. There was a signal for increased heart failure hospitalizations with saxagliptin and alogliptin, but not with sitagliptin. These should have very little, if any, role in your management.  See Figures for the “Overall Approach” from the 2019 EASD-ADA update.   Which anti-glycemic drugs have a proven cardiovascular outcomes benefit?  GLP1 Agonists: bind to GLP1 receptor and promote glucose dependent insulin release, inhibit glucagon secretion, and delay gastric emptying. Note that patients should be counseled that these are injectables (oral semaglutide has not yet proven CV  benefit). Liraglutide (LEADER trial) and injectable semaglutide (SUSTAIN-6) showed significant MACE reduction, but CV benefit does not appear to be a class effect. They likely have an anti-atherothrombotic effect as well as benefits on blood pressure, weight, and glycemic control without hypoglycemia. There is no apparent impact on heart failure hospitalizations. Warn of primarily GI side effects and infrequent risk of acute pancreatitis. Start low and slowly up-titrate as tolerated as GI symptoms typically abate with time.  There is a black box warning for medullary thyroid cancer so AVOID if there is a family or personal history of this.  SGLT2 Inhibitors: bind to and block the SGLT2 co-transporter in the renal proximal renal tubules, thereby inhibiting glucose reabsorption and increasing glucose loss via urine (glycosuria) along with osmotic diuresis as well as weight and blood pressure reduction. They have both cardiovascular and renal outcomes benefits. Importantly they reduce HF and cardiovascular death in those with HFrEF independent of hypoglycemic action and are now a key component for HFrEF optimal medical therapy (enjoy Ep #36 with Dr. Robert Mentz). Risks include: dehydration due to osmotic diuresis (consider reducing concurrent diuretic doses), genitourinary fungal infections (not UTIs including pyelonephritis; caution in those with urinary incontinence and poor perineal hygiene), euglycemic DKA (caution in T1DM and those with ketosis-prone T2DM), and a questionable risk of amputations and fractures associated with canagliflozin but not others in the class.   NOTE: many patients with CVD remain on outdated hypoglycemic agents rather than on these newer agents with proven CV benefit. Much of this is related to cost and access. Whenever you see a patient with DM, review their med list and help them bring it up to speed with the latest data!    What is the role of metabolic surgery in patients with DM? The prevalence of obesity is rising at an alarming rate and portrays an equally grim epidemiology for rising rates of diabetes and cardiovascular disease. By 2025, 1/5 of the world may be obese. Already, >1/3 of US adults are obese with stark differences based on race and socioeconomic status. The worldwide prevalence of diabetes is similarly expected to rise: >50% in the next decade! Rates of CV disease and mortality will follow suit.  Preventing obesity via education, lifestyle, and policy is of the utmost importance.  Managing obesity requires a multipronged approach with shared decision making including: promoting a healthy lifestyle with diet and exercise, +/- pharmacologic weight loss, +/- metabolic (bariatric) surgery.  Behavioral intervention promoting a healthy lifestyle is the cornerstone for all overweight and obese patients as part of primary, secondary, and tertiary prevention. However the results are typically modest and inconsistently sustained over longer periods.  Pharmacologic intervention for weight loss may provide added benefit over lifestyle alone and is indicated for individuals with BMI ≥30 kg/m2 or BMI ≥27 kg/m2 with at least 1 obesity-associated comorbidity who are motivated, but have failed to lose weight or maintain weight loss by using high-intensity lifestyle intervention alone. Obesity-associated comorbidities include: T2DM, HTN, HLD, ASCVD (CAD, CVA, PAD), CHF, Afib, VTE, OSA, and CKD. There are 5 antiobesity drugs approved by the US FDA: orlistat, lorcaserin, naltrexone-bupropion, phentermine-topiramate, and liraglutide. Of these, only liraglutide has proven CV benefit.  Metabolic (bariatric) surgery is most effective for clinically significant and sustained weight loss and for diabetes remission in obese individuals. Surgical options include: Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), adjustable gastric banding (AGB), and biliopancreatic diversion with duodenal switch (BPDDS). Metabolic surgery is recommended for patients with a BMI ≥40 kg/m2 without concomitant medical problems and in patients with a BMI ≥35 kg/m2 who have at least 1 severe obesity-associated comorbidity (e.g. T2DM). Interestingly, some of the cardiometabolic benefits of metabolic surgery are independent of weight loss and include mechanisms related to incretin levels, insulin secretion/sensitivity, inflammatory mediator profile, bile acid circulation, and gut microbiota. The peri-operative risk is low and has declined with improved technique. Nutritional deficiencies are the most common long-term complications and can be prevented with follow-up and supplementation.  Show notes updated as of 12.13.2020 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. Dennis Bruemmer is the Director of the Center for Cardiometabolic Health in the Section of Preventive Cardiology and Rehabilitation at the Cleveland Clinic. Dr. Bruemmer earned his MD/PhD degrees from the University of Hamburg in Germany. Following residency training in internal medicine and cardiology in Berlin, Dr. Bruemmer completed a two-year research fellowship as the Diabetes Center Fellow in the Department of Endocrinology at UCLA. He is board-certified in Internal Medicine, Endocrinology, Cardiovascular Disease, and Echocardiography, quite a unique combination! Dr. Bruemmer’s research is focused on mechanisms of atherosclerosis and risk factor intervention for the prevention of coronary artery disease.  References and Links – (bold indicates review or guideline) 1. 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD: The Task Force for diabetes, pre-diabetes, and cardiovascular diseases of the European Society of Cardiology (ESC) and the European Associ. Rev Española Cardiol (English Ed. 2020. doi:10.1016/j.rec.2020.04.007  2. Acharya T, Deedwania P. The Role of Newer Anti-Diabetic Drugs in Cardiovascular Disease. ACC.org Expert Analysis. https://www.acc.org/latest-in-cardiology/articles/2018/05/22/16/59/the-role-of-newer-anti-diabetic-drugs-in-cv-disease. Published 2018. Accessed December 12, 2020.  3. Buse JB, Wexler DJ, Tsapas A, et al. Correction to: 2019 update to: Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of diabetes (EASD) (Diabetologia, (2020), 63, 2, (221-228), 10.1. Diabetologia. 2020;63(8):1667. doi:10.1007/s00125-020-05151-2  4. Buse JB, Wexler DJ, Tsapas A, et al. 2019 update to: Management of hyperglycemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2020. doi:10.2337/dci19-0066  5. Davies MJ, D’Alessio DA, Fradkin J, et al. Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2018. doi:10.1007/s00125-018-4729-5  6. Gæde P, Lund-Andersen H, Parving H-H, Pedersen O. Effect of a Multifactorial Intervention on Mortality in Type 2 Diabetes. N Engl J Med. 2008. doi:10.1056/nejmoa0706245  7. Johnson EL, Feldman H, Butts A, et al. Standards of medical care in diabetes—2020 abridged for primary care providers. Clin Diabetes. 2020. doi:10.2337/cd20-as01  8. Kernan WN, Viscoli CM, Furie KL, et al. Pioglitazone after Ischemic Stroke or Transient Ischemic Attack. N Engl J Med. 2016. doi:10.1056/nejmoa1506930  9. Pareek M, Schauer PR, Kaplan LM, Leiter LA, Rubino F, Bhatt DL. Metabolic Surgery: Weight Loss, Diabetes, and Beyond. J Am Coll Cardiol. 2018;71(6):670-687. doi:10.1016/j.jacc.2017.12.014  10. Zelniker TA, Braunwald E. Clinical Benefit of Cardiorenal Effects of Sodium-Glucose Cotransporter 2 Inhibitors: JACC State-of-the-Art Review. J Am Coll Cardiol. 2020;75(4):435-447. doi:10.1016/j.jacc.2019.11.036  11. Zelniker TA, Braunwald E. Mechanisms of Cardiorenal Effects of Sodium-Glucose Cotransporter 2 Inhibitors: JACC State-of-the-Art Review. J Am Coll Cardiol. 2020;75(4):422-434. doi:10.1016/j.jacc.2019.11.031  Dennis Bruemmer, MD, PhD Amit Goyal, MD Daniel Ambinder, MD

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.  Class III: Low-dose aspirin (75-100 mg orally daily) should not be administered for the primary prevention of ASCVD among adults of any age who are at increased risk of bleeding.  What is the role of Vitamin D supplementation in preventing cardiovascular disease?             The Conundrum: Low levels of Vit D is associated with increased risk of CV outcomes including myocardial infarction, stroke, heart failure, atrial fibrillation, and more. But while low Vit D seems to be a marker for bad outcomes, correlation ≠ causation. Notably, this correlation was not confirmed by Mendelian randomization studies, further refuting possible causation. Confounding factors include links between low Vit D levels and obesity and sedentary lifestyle, themselves risk factors for adverse CV outcomes.  The Question: Given the association between low Vit D levels & CV disease –> can you prevent CV disease by identifying and treating low Vit D with supplementation.   The Data:  Randomized Clinical Trials –> treatment with vitamin D does not prevent CV disease.  Women’s Health Initiative: Calcium & Vit D supplementation had no effect on incident coronary or cerebrovascular events. But perhaps this was due to a low Vit D dose of only 400 IU daily. Would a higher dose have benefit?  ViDA Study: monthly high-dose Vit D supplementation (100,000 IU of D3) did not prevent CV disease, including within the 25% of patients who had level < 20 ng/mL. But this was an atypical supplementation regimen.  Vital Trial: neither n-3 fatty acid (1g/day) nor Vit D3 (2000 IU/day) were effective for primary prevention of CV or cancer events among healthy middle-aged men and women over 5 years of follow-up. This was among the largest of the Vit D supplementation trials targeting CV outcomes and most definitively argues against the benefit of supplementation.                The Recommendations:       Data for Vit D supplementation to improve CV outcomes is all null.   National Academy of Medicine:  Age 19-70 years: 600 IU daily  Age > 70: 800 IU daily  Level <12 ng/mL indicates deficiency, 12-20 ng/mL is inadequate, and >20 ng/mL is adequate for bone and overall health. But the optimal level remains contested. The Endocrine Society recommends aiming for level ≥ 30 ng/mL.  What is the role of Calcium supplementation in preventing cardiovascular disease?  The Conundrum: Calcium supplementation is common and important for bone health. However there is some concern that excess calcium may worsen adverse CV outcomes.   The Question: Does calcium intake cause CV harm?  The Data:  The Auckland Calcium Study: raised concern that calcium supplementation may increase cardiovascular risk (secondary analysis of a study designed to assess impact on bone health).  EPIC-Heidelberg, MESA, & other observational studies: calcium supplementation is associated with adverse cardiovascular events.  In contrast, calcium intake from food sources does not seem to be associated with adverse CV events.   Meta-analysis by Khan et al. 2019: calcium + Vit D was associated with an increased risk for stroke.  These findings may be from the bolus effect of calcium supplementation whereby a sudden rise in serum calcium levels may result in vascular calcium deposition and interact with the coagulation cascade.   The Recommendations:  Use calcium supplementation cautiously, according to the recommended daily intake, and using food sources.  Personalized approach using shared decision making considering CV risk and bone health.  Avoid excess calcium supplementation.  Recommended daily intake:  Adults aged 19-50 years old & Men aged 51-70 years: 1000 mg/day  Adults aged >70 years and Women aged 51-70: 1200 mg/day   What is the role of Omega-3 Polyunsaturated Fatty Acids in preventing cardiovascular disease?   The Conundrum: High triglyceride levels are associated with adverse CV events, but triglyceride-reducing agents like niacin and fibrates, have not been effective in reducing the risk of these events.  The Question: Does intake of Omega-3 Fatty Acids improve CV health and if so, what is the appropriate formulation?  The Data:  ASCEND Omega-3 Trial & VITAL Trial: lower doses of EPA/DHA combination omega-3 fatty acids ~840mg daily are not beneficial in reducing CV events.  REDUCE-IT Trial: 4g of icosapent ethyl (IPE – a pure EPA formulation) daily reduced MACE events in those with elevated triglyceride levels despite statin use.  The Japanese JELIS trial also showed a CV benefit using a lower dose of pure EPA (1.8mg daily) among statin-treated adults with hyperlipidemia.    STRENGTH Trial: 4g EPA/DHA Omega 3-fatty acid formulation failed to show CV benefit among statin-treated patients with dysplipidemia. The difference from REDUCE-IT trial may be due to the drug formulations (pure EPA vs EPA/DHA combination). Notably, in REDUCE-IT, the benefit had a dose-response relationship with blood levels of EPA; the higher the EPA, the greater the benefit.   Dietary fish oil supplements may include a substantial portion of harmful saturated fats vs the beneficial polyunsaturated fats. Dietary supplements have been shows to contain far less Omega-3 fatty acids than indicated on the label! Furthermore, dietary supplements may get oxidized and contain harmful contaminants.   The Recommendations:  Use IPE 4g daily for patients ≥ 45 years old with established ASCVD or ≥ 50 years old with diabetes & other risk factor(s) who are on maximally tolerated statin and continue to have elevated Triglyceride level 135-499 mg/dL.  The marked CV benefit from icosapent ethyl seen in the REDUCE-IT trial should not be extrapolated to other fish oil preparations!         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. Cardionerds Cardiovascular Prevention Series Guest Profiles Dr. Erin Donnelly Michos is an Associate Professor of Medicine at Johns Hopkins School of Medicine, with joint appointment in the Department of Epidemiology at the Johns Hopkins Bloomberg School of Public Health. She is the Director of Women’s Cardiovascular Health and the Associate Director of Preventive Cardiology with the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease. Dr. Michos completed medical school at Northwestern University in Chicago, IL, and then completed both her Internal Medicine residency and Cardiology fellowship at the Johns Hopkins Hospital in Baltimore, MD.  She also completed her MHS in Cardiovascular Epidemiology at the Johns Hopkins Bloomberg School of Public Health. She has authored or co-authored over 300 manuscripts in peer reviewed journals and is an internationally known leader in preventive cardiology and women’s health.  Dr. Rick Ferraro is midwest raised, spent two years as a Teach For America Corps member teaching science in Milwaukee before heading to medical school at Weill Cornell Medicine in NYC. Current senior resident at the Osler Medical Residency program and will begin cardiology fellowship at Johns Hopkins Hospital in 2021. Completed intern year under the incredible leadership of Dr. Amit Goyal. Interested in cardiovascular prevention and imaging Dr. Andi Shahu is a resident physician in the Osler Medical Residency in Internal Medicine at Johns Hopkins Hospital in Baltimore, MD. He will begin General Cardiology fellowship in July 2021 at Yale University. He is interested in the intersection between cardiovascular outcomes, health equity and health policy. You can follow him on Twitter @andishahu.  Sunyoung (Sarah) Jang is a third year medical student at the Johns Hopkins School of Medicine in Baltimore, MD. Interested in public health, she was drawn to Cardiology when she learned that cardiovascular diseases were the leading cause of death globally. She aspires to pursue a career in Cardiology with continued interest in public health, preventative medicine and high value care.  References and Links 1. Al Mheid I, Quyyumi AA. Vitamin D and Cardiovascular Disease: Controversy Unresolved. J Am Coll Cardiol. 2017. doi:10.1016/j.jacc.2017.05.031  2. Effects of Aspirin for Primary Prevention in Persons with Diabetes Mellitus. N Engl J Med. 2018. doi:10.1056/nejmoa1804988  3. McNeil JJ, Nelson MR, Woods RL, et al. Effect of Aspirin on All-Cause Mortality in the Healthy Elderly. N Engl J Med. 2018. doi:10.1056/nejmoa1803955  4. Manson JE, Cook NR, Lee I-M, et al. Vitamin D Supplements and Prevention of Cancer and Cardiovascular Disease. N Engl J Med. 2019. doi:10.1056/nejmoa1809944  5. Scragg R, Stewart AW, Waayer D, et al. Effect of monthly high-dose vitamin D supplementation on cardiovascular disease in the vitamin D assessment study: A randomized clinical trial. JAMA Cardiol. 2017. doi:10.1001/jamacardio.2017.0175  6. Bolland MJ, Barber PA, Doughty RN, et al. Vascular events in healthy older women receiving calcium supplementation: Randomised controlled trial. BMJ. 2008. doi:10.1136/bmj.39440.525752.BE  7. Li K, Kaaks R, Linseisen J, Rohrmann S. Associations of dietary calcium intake and calcium supplementation with myocardial infarction and stroke risk and overall cardiovascular mortality in the Heidelberg cohort of the European Prospective Investigation into Cancer and Nutrition study (EPIC-Heidelberg). Heart. 2012. doi:10.1136/heartjnl-2011-301345  8. Khan SU, Khan MU, Riaz H, et al. Effects of nutritional supplements and dietary interventions on cardiovascular outcomes. Ann Intern Med. 2019. doi:10.7326/M19-0341  9. Yokoyama M, Origasa H, Matsuzaki M, et al. Effects of eicosapentaenoic acid on major coronary events in hypercholesterolaemic patients (JELIS): a randomised open-label, blinded endpoint analysis. Lancet. 2007. doi:10.1016/S0140-6736(07)60527-3  10. Orringer CE, Jacobson TA, Maki KC. National Lipid Association Scientific Statement on the use of icosapent ethyl in statin-treated patients with elevated triglycerides and high or very-high ASCVD risk. J Clin Lipidol. 2019. doi:10.1016/j.jacl.2019.10.014  11. Gaziano JM, Brotons C, Coppolecchia R, et al. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial. Lancet. 2018. doi:10.1016/S0140-6736(18)31924-X  12. Nicholls SJ, Lincoff AM, Garcia M, et al. Effect of High-Dose Omega-3 Fatty Acids vs Corn Oil on Major Adverse Cardiovascular Events in Patients at High Cardiovascular Risk. JAMA. 2020.  13. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2019;74(10):1376-1414. doi:10.1016/j.jacc.2019.03.009  Referenced work by Dr. Michos Mentees in this episode Jang S, Ogunmoroti O, Ndumele CE, et al. Association of the Novel Inflammatory Marker GlycA and Incident Heart Failure and Its Subtypes of Preserved and Reduced Ejection Fraction: The Multi-Ethnic Study of Atherosclerosis. Circ Hear Fail. 2020;(August):251-260. doi:10.1161/CIRCHEARTFAILURE.120.007067 AHA Press release: Low-income adults less likely to receive preventive heart disease care. ASSOCIATION BETWEEN INDIVIDUAL INCOME AND INCIDENCE OF HEART FAILURE SUBTYPES IN THE MULTI-ETHNIC STUDY OF ATHEROSCLEROSIS (MESA) Ferraro R, Latina JM, Alfaddagh A, et al. Evaluation and Management of Patients With Stable Angina: Beyond the Ischemia Paradigm: JACC State-of-the-Art Review. J Am Coll Cardiol. 2020;76(19):2252-2266. doi:10.1016/j.jacc.2020.08.078

CardioNerds (Amit Goyal) joins Thomas Jefferson cardiology fellows (Jay Kloo, Preya Simlote and Sean Dikdan – host of the Med Lit Review podcast) for some amazing craft beer from Independence Beer Garden in Philadelphia! They discuss a fascinating case of atrioesophageal fistula (AEF) formation after pulmonary vein isolation (PVI). Dr. Daniel Frisch provides the E-CPR and program director Dr. Gregary Marhefka provides a message for applicants. Johns Hopkins internal medicine resident Colin Blumenthal 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 The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus. We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director. CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza Patient Summary A man in his mid-60s with a history of paroxysmal Afib presented to the ED after one week of chest pain and altered mental status. His afib had been difficult to rate and rhythm control, and thus he had undergone catheter ablation with pulmonary vein isolation 3 weeks prior to presentation. In the ED he was found to be febrile and had a witnessed seizure. Blood cultures returned positive for Strep agalactiae and his CT head showed multiple areas of intravascular air. Join the Thomas Jefferson University Cardionerds as they take us through an expert discussion on the differential of post-catheter complications, the diagnosis of atrial-esophageal fistula and ultimately management of this potentially fatal complication! Case Media A B C D E F Click to Enlarge A. ECG: Normal sinus rhythm HR 105 bpmB. CXRC. CT head: Multiple tiny foci of air throughout bilateral cerebral hemispheres. Appearance is most suggestive of intravascular air, although it is unclear if it is venous, arterial or both.D. MRI: 1. Restricted diffusion in bilateral cortical watershed zones, as well as in the posterior medial left cerebellar hemisphere, most consistent with recent infarctions.E. CT Chest: A small focus of air tracking along the left mainstem bronchus anterior to the esophagus, may represent a small amount of pneumomediastinum versus air in an outpouching of the esophagus. No air tracking more cranially along the mediastinal soft tissues. No definite soft tissue defect in the esophagus.F. Surgical repair of LA & Esophagus Episode Teaching The CardioNerds 5! – 5 major takeaways from the #CNCR case What is a pulmonary vein isolation? What are the most common complications? When is catheter ablation indicated? The majority of Afib triggers come from areas where the pulmonary veins attach to the left atrium. Approximately 15-20% of patients undergoing ablation will have non-pulmonary vein triggers. Guided by this anatomic and pathophysiologic underpinning, electrical isolation and ablation of these areas helps prevent propagation of the Afib impulses. The most effective method for pulmonary vein isolation (PVI) is ablation of the PV antrum, areas located near the PV ostia, using an oval mapping catheter to confirm ablation of electrical activity from the PV ostia. Vascular access complications (e.g. hematoma, pseudoaneurysm) are the most common complications following PVI and occur in approximately 1-4% (KD: I think complication rate is lower in studies I’ve reviewed) cases. Most other complications occur in less than 1% of cases and include cardiac tamponade/perforation, TIA/stroke, PV stenosis, pneumonia, phrenic nerve palsy, gastric motility disorders, atrial-esophageal fistula, and death. There is some growing evidence that catheter ablation may be superior to medical management alone in certain symptomatic populations (e.g., HFrEF). However, in the recent CABANA trial, catheter ablation did not significantly reduce death, disabling stroke, or serious bleeding compared to medical management in all comers with new-onset or untreated symptomatic Afib. The 2020 ESC guidelines on AFib give a Class I recommendation to Afib ablation for (1) symptom control in patients with paroxysmal or persistent AFib who have failed or are intolerant of at least one Class I or III antiarrhythmic drug (AAD); or (2) to reverse LV dysfunction in AFib patients when tachycardia-induced cardiomyopathy is highly probable regardless of their symptom status. What is an atrial esophageal fistula (AEF) and how does it form after a PVI? Esophageal perforation is a rare complication of PVI and occurs in 0.1-0.25% of procedures. If it goes undetected, an AEF can form, which is an abnormal connection between the esophagus and the left atrium. Overall it is the 2nd most common cause of death after PVI, with acute cardiac tamponade being the most common. In normal human anatomy, the esophagus runs just posterior to the LA, often coming within a few millimeters at its closest point. Regardless of modality (e.g. cryoablation, radiofrequency ablation), this close proximity can lead to damage of the esophagus via multiple mechanisms.  First, all current ablation techniques use thermal injury, which can lead to direct mucosal damage the esophagus. Additionally, damage to the anterior esophageal plexus can impact gastric motility and emptying, which can increase reflux and lead to esophageal ulceration. Finally, thermal damage to the end arterioles can cause ischemic injury to the esophagus, which weakens the esophagus and predisposes it to ulcer and fistula formation. Though data is limited, ulceration of the esophagus appears to be the primary defect in AEF with the ulcer slowly propagating from the esophagus through the pericardium to the LA, forming a one way connection from the esophagus to the LA. What can be done to help avoid AEF formation during a PVI? What risk factors put patients at high risk for AEF formation? Esophageal temperature monitoring is frequently implemented to help reduce the risk of esophageal damage. In the 2017 HRS-led expert consensus statement on ablation of AFib, three-quarters of the writing group members terminate ablation if they observe a 1 C or 2 C rise in temperature from baseline, or a recorded temperature of 39C-40C in their practice. Temperatures above 41C increase the risk of AEF formation. Many providers also prescribe a PPI to reduce gastric acid secretion, a possible contributor to esophageal damage, but this data is not based clinical trial data. Multiple systems including esophageal cooling devices and methods to move the esophagus away from the LA are under development, but none have substantial clinical data to warrant widespread use. Risk factors for AEF formation include RF ablation (though can be seen with all ablation energy sources), higher esophageal temperature, and higher energy delivery (longer contact time, higher power, increased contact force, larger catheter tip, and  higher irrigation flow). What are the most common signs and symptoms of an AEF and how is it diagnosed? Since AEFs start as an esophageal ulcer that progresses to a fistula, AEF formation typically takes 1-6 weeks (mean 20 days) from the time of ablation. Many of the common signs and symptoms are nonspecific and include fever, fatigue, AMS, chest pain, nausea, vomiting, dysphagia, hematemesis, melena, and dyspnea. Common complications include sepsis from bacteria (generally gram-positive organisms) entering the blood stream from the esophagus and stroke from air emboli. CT with oral and IV contrast or MRI imaging of the esophagus are the most useful diagnostic modalities. Occasionally this can show contrast extravasation from the LA to the esophagus, but more commonly it will show air from the esophagus into the pericardial space. Barium swallow can also be helpful as it has a very high specificity, but unfortunately a low sensitivity. Blood cultures and head CT are often obtained given the symptoms that patients present with and increase clinical suspicion if they demonstrate bacteremia or air emboli. Importantly, once AEF is suspected, EGD is contraindicated as insufflation of the esophagus can lead to a large air embolus and stroke. How are AEFs treated? What is the prognosis? Early diagnosis and treatment of AEFs is crucial as mortality is 100% without treatment. Esophageal ulceration or even pericardial esophageal fistulas have significantly better prognosis, highlighting the necessity for early identification. Esophageal stenting has not shown to be effective, and surgical repair with primary repair of the esophagus is the gold standard. Broad spectrum antibiotics should be utilized to treat or prevent the development of bacteremia and sepsis. Even with early identification and proper treatment, mortality is still very high with up to ~40% of patients dying after surgery. References Arruda, M. S., Armaganijan, L., Biase, L. D., Rashidi, R., & Natale, A. (2009). Feasibility and Safety of Using an Esophageal Protective System to Eliminate Esophageal Thermal Injury: Implications on Atrial-Esophageal Fistula Following AF Ablation. 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