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Estatinas no idoso: quando é hora de desprescrever? Neste episódio, discutimos um tema essencial para quem atende pacientes idosos: até quando vale a pena manter o uso de estatinas? Com base nas diretrizes da SBC, ACC/AHA e ESC, além de evidências atualizadas, você vai entender quando a desprescrição é segura, ética e clinicamente indicada.
Send us a textToday we're introducing a new format—the first episode in our Clinical Practice Guidelines series. This week, Drs. Mike and John Fralick discuss the 2025 ACC/AHA Clinical Practice Guidelines for Acute Coronary Syndrome. Here we go! Support the show
Send us a textWelcome back Rounds Table Listeners! Today we're introducing a new format—the first episode in our Clinical Practice Guidelines series. This week, Drs. Mike and John Fralick discuss the 2025 ACC/AHA Clinical Practice Guidelines for Acute Coronary Syndrome. Here we go!2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes (0:00 - 18:56)Mike's interview with Dr. Jeff Carson:Episode 110 - Restrictive versus Liberal Transfusion in Myocardial Infarction with Dr. Jeff CarsonThe Good Stuff:Egg cracking tips! (18:57 - 19:47)Jerro (19:48 - 20:47)Questions? Comments? Feedback? We'd love to hear from you! @roundstable @InternAtWork @MedicinePods
2024 ACC/AHA guideline update, including biomarker testing, MINS, and other consulting tips Master perioperative medicine! Learn when to hold ACE inhibitors, how to manage OSA without delaying surgery, and why "NPO after midnight" is outdated. We're joined by Dr. Avital O'Glasser, our Chief of Perioperative Medicine! Claim CME for this episode at curbsiders.vcuhealth.org! Patreon | Episodes | Subscribe | Spotify | YouTube | Newsletter | Contact | Swag! | CME Show Segments Intro Case Preoperative Assessment & Consulting Tips Risk Calculators Frailty Pulmonary Considerations Cardiovascular Meds & BP Management NPO: Why Are We Still Doing This? Biomarkers & Postoperative Risk MINS Outro Credits Written and produced, show notes, cover art, CME, and infographics: Paul Wurtz MD. Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP Reviewer: Molly Heublein MD Showrunners: Matthew Watto MD, FACP; Paul Williams MD, FACP Technical Production: PodPaste Guest: Avital O'Glasser MD Disclosures Dr. O'Glasser reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. Sponsor: EZResus Listeners of the Cribsiders and Curbsiders podcasts get access to a 2-month free trial,letting them use 100% of the features of the For more information, www.ezresus.com/curbsiders and Use promo code Curbsiders Sponsor: Freed Visit Freed.ai and Usecode:CURB50 to get $50 off your first month when you subscribe. Sponsor: Mint Mobile Get 3 months of premium wireless service from Mint Mobile for $15 a month.Shop plans at mintmobile.com/curb
Due to advancements in medical and surgical care, the survival of patients with congenital conditions into adulthood has dramatically increased. However, as these individuals transition to adulthood, their unique physiology, chronic complications, and evolving care needs create significant challenges for their management when they are admitted to adult intensive care units (ICUs). This episode will discuss adult congenital disease in the ICU. Dr. Zanotti is joined by Dr. Cameron Dezfulian, a pediatric and adult critical care physician. He is the director of the Adult Congenital Heart Disease Program Development for the Section of Critical Care at Texas Children's Hospital and a faculty member at Cardiothoracic Critical Care at Baylor St. Luke's Medical Center. He is also a Senior Faculty member at Baylor College of Medicine in Houston, Texas. Additional resources: ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease. Circulation 2008: https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.108.190690 Special Considerations in Critical of the Congenital Heart Disease Patient. E Neethling, et al. Can J Cardiol. 2023: https://pubmed.ncbi.nlm.nih.gov/36682483/ Management of the Critically Ill Adult with Congenital Heart Disease. WB Kratzert, et al. J Cardiothorac Vasc Anesth 2018: https://pubmed.ncbi.nlm.nih.gov/29500124/ Adults with childhood-onset chronic conditions admitted to US pediatric and adult intensive care units. J Edwards, et al. J Crit Care 2015: https://pubmed.ncbi.nlm.nih.gov/25466316/ Down Syndrome. MJ Bull. N Eng J Med 2020. https://www.nejm.org/doi/full/10.1056/NEJMra1706537 Books and Music mentioned in this episode: The Bible: https://bit.ly/3EK4LL6
February 7-14 is Congenital Heart Disease Awareness Week. In this, Dr. Sergio Zanotti discuss adult congenital heart disease through the lens of his experience as a patient. He shares some reflections based on my experience as a lifelong patient with complex adult congenital heart disease and a recent procedure that allowed him to experience medical care from the patient side. Additional resources: ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease. Circulation 2008: https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.108.190690 The Bell Curve. By Atul Gawande. The New Yorker 2004: https://www.newyorker.com/magazine/2004/12/06/the-bell-curve Website for the Adult Congenital Heart Association: https://www.achaheart.org/ Books and music mentioned in this episode: Montaigne. By Stefan Zweig: https://bit.ly/4gEOVP2 The Heart. A Novel. By Maylis De Kerangal: https://bit.ly/41ehqin The Essays: A Selection (Penguin Classics). By. Michel de Montaigne: https://bit.ly/3EvFwvW
February 7-14 is Congenital Heart Disease Awareness Week. In this, Dr. Sergio Zanotti discuss adult congenital heart disease through the lens of his experience as a patient. He shares some reflections based on my experience as a lifelong patient with complex adult congenital heart disease and a recent procedure that allowed him to experience medical care from the patient side. Additional resources: ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease. Circulation 2008: https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.108.190690 The Bell Curve. By Atul Gawande. The New Yorker 2004: https://www.newyorker.com/magazine/2004/12/06/the-bell-curve Website for the Adult Congenital Heart Association: https://www.achaheart.org/ Books and music mentioned in this episode: Montaigne. By Stefan Zweig: https://bit.ly/4gEOVP2 The Heart. A Novel. By Maylis De Kerangal: https://bit.ly/41ehqin The Essays: A Selection (Penguin Classics). By. Michel de Montaigne: https://bit.ly/3EvFwvW
Join us as we review recent practice-changing articles on a new triple pill for hypertension, how arm position affects blood pressure, early TAVR for asymptomatic patients with severe AS, liberal versus restrictive transfusion strategy in patients with acute brain injury, and a quick overview of the 2024 ACC/AHA perioperative medicine guidelines. Fill your brain hole with a delicious stack of tofurkey cakes! Featuring Paul Williams (@PaulNWilliamz), Rahul Ganatra (@rbganatra), Jen DeSalvo (@drjendesalvo), and Matt Watto (@doctorwatto). Claim CME for this episode at curbsiders.vcuhealth.org! Episodes | Subscribe | Spotify | Swag! |Mailing List | Contact | CME! Credits Written and Hosted by: Rahul Ganatra MD, MPH; Jen DeSalvo MD; Paul Williams, MD, FACP, Matthew Watto MD, FACP Cover Art: Matthew Watto MD, FACP Reviewer: Rahul Ganatra MD, MPH Technical Production: Pod Paste Showrunners: Matthew Watto MD, FACP; Paul Williams MD, FACP Show Segments Intro, disclaimer A new triple pill for hypertension How arm position affects blood pressure Early TAVR for asymptomatic patients with severe AS Liberal versus restrictive transfusion strategy in patients with acute brain injury A quick overview of the 2024 ACC/AHA perioperative medicine guidelines Outro Sponsor: Freed You can try Freed for free right now by going to freed.ai. And listeners of Curbsiders can use code CURB50 for $50 off their first month. Sponsor: AquaTru Today listeners receive 20% off any AquaTru purifier! Just go to AquaTru.com and enter code “CURB“ at checkout. Sponsor: Uncommon Goods To get 15% off your next gift, go to uncommongoods.com/curb.
The following question refers to Sections 2.1 and 4.2 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.The question is asked by CardioNerds Academy Intern Dr. Adriana Mares, answered first by CardioNerds FIT Trialist Dr. Christabel Nyange, and then by expert faculty Dr. Shelley Zieroth. Dr. Zieroth is an advanced heart failure and transplant cardiologist, Head of the Medical Heart Failure Program, the Winnipeg Regional Health Authority Cardiac Sciences Program, and an Associate Professor in the Section of Cardiology at the University of Manitoba. Dr. Zieroth is a past president of the Canadian Heart Failure Society. She has been a PI Mentor for the CardioNerds Clinical Trials Program. The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. American Heart Association's Scientific Sessions 2024As heard in this episode, the American Heart Association's Scientific Sessions 2024 is coming up November 16-18 in Chicago, Illinois at McCormick Place Convention Center. Come a day early for Pre-Sessions Symposia, Early Career content, QCOR programming and the International Symposium on November 15. It's a special year you won't want to miss for the premier event for advancements in cardiovascular science and medicine as AHA celebrates its 100th birthday. Registration is now open, secure your spot here!When registering, use code NERDS and if you're among the first 20 to sign up, you'll receive a free 1-year AHA Professional Membership! Question #36 A 50-year-old woman presents to establish care. Her medical history includes COPD, prediabetes, and hypertension. She is being treated with chlorthalidone, amlodipine, lisinopril, and a tiotropium inhaler. She denies chest pain, dyspnea on exertion, or lower extremity edema. On physical exam, blood pressure is 154/88 mmHg, heart rate is 90 beats/min, and respiration rate is 22 breaths/min with an oxygen saturation of 94% breathing ambient room air. BMI is 36 kg/m2. Jugular venous pulsations are difficult to assess due to her body habitus. Breath sounds are distant, with occasional end-expiratory wheezing. Heart sounds are distant, and extra sounds or murmurs are not detected. Extremities are warm and without peripheral edema. B-type natriuretic peptide level is 28 pg/mL (28 ng/L). A chest radiograph shows increased radiolucency of the lungs, flattened diaphragms, and a narrow heart shadow consistent with COPD. An electrocardiogram shows evidence of left ventricular hypertrophy. The echocardiogram showed normal LV and RV function with no significant valvular abnormalities. In which stage of HF would this patient be classified?AStage A: At Risk for HFBStage B: Pre-HFCStage C: Symptomatic HFDStage D: Advanced HF Answer #36 Explanation The correct answer is A – Stage A or at risk for HF. This asymptomatic patient with no evidence of structural heart disease or positive cardiac biomarkers for stretch or injury would be classified as Stage A or “at risk” for HF. The ACC/AHA stages of HF emphasize the development and progression of disease with specific therapeutic interventions at each stage. Advanced stages and disease progression are associated with reduced survival. The stages were revised in this edition of guidelines to emphasize new terminologies of “at risk” for Stage A and “pre...
In the ACOG practice bulletin 203, the ACOG states that, “Traditionally, the diagnosis of hypertension (HTN) in pregnancy has been 140/90, on 2 occasions at least 4 hrs apart“. The keyword there is… “Traditionally”. In 2017, the ACC/AHA redefined hypertension with Stage I HTN being 130/80. Do some societies recommend the use of this lowered blood pressure criteria in pregnancy? It's a complicated answer. Does aspirin help prevent preeclampsia in women with Stage I (130/80) hypertension? The answer may surprise you! In this episode, we will do a deep dive into ACOG PB 203, the ACOG practice advisory from 2022 in response to the CHAP trial, and discuss the CLIP 2021 published data. This is a story of CHIP, CHAP, and CLIP… And we will give clear clinical implications of each in this episode!
In this episode, experts discuss a crucial 2024 document outlining appropriate use criteria for multimodality imaging in cardiovascular evaluation before non-emergent non-cardiac surgery, addressing the rising annual surgeries and associated cardiac risks. They delve into balancing the necessity of imaging with cost-effectiveness while exploring the potential of artificial intelligence to enhance future evaluations.
2023 ACC/AHA Guideline for the Management of Patients With Chronic Coronary Disease - Link Já agora... RCM eicosapente de etilo - Link Prémios MF's de Ouro - Link --- Nova Android & iOS app MGFamiliar - Link --- Subscreva o Podcast MGFamiliar para não perder qualquer um dos nossos episódios. Além disso, considere deixar-nos uma revisão ou um comentário no Apple Podcasts ou no Spotify. --- Music Kind of a Party by Mini Vandals - Link
In this episode, Dr. Valentin Fuster reviews a pivotal document on Social Determinants of Health (SDOH) in cardiology, highlighting their critical role in shaping health outcomes. He outlines ten key insights, emphasizing the need for standardized definitions and integration of SDOH into electronic health records to promote equitable healthcare and improve patient outcomes.
Guidelines ACC/AHA - Link AF-React Study: artigo BMJ Open 1 - Link AF-React Study: artigo BMJ Open 2 - Link AF-React Study: artigo Frontiers in Medicine - Link (63) Sub e sobretratamento da fibrilhação auricular em Portugal - Link --- Nova Android & iOS app MGFamiliar - Link --- Subscreva o Podcast MGFamiliar para não perder qualquer um dos nossos episódios. Além disso, considere deixar-nos uma revisão ou um comentário no Apple Podcasts ou no Spotify. --- Music Good Life by BraveLion - Link
Commentary by Dr. Valentin Fuster
HelixTalk - Rosalind Franklin University's College of Pharmacy Podcast
In this episode, we discuss principles for medication use in the geriatric patient population and summarize the updated 2023 American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Key Concepts The Beer's Criteria was originally developed by Dr. Mark Beers in 1991 to identify medications in which the risks may outweigh the benefits in nursing home patients. This list is now maintained by the American Geriatrics Society and includes a variety of drug safety information related to elderly patients including medications that are considered potentially inappropriate (Table 2 and 3), medications used with caution (Table 4), drug-drug interactions (Table 5), drugs with renal dose adjustments (Table 6), and drugs with anticholinergic properties (Table 7). The newest update prefers apixaban over other DOACs for VTE and atrial fibrillation in elderly patients. This is a very controversial recommendation given that other guidelines (e.g. from the ACC/AHA) have not published a similar preference of one DOAC over another. Many of the medications that are potentially inappropriate involve drugs that have anticholinergic properties and drugs that increase the risk of incoordination and falls. Other resources exist to guide drug therapy decisions in elderly patients. As an example, the STOPP/START criteria (published in the European Geriatric Medicine journal) outlines drugs to avoid but also drugs to consider in elderly patients. References By the 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 Updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J AM Geriatr Soc. 2023;71(7):2052-2081. doi:10.1111/jgs.18372. O'Mahony D, Cherubini A, Guiteras AR, Denkinger M, Beuscart JB, Onder G, Gudmundsson A, Cruz-Jentoft AJ, Knol W, Bahat G, van der Velde N, Petrovic M, Curtin D. STOPP/START criteria for potentially inappropriate prescribing in older people: version 3. Eur Geriatr Med. 2023 Aug;14(4):625-632. doi: 10.1007/s41999-023-00777-y.
How to Integrate NON-Statin Therapy in Your Practice. Updates from the Latest 2022 LDL-Cholesterol Lowering Guidelines Guest: Regis I. Fernandes, M.D. Hosts: Sharonne N. Hayes, M.D. Since the last ACC/AHA cholesterol guidelines in 2018, the FDA has approved new non-statin cholesterol medications, which have increased our ability to provide a broader range of lipid-lowering drugs. In this podcast, we will discuss the new 2022 ACC expert consensus decision pathway on the role of non-statin therapies for LDL lowering in managing atherosclerotic cardiovascular disease risk. We will review these new drugs and discuss which ones to consider, when, and in what order. Topics Discussed: What are these new FDA-approved nonstatin drugs for lipid-lowering? To whom and when non-statins should be considered? Are there new LDL targets or thresholds for certain patients? What are the new guideline recommendations for patients with statin intolerance? Connect with Mayo Clinic's Cardiovascular Continuing Medical Education online at https://cveducation.mayo.edu or on Twitter @MayoClinicCV and @MayoCVservices. LinkedIn: Mayo Clinic Cardiovascular Services Cardiovascular Education App: The Mayo Clinic Cardiovascular CME App is an innovative educational platform that features cardiology-focused continuing medical education wherever and whenever you need it. Use this app to access other free content and browse upcoming courses. Download it for free in Apple or Google stores today! No CME credit offered for this episode. Podcast episode transcript found here.
CME credits: 1.00 Valid until: 15-03-2025 Claim your CME credit at https://reachmd.com/programs/cme/what-are-the-10-key-takeaways-for-the-2023-accahaaccphrs-guideline-for-af/19780/ The recently published 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines are based on systematic methods to evaluate and classify evidence and provide a foundation for the delivery of quality cardiovascular care. This program will help distill these valuable clinical guidelines to help healthcare professionals better understand these recommendations to incorporate into their clinical practice.
CardioNerds Atrial Fibrillation Series Co-Chairs Dr. Colin Blumenthal (University of Pennsylvania Cardiology fellow) and Dr. Kelly Arps (Duke University Electrophysiology Fellow) join the 2023 atrial fibrillation guideline writing committee Chair Dr. José Joglar (UT Southwestern) and Vice Chair Dr. Mina Chung (Cleveland Clinic). They review the key takeaways from the 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Audio editing by CardioNerds academy intern, student doctor Pace Wetstein. This podcast was developed in collaboration with the American Heart Association. For more on these guidelines, access the AHA Science News AF Guideline landing page. CardioNerds Atrial Fibrillation PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!
Commentary by Dr. Valentin Fuster
Guest: Nancy M. Albert, PhD, CCNS, CHFN, CCRN, NE-BC, FAHA, FCCM, FHFSA, FAAN There are 4 stages of heart failure, ranging from being at risk for heart failure to having an advanced condition. So what key insights should we know about the ACC/AHA stages of heart failure and the NYHA heart failure functional classifications? Discover more with Dr. Nancy Albert, associate chief nursing officer for the Office of Nursing Research and Innovation. Sponsored by Boehringer Ingelheim Pharmaceuticals, Inc. and Lilly USA, LLC. SC-US-75207 3/23
Guest: Nancy M. Albert, PhD, CCNS, CHFN, CCRN, NE-BC, FAHA, FCCM, FHFSA, FAAN There are 4 stages of heart failure, ranging from being at risk for heart failure to having an advanced condition. So what key insights should we know about the ACC/AHA stages of heart failure and the NYHA heart failure functional classifications? Discover more with Dr. Nancy Albert, associate chief nursing officer for the Office of Nursing Research and Innovation.
The study in question is a randomized clinical trial looking at the Million Hearts Model. This model paid health care organizations to assess and reduce CV risk. Obviously, this is an important goal. Heart disease, specifically, atherosclerotic vascular disease, is a leading killer of humans. Any reduction of heart disease should have a benefit on both a person and a population. But paying health systems to do specific things is a policy intervention. Even though a policy, like this one, makes sense, policies can have benefits and potential harms. (An example is the hospital readmissions reduction program (HRRP), which penalized hospitals for excess readmissions. This resulted in a fewer readmissions but it also associated with an increase in death rates in patients with heart failure.)Both Andrew and I were happy that the nudging of Million Hearts was studied The Trial and ProgramThis was a big pragmatic cluster randomized trial that ran over 4 years. More than 300 organizations were randomly assigned 1:1 to have the Million Hearts model or standard care. There were two parts of the model. First there was $10 for every patient who had their 10-year risk calculated with a risk equation. (ACC/AHA is a simple one you can do in 15 seconds with a smartphone.) Then CMS paid each organization $0, $5, or $10 PBPM for each high-risk beneficiary with an annual risk reassessment, with monthly payment amounts dependent on mean risk score change across all of the organization's high-risk beneficiaries reassessed.Keep in mind that the only components of the risk calculation that are modifiable are cholesterol and blood pressure. (*smoking cessation for smokers). Foy pointed out that Million Hearts was in many ways an incentive system to nudge providers, who then may nudge patients, to take more BP and cholesterol medicine. Sensible Medicine is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.The authors chose two primary outcomes: one a MACE endpoint with MI, stroke, and TIA. The second primary was the same as the first, plus CV death. They originally planned to include only high-risk patients, but then added moderate-risk patients. This factored heavily in the results. Patients were mostly 75 year-olds, men-women split 2/3rds, 1/3rd. Outcomes were derived from claims data—which is messy when it comes to judging MIs and TIAs and specific causes of death. The Results:The first primary endpoint (MI, stroke, TIA) occurred at a rate of 14.8 per 1000 patient-years vs 17.0 per 1000 patient-years. The Hazard ratio came to 0.97 (90% CI - 0.93-1.0). The P-value was 0.09. (The authors had previously stipulated that the P threshold would be 0.10). The second primary, adding in CV death, was similar. A HR of 0.96 (90% CI 093-0.99) and a P = 0.02. These are positive results. But let's look further. Drivers of the Results: The results were driven almost exclusively by moderate risk patients. Look at Table 3. Reductions in events rates were largest and significant statistically in the moderate-risk but not high-risk group. That is something we have emphasized here at Sensible Medicine. Even though you would think that high-risk patients have the most to gain, they also have more competing risks and perhaps more chance for treatment harm. Like so many other studies, the sweet spot for primary prevention seems to be in the moderate-risk group. Unintended Consequences: A second finding, noted by Andrew, was the highly significant increase in all-cause hospitalizations in the intervention group. These had the most significant p-values of the entire study. Other Limitations:The Million Hearts model randomization was offered to more than 500 organizations but only 342 accepted. This raises the question of generalizability. Were the 342 organizations special in some way? Another factor is that outcomes were modeled on a sample of events—not raw counts. The choice to use 90% confidence intervals rather than 95% confidence intervals and P thresholds of 0.1 rather than the more standard of 0.05 is a weakness. For instance, the first primary endpoint would have missed significance if this were evaluated in the usual fashion. I did not find a strong justification for this choice. Readers with statistical expertise, please weigh in. Our Conclusions: First, we were both happy that a policy was studied rather than just implemented because it made sense. This should serve as a model for future policy endeavors. Second, there did look to be a modest effect on reducing important outcomes. And, these were driven mostly be moderate-risk (not high-risk) patients. This argues for a heterogenous treatment effect based on co-morbidity. Third, the statistically significant increase in all-cause hospitalizations in the intervention arm suggests that more aggressive attempts at blood pressure and cholesterol levels may have risen the risk of off-target ill effects. In the end, Andrew felt like the study was a wash. He did not feel strongly that the Million Hearts endeavor made a real difference. Comments on our Audio— I think we misspoke about the patient years. We said per 100,000 patient years. It was 1000 patient years. I also think we misspoke about deaths being similar. It was actually slightly lower in the intervention arm. Recall that Sensible Medicine remains a subscriber supported site. Thanks for your generous support. We are excited to bring you content that can't easily be found elsewhere. I have an excellent recording to post soon on screening for atrial fibrillation. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe
Commentary by Dr. Valentin Fuster
CardioNerds co-founder Dr. Dan Ambinder joins CardioNerds join Dr. Pooja Prasad, Dr. Khoa Nguyen and expert Dr. Abigail Khan (Assistant Professor of Medicine, Division of Cardiovascular Medicine, School of Medicine) from Oregon Health & Science University and discuss a case of mechanical valve thrombosis. Audio editing by CardioNerds Academy Intern, student doctor Adriana Mares. A 23-year-old pregnant woman with a mechanical aortic valve presented to the maternal cardiac clinic for a follow-up visit. On physical exam, a loud grade three crescendo-decrescendo murmur was audible and transthoracic echocardiography revealed severely elevated gradients across the aortic valve. Fluoroscopy confirmed an immobile leaflet disk. Thrombolysis was successfully performed using a low dose ultra-slow infusion of thrombolytic therapy, leading to normal valve function eight days later. Treatment options for mechanical aortic valve thrombosis include slow-infusion, low-dose thrombolytic therapy or emergency surgery. In addition to discussing diagnosis and management of mechanical valve thrombosis, we highlight the importance of preventing valve thrombosis during the hypercoagulable state of pregnancy with careful pre-conception counseling and a detailed anticoagulation plan. See this case published in European Heart Journal - Case Reports. US Cardiology Review is now the official journal of CardioNerds! Submit your manuscript here. CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls - mechanical valve thrombosis The hypercoagulable state of pregnancy presents a risk for women with mechanical heart valves with contemporary data estimating the rate of valve thrombosis during pregnancy at around 5%. Thrombolytic therapy is a (relatively) safe alternative to surgery and should be considered first line for treatment of prosthetic valve thrombosis in all patients, especially in pregnant women. Pre-conception counselling and meticulous anticoagulation management for patients with mechanical heart valves are key aspects of their care. The evaluation for prosthetic valve thrombosis in pregnant persons requires a review of anti-coagulation history and careful choice of diagnostic testing to confirm the diagnosis and minimize risks to the parent and the baby. Multi-disciplinary care with close collaboration between cardiology and obstetrics is critical when caring for pregnant persons with cardiac disease. Show Notes - mechanical valve thrombosis How can we counsel and inform women with heart disease who are contemplating pregnancy? Use the Modified World Health Organization classification of maternal cardiovascular risk to counsel patients on their maternal cardiac event rate and recommended follow-up visits and location of delivery (local or expert care) if pregnancy is pursued. To learn about normal pregnancy cardiovascular physiology and pregnancy risk stratification in persons with cardiovascular disease, enjoy CardioNerds Episode #111. Cardio-Obstetrics: Normal Pregnancy Physiology with Dr. Garima Sharma. Adapted from the 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy What is the differential diagnosis for a new murmur in a pregnant person who has undergone heart valve replacement? Normal physiology - elevated flow from hyperdynamic state and/or expansion of blood volume in pregnancy. Pathologic - increased left ventricular outflow tract flow from turbulence of flow due to pannus ingrowth, new paravalvular leak, or obstructive mechanical disk motion from vegetation or thrombus. What are diagnostic modalities for the evaluation of suspected prosthetic valve thrombosis? The 2020 ACC/AHA guidelines gave a class I recommendation for evaluation of susp...
The following question refers to Section 4.5 of the 2021 ESC CV Prevention Guidelines. The question is asked by Dr. Maryam Barkhordarian, answered first by pharmacy resident Dr. Anushka Tandon, and then by expert faculty Dr. Noreen Nazir. Dr. Nazir is Assistant Professor of Clinical Medicine at the University of Illinois at Chicago, where she is the director of cardiac MRI and the preventive cardiology program. The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #33 Mr. V is a 37-year-old man who presents to clinic after a recent admission for anterior STEMI and is status-post emergent percutaneous intervention to the proximal LAD. He has mixed hyperlipidemia and a 10 pack-year history of (current) tobacco smoking. Which of the following points related to tobacco use is LEAST appropriate for today's visit? A Providing assessment and encouragement for smoking cessation, even if for only a 30-second “very brief advice” intervention. B Reviewing and offering pharmacotherapy support options for smoking cessation if Mr. V expresses readiness to quit today. C Recommending a switch from traditional cigarettes to e-cigarettes as a first step towards cessation, as e-cigarettes are safer for use. D Discussing that smoking cessation is strongly recommended for all patients, regardless of potential weight gain. Answer #33 Explanation Answer C is LEAST appropriate and therefore is the correct answer. Answer C is not appropriate. Although e-cigarettes may be more effective than nicotine replacement therapy (NRT) for smoking cessation, the long-term effects of e-cigarettes on cardiovascular and pulmonary health are unknown. According to the 2019 ACC/AHA prevention guidelines, e-cigarettes may increase the risk of CV and pulmonary diseases; their use has been reportedly associated with arrhythmias and hypertension. Therefore, neither the ESC nor ACC/AHA suggest clinicians recommend e-cigarettes over traditional cigarettes to patients. Answer A: Smoking cessation is one of the most effective CVD risk-lowering preventive measures, with significant reductions in (repeat) myocardial infarctions or death. ESC guidelines emphasize the importance of encouraging smoking cessation even in settings where time is limited. “Very brief advice” on smoking is a proven 30-second clinical intervention, developed in the UK, which identifies smokers, advises them on the best method of quitting, and supports subsequent quit attempts. While ESC does not explicitly suggest a frequency of assessment, the 2019 ACC/AHA guidelines specifically recommend that “all adults should be assessed at every healthcare visit for tobacco use and their tobacco use status recorded as a vital sign to facilitate tobacco cessation.” Answer B: The ESC suggests (class 2) that offering follow-up support, nicotine replacement therapy, varenicline, and bupropion individually or in combination should be considered in smokers. A meta-analysis of RCTs in patients with ASCVD reflects that varenicline (RR 2.6), bupropion (RR 1.4), telephone therapy (RR 1.5), and individual counselling (RR 1.6) all increased quit rates versus placebo; NRT therapies were well-tolerated but had inconclusive effects on quit rates (RR 1.22 with 95% CI 0.72-2.06). The 2019 ACC/AHA recommendation to combine behavioral and pharmacotherapy interventions to maximize quit rates is a class 1 recommendation. Answer D: The ESC gives a class 1 recommendation to recommending smoking cessation regardless of weight grain. Smokers who quit may expect an average weight gain of 5 kg, but the health benefits of tobacco cessation (both CVD and non-CVD related) consistently outweigh risks from weight...
CardioNerds CardioOncology Series Co-Chairs, Dr. Teodora Donisan and Dr. Dinu Balanescu, and FIT Lead Dr. Bala Pushparaji discuss Interventional CardioOncology with Prof. Cezar Iliescu. In this episode, we discuss the spectrum of cardiovascular diseases encountered by the interventional onco-cardiologist, with a focus on nuances in endovascular therapies tailored to cancer patients and their unique comorbidities and complications. We also discuss certain special scenarios seen in the critically ill cancer patient, such as chronic thrombocytopenia, and how they alter standard of care compared to non-cancer patients. Show notes were drafted by Dr. Bala Pushparaji and episode audio editing was performed by Dr. Akiva Rosenzveig. This episode is supported by a grant from Pfizer Inc. This CardioNerds Cardio-Oncology series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Giselle Suero Abreu, Dr. Dinu Balanescu, and Dr. Teodora Donisan. CardioNerds Cardio-Oncology PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls and Quotes - Interventional CardioOncology Cancer should be treated as a chronic illness akin to hypertension or diabetes and should not deprive patients from receiving appropriate cardiovascular treatment if otherwise indicated (e.g., PCI for acute coronary syndromes, etc.). In cancer patients with stable angina, along with maximizing medical therapy, multimodality imaging (CTA/PET), intravascular imaging (IVUS/OCT), and physiologic testing (iFR/FFR) should be used routinely to prevent unnecessary stenting. Caution is required in the cath lab for the cancer patient with thrombocytopenia. Techniques include utilizing micropuncture access, transfusing appropriate blood products based on thromboelastogram (TEG), and adjusting antiplatelet therapy regimens and duration. Transcatheter aortic valve replacement (TAVR) is now the recommended treatment for most cancer patients with symptomatic/severe aortic stenosis and, if otherwise indicated, should preferably be pursued prior to cancer treatment to optimize the patient's cardiovascular fitness and tolerance of anti-cancer therapy. Pericardiocentesis in the cancer patient should be performed preferably under fluoroscopy with echocardiography and vascular ultrasound guidance (“triple guidance”). Show notes - Interventional CardioOncology What is the general approach to cardiovascular illness in the cancer patient? Cancer and cardiovascular diseases share numerous risk factors. In addition, cancer and cancer therapies can be atherogenic, by means of inducing pro-inflammatory and hyprecoagulable states, increasing the risk of ischemic heart disease, stroke, and peripheral arterial disease.1 In the outpatient setting, emphasis should be placed on optimizing cardiovascular risk factors and improving overall cardiovascular fitness by exercising, having a healthy diet, and having regular sleep hours as these favor survivorship after cancer treatment. Questions to be answered in the clinic are - Is the patient cardiovascularly fit? Will the patient's heart withstand cancer treatment? Is there concern for coronary artery disease, valvular disease, pericardial disease, or pulmonary hypertension? Risk assessment and treatment for cancer patients with suspected or known cardiovascular disease should generally follow established ACC/AHA guidelines, with special considerations as outlined by the Society of Cardiovacular Angiography and Interventions (SCAI).2 Pre-chemotherapy cardioprotection for patients without coronary artery disease (CAD) with prophylactic beta-blockers, ACEi/ARB, and statins should be considered when appropriate.
Commentary by Dr. Valentin Fuster
CardioNerds co-founder Dr. Amit Goyal and episode leads Dr. Jaya Kanduri (FIT Ambassador from Cornell University) and Dr. Jenna Skowronski (FIT Ambassador from UPMC) discuss Complications of acute myocardial infarction with expert faculty Dr. Jeffrey Geske. They discuss various complications of acute MI such as cardiogenic shock, bradyarrythmias, left ventricular outflow tract obstruction, ruptures (papillary muscle rupture, VSD, free wall rupture), and more. Show notes were drafted by Dr. Jaya Kanduri. Audio editing by CardioNerds Academy Intern, student doctor Tina Reddy. The CardioNerds Beyond the Boards Series was inspired by the Mayo Clinic Cardiovascular Board Review Course and designed in collaboration with the course directors Dr. Amy Pollak, Dr. Jeffrey Geske, and Dr. Michael Cullen. CardioNerds Beyond the Boards SeriesCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls and Quotes - Complications of Acute Myocardial Infarction Sinus tachycardia is a “harbinger of doom”! The triad for RV infarction includes hypotension, elevated JVP, and clear lungs. These patients are preload dependent and may need fluid resuscitation despite having an elevated JVP. Bradyarrythmias in inferior MIs are frequently vagally mediated. The focus should be on medical management before committing to a temporary transvenous pacemaker, such as reperfusion, maintaining RV preload and inotropy, avoiding hypoxia, and considering RV-specific mechanical circulator support (MCS). Worsening hypotension with inotropic agents (e.g., dobutamine, epinephrine, dopamine, norepinephrine) after a large anterior-apical MI should raise suspicion for dynamic left ventricular outflow tract obstruction due to compensatory hyperdynamic basal segments. The myocardium after a late presentation MI is as “mushy as mashed potatoes”! Need to look out for papillary muscle rupture, VSD, and free wall rupture as potential complications. Papillary muscle rupture can occur with non-transmural infarcts, and often presents with flash pulmonary edema. VSDs will have a harsh systolic murmur and are less likely to present with pulmonary congestion. Free wall rupture can present as a PEA arrest. All of these complications require urgent confirmation on imaging and early involvement of surgical teams. Notes - Complications of Acute Myocardial Infarction How should we approach cardiogenic shock (CS) in acute myocardial infarction (AMI)? Only 10% of AMI patients present with CS, but CS accounts for up to 70-80% of mortality associated with AMI, usually due to extensive LV infarction with ensuing pump failure. Physical examSinus tachycardia is considered a “harbinger of doom”, when the body compensates for low cardiac output by ramping up the heart rateThe presence of sinus tachycardia and low pulse and/or blood pressure in a patient with a large anterior MI should raise suspicion for cardiogenic shockBe wary of giving IV beta blockers in this situation as negative inotropes can precipitate cardiogenic shock (Commit Trial) When interpreting a patient's blood pressure in the acute setting, it is helpful to know their baseline blood pressure and if they have a significant history of hypertension. Patients
The following question refers to Figures 6-8 from Sections 3.2 of the 2021 ESC CV Prevention Guidelines. The question is asked by student Dr. Hirsh Elhence, answered first by Ohio State University Cardiology Fellow Dr. Alli Bigeh, and then by expert faculty Dr. Eugene Yang.Dr. Yang is Professor of Medicine at the University of Washington where he is also the Medical Director of the Eastside Specialty Center and the co-Director of the Cardiovascular Wellness and Prevention Program. Dr. Yang is former Governor of the ACC Washington Chapter and as well as former Chair of the ACC Prevention of CVD Section. The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #31 The 2021 ESC CV Prevention guidelines recommend a stepwise approach to risk stratification and treatment options. What is the first step in risk factor treatment regardless of past medical history, risk factors, or established ASCVD?AInitiate statin for goal LDL
Commentary by Dr. Valentin Fuster
The following question refers to Section 4.3 of the 2021 ESC CV Prevention Guidelines. The question is asked by CardioNerds Academy Intern Dr. Maryam Barkhordarian, answered first by medicine resident CardioNerds Academy House Chief Dr. Ahmed Ghoneem, and then by expert faculty Dr. Kim Williams.Dr. Williams is Chief of the Division of Cardiology and is Professor of Medicine and Cardiology at Rush University Medical Center. He has served as President of ASNC, Chairman of the Board of the Association of Black Cardiologists (ABC, 2008-2010), and President of the American College of Cardiology (ACC, 2015-2016). The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #27 Mr. O is a 48-year-old man with a past medical history significant for obesity (BMI is 42kg/m2), hypertension, type 2 diabetes mellitus, and hypercholesterolemia. His calculated ASCVD risk score today is 18.8%. You counsel him on the importance of weight loss in the context of CVD risk reduction. Which of the following weight loss recommendations is appropriate?AMaintaining a weight loss of at least 25% from baseline is required to influence blood pressure, cholesterol, and glycemic control. BHypocaloric diets lead to short term weight loss, but a healthy diet should be maintained over time to reduce CVD risk.CLiraglutide can be used to induce weight loss, as an alternative to diet and exercise.DBariatric surgery is effective for weight loss but has no ASCVD risk reduction benefit. Answer #27 Explanation The correct answer is B. Energy restriction is the cornerstone of management of obesity. All the different types of hypocaloric diets achieve similar short-term weight loss, but these effects tend to diminish by 12 months. It is a class I recommendation to maintain a healthy diet over time to achieve CVD risk reduction. The Mediterranean diet is an example of a diet that can have persistent CV benefit beyond the 12 months. Choice A is incorrect because maintaining even a moderate weight loss of 5 – 10% from baseline has favorable effects on risk factors including blood pressure, cholesterol, and glycemic control, as well as on premature all-cause mortality. Choice C is incorrect because medications approved as aids to weight loss (such as liraglutide, orlistat and naltrexone/bupropion) may be used in addition to lifestyle measures to achieve weight loss and maintenance; they are not alternatives to a healthy lifestyle. Meta-analysis of medication-assisted weight loss found favorable effects on BP, glycemic control, and ASCVD mortality. Choice D is incorrect because patients undergoing bariatric surgery had over 50% lower risks of total ASCVD and cancer mortality compared with people of similar weight who did not have surgery. Bariatric surgery should be considered for obese high-risk individuals when lifestyle change does not result in maintained weight loss (Class IIa). The ACC/AHA guidelines focused primarily on lifestyle interventions for obesity and had no specific recommendations for bariatric surgery or medication-assisted weight loss. Main Takeaway Weight reduction (even as low as 5-10% from baseline) and long-term maintenance of a healthy diet are recommended to improve the CVD risk profile of overweight and obese people. Medication and/or bariatric surgery may have a useful adjunctive role in some patients. Guideline Loc. Section 4.3.3 CardioNerds Decipher the Guidelines - 2021 ESC Prevention SeriesCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor RollCardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!
The following question refers to Sections 3.3 and 3.4 of the 2021 ESC CV Prevention Guidelines. The question is asked by CardioNerds Academy Intern student Dr. Adriana Mares, answered first by Brigham & Women's medicine resident & Director of CardioNerds Internship Dr. Gurleen Kaur, and then by expert faculty Dr. Allison Bailey. Dr. Bailey is an advanced heart failure and transplant cardiologist at Centennial Heart. She is the editor-in-chief of the American College of Cardiology's Extended Learning (ACCEL) editorial board and was a member of the writing group for the 2018 American Lipid Guidelines. The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #26 Ms. Priya Clampsia is a 58-year-old never-smoker with a history of hypertension. Her BMI is 29 kg/m2. She also mentions having pre-eclampsia during her pregnancy many years ago. She describes a predominately sedentary lifestyle and works as a receptionist. You see her in the clinic to discuss routine preventive care. Her most recent lipid panel results were LDL of 101 mg/dL, HDL of 45 mg/dL, and triglycerides of 190 mg/dL. What additional step will provide valuable information regarding her CVD risk profile? A Send additional lab workup including C-reactive protein and lipoprotein (a) B Measure her waist circumference C Assess her work stress D Ask her about history of preterm birth E B, C, and D Answer #26 Explanation The correct answer is E – measuring her waist circumference, assessing her occupational stress, and obtaining history about adverse pregnancy outcomes including preterm birth all add valuable information for CVD risk stratification. BMI is easily measured and can be used to define categories of body weight. However, body fat stores in visceral tissue carry higher risk than subcutaneous fat and therefore, waist circumference can be a simple way to measure global and abdominal fat. When waist circumference is ≥102 cm in men and ≥88 cm in women, weight reduction is advised. While these WHO thresholds are widely accepted in Europe, it is important to note that different cut-offs may be appropriate in different ethnic groups. Work stress is important to ascertain as well because there is preliminary evidence of the detrimental impact of worse stress on ASCVD health, independent of conventional risk factors and their treatment. Work stress is determined by job strain (i.e., the combination of high demands and low control at work) and effort-reward imbalance. Pre-eclampsia is associated with increase in CVD risk by factor of 1.5-2.7 compared with all women. Both preterm (RR 1.6) and still birth (RR 1.5) are also associated with a moderate increase in CVD risk. Taking a thorough pregnancy history is important in determining future cardiovascular risk in women. The ESC guidelines give a Class IIb (LOE B) recommendation that in women with history of premature or stillbirth, periodic screening for hypertension and DM may be considered. Of note, the 2018 ACC/AHA guidelines include preeclampsia and premature menopause (occurring at age
The following question refers to Section 4.4 of the 2021 ESC CV Prevention Guidelines. The question is asked by Dr. Maryam Barkhordarian, answered first by medicine resident Dr. Ahmed Ghoneem, and then by expert faculty Dr. Noreen Nazir. Dr. Nazir is Assistant Professor of Clinical Medicine at the University of Illinois at Chicago, where she is the director of cardiac MRI and the preventive cardiology program. The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association. Question #21 Ms. J is a 57-year-old woman with a past medical history of myocardial infarction resulting in ischemic cardiomyopathy, heart failure with reduced ejection fraction, and major depressive disorder who presents today for follow-up. She reports feeling extremely overwhelmed lately due to multiple life stressors. She is on appropriate cardiovascular GDMT agents and is not prescribed any medications for her mood disorder. True or false: in addition to psychotherapy for stress management, it is appropriate to consider Ms. J for anti-depressant SSRI pharmacotherapy at this time to improve cardiovascular outcomes. A True B False Answer #21 Explanation The correct answer is FALSE. An ESC class 3 recommendation states that SSRIs, SNRIs, and tricyclic antidepressants are not recommended in patients with heart failure and major depression; this is based on data suggesting potential lack of SSRI efficacy for reducing depression or cardiovascular events, as well as safety data indicating an association between SSRI use and increased risk of CV events and all-cause as well as cardiovascular mortality among HF patients. Mental health disorders are associated with worse outcomes in patients with ASCVD and appropriate treatment effectively reduces stress symptoms and improves quality of life. Nonpharmacologic modalities of treatment (exercise therapy, psychotherapy, collaborative care) should be considered before pharmacotherapy to improve cardiovascular outcomes in patients with heart failure. Of note, the ESC suggests SSRI treatment be considered for patients with coronary heart disease (without HF) and moderate-to-severe major depression based on data that SSRI treatment is associated with lower rates of CHD readmission (RR 0.63), all-cause mortality (RR 0.56), and the composite endpoint of all-cause mortality/MI/PCI (HR 0.69) vs. no treatment. This is a class 2a recommendation. ESC also gives a class 2a recommendation to consider referral to psychotherapeutic stress management for individuals with stress and ASCVD to improve CV outcomes and reduce stress symptoms. The ACC/AHA guidelines do not provide focused recommendations regarding mental health considerations in patients with elevated cardiovascular risk. Main Takeaway It is important to consider mental health treatment in patients with ASCVD as mental disorders are associated with increased CVD risk and poor patient prognosis, and data support that mental health interventions can improve overall and CVD outcomes, as well as improve quality of life. Guideline Loc. Section 4.4 CardioNerds Decipher the Guidelines - 2021 ESC Prevention Series CardioNerds Episode Page CardioNerds Academy Cardionerds Healy Honor Roll CardioNerds Journal Club Subscribe to The Heartbeat Newsletter! Check out CardioNerds SWAG! Become a CardioNerds Patron!
In this week's View, Dr. Eagle discusses a prespecified analysis of the NUDGE-FLU trial that reported on the effectiveness of electronic nudges on influenza vaccination rate in older adults with cardiovascular disease, then looks at a comparison of the ESC/EACTS vs. ACC/AHA guidelines for the management of severe aortic stenosis. Finally, Dr. Eagle explores a long-term study of pregnancy complications and long-term mortality in a diverse cohort. Subscribe to Eagle's Eye View
Dr. Ehtisham Mahmud, on behalf of the document leadership team and writing committee for the ACC/AHA/SCAI Interventional Cardiology Advanced Training Statement, presents a high-level overview of the cardiovascular profession's first document covering the breadth of interventional cardiology training, including coronary, peripheral vascular, structural heart, and adult congenital heart interventions.
The following question refers to Section 2.1 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by Keck School of Medicine USC medical student & CardioNerds Intern Hirsh Elhence, answered first by Mount Sinai Hospital cardiology fellow and CardioNerds FIT Trialist Dr. Jason Feinman, and then by expert faculty Dr. Biykem Bozkurt. Dr. Bozkurt is the Mary and Gordon Cain Chair, Professor of Medicine, Director of the Winters Center for Heart Failure Research, and an advanced heart failure and transplant cardiologist at Baylor College of Medicine in Houston, TX. She is former President of HFSA, former senior associate editor for Circulation, current Editor-In-Chief of JACC Heart Failure. Dr. Bozkurt was the Vice Chair of the writing committee for the 2022 Heart Failure Guidelines. The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #1 A 23-year-old man presents to his primary care physician for an annual visit. His father was diagnosed with idiopathic cardiomyopathy at 40 years of age. His blood pressure in clinic is 146/90 mmHg. He is a personal trainer and exercises daily, including both weightlifting and cardio. He denies any anabolic steroid use. He is an active tobacco smoker, approximately ½ pack per day. Review of systems is negative for symptoms. What stage of heart failure most appropriately describes his current status? A Stage A B Stage B C Stage C D Stage D E None of the above Answer #1 The correct answer is A – Stage A of heart failure. Overall, the ACC/AHA stages of HF were designed to emphasize the development and progression of disease. More advanced stages and progression are associated with reduced survival. Stage A HF is where patients are “at risk for HF”, but without current or previous symptoms or signs of HF, and without structural/functional heart disease or abnormal biomarkers. At-risk patients include those with hypertension, cardiovascular disease, diabetes, obesity, exposure to cardiotoxic agents, genetic variant for cardiomyopathy, or family history of cardiomyopathy. Stage B HF is the “pre-heart failure” stage where patients are without current or previous symptoms or signs of HF but do have at least one of the following: Structural heart disease (i.e., reduced left or right ventricular systolic function, ventricular hypertrophy, chamber enlargement, wall motion abnormalities, and valvular heart disease) Evidence of increased filling pressures Risk factors and increased natriuretic peptide levels or persistently elevated cardiac troponin in the absence of an alternate diagnosis Stage C HF indicates symptomatic heart failure where patients have current or previous symptoms or signs of HF. Stage D HF indicates advanced heart failure with marked HF symptoms that interfere with daily life and with recurrent hospitalizations despite attempts to optimize guideline-directed medical therapy. Therapeutic interventions in each stage aim to modify risk factors (Stage A), treat risk and structural heart disease to prevent HF (stage B), and reduce symptoms, morbidity, and mortality (stages C and D). Given this patient's family and social histories, along with the clinical finding of elevated blood pressure, he is best classified as having Stage A, or at risk for HF.
It's another session of CardioNerds Rounds! In these rounds, Dr. Natalie Stokes (Formerly FIT at University of Pittsburgh and now General Cardiology Faculty at University of Pittsburgh) and Dr. Karan Desai (formerly FIT at University of Maryland and now General Cardiology faculty at Johns Hopkins) join Dr. Rick Nishimura (Professor of Medicine at Mayo Clinic) to discuss the nuances of managing mitral regurgitation through real cases. Dr. Nishimura has been an author or Chair of the ACC/AHA valve guidelines going back 20 years and has been recognized internationally as one of the world's best educators, so you don't want to miss the #NishFactor on these #CardsRounds! Audio editing by CardioNerds academy intern, Pace Wetstein. This episode is supported with unrestricted funding from Zoll LifeVest. A special thank you to Mitzy Applegate and Ivan Chevere for their production skills that help make CardioNerds Rounds such an amazing success. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds. Case details are altered to protect patient health information. CardioNerds Rounds is co-chaired by Dr. Karan Desai and Dr. Natalie Stokes. Speaker disclosures: None Challenging Cases - Atrial Fibrillation with Dr. Hugh Calkins CardioNerds Rounds PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Show notes - Mitral Regurgitation with Dr. Rick Nishimura Case #1 Synopsis: A man in his 70s with a history of non-ischemic cardiomyopathy (last known LVEF 15-20%) and atrial fibrillation, presented with decompensated heart failure in the setting of moderate to severe mitral regurgitation. He was diuresed, transitioned to GDMT, and referred to cardiac rehabilitation. Over the next 6 months, he continued to have debilitating dyspnea (NHYA Class IIIa) and his outpatient physicians were limited on titrating GDMT further due to hypotension. A TEE was done which demonstrated EF 15%, severe MR by color and quantitation (EROA of 0.5 cm2; Regurgitant Volume of 65 mL), systolic flow reversal in the pulmonary vein and severe tricuspid regurgitation. We were asked how we would approach this case Case #1Takeaways In attempting to keep the evaluation of chronic mitral regurgitation relatively simple, we should ask ourselves three primary questions: (1) What is causing the MR; (2) How much MR is there; and (3) What is the hemodynamic consequence of the MR.To the first question of what is the etiology of the MR – a simple framework is to think of the etiology as an issue of the valve (primary) or an issue of the ventricle/atria (secondary). There is further classification that can be made based on the Carpentier Classification which speaks to the valve leaflet movement and position (normal leaflet motion, excessive leaflet motion [e.g., prolapse], or restricted in systole and/or diastole [e.g., rheumatic heart disease]).During rounds, Dr. Nishimura provided some historical context in that the original valve guidelines had recommendations for intervention on primary mitral regurgitation and not secondary – given that it is considered a disease of the ventricle. Trials like the COAPT trial have greatly shifted our practice in treating secondary mitral regurgitation. Though, we have to be familiar with which patients with secondary MR would truly derive benefit from mitral valve interventionIn regards to the COAPT trial, patients with moderate to severe (3+) or severe (4+) mitral regurgitation who remained symptomatic despite maximally tolerated guideline-directed medical therapy (GDMT) were included. Dr. Nishimura makes the point that about one-third of patients intended to be enrolled in the trial were not included because they improved so much on GDMT. And thus, when evaluating patients for consideration of mitral valve intervention in secondary MR – a...
Computerized Left Ventricular Hypertrophy Detection Guest: Bob Farrell, Ph.D. Hosts: Anthony H. Kashou, M.D. (@anthonykashoumd) When the heart in the human body's source to pump blood has decreased, it is referred to as the left ventricle. Furthermore, the hypertrophy or the heart's wall eventually loses its firmness, which leads to a higher risk of hypertension or high blood pressure. Often, the heart tends to lose its ability to pump blood. In addition, some signs to stay aware of are feeling fatigued, dizziness, fainting, and frequent chest pain. Patients affected by Left Ventricular Hypertrophy are more at risk of becoming diagnosed if they experience decreased or increased heart rhythm signals or congestive heart failure. Therefore, when the doctor recommends testing, an Electrocardiogram is used to record signals to test the heart rhythm and abnormalities. In addition, an MRI or Echocardiogram is used to test Computerized Left Ventricular Hypertrophy as well. Joining us today to discuss Computerized Left Ventricular Hypertrophy Detection is Bob Farrell, M.D., professor of medicine at Queen's University in Kingston, Ontario, Canada. Furthermore, Dr. Farrell is currently a member of the board of directors of the International Society of Computerized Electrocardiology. Specific topics discussed: With other modalities available to clinicians (e.g., echo, cardiac MR), is ECG still relevant in the discussion of LVH? You have recently made some updates in the GE “12SL” program related to LVH. What drove the changes that you made? Customer feedback, opaqueness of the criteria, ACC/AHA recommendations to manufacturers So what were the changes you made? How did you pick which of the many criteria out there to use and how important was it to explicitly list the positive criteria in the interpretation? You mentioned earlier that ECG-LVH is an entity in its own right and is associated with poorer outcomes. Can you talk about ECG-LVH and risk prediction, and how the changes you've made in the GE 12SL program aid in the risk prediction? Connect with Mayo Clinic's Cardiovascular Continuing Medical Education online at https://cveducation.mayo.edu or on Twitter @MayoClinicCV and @MayoCVservices. Facebook: MayoCVservices LinkedIn: Mayo Clinic Cardiovascular Services NEW Cardiovascular Education App: The Mayo Clinic Cardiovascular CME App is an innovative educational platform that features cardiology-focused continuing medical education wherever and whenever you need it. Use this app to access other free content and browse upcoming courses. Download it for free in Apple or Google stores today! No CME credit offered for this episode. Podcast episode transcript found here.
This week, please join authors Svati Shah and Senthil Selvaraj as well as Guest Editor and Editorialist Manuel Mayr as they discuss the article "Metabolomic Profiling of the Effects of Dapagliflozin in Heart Failure With Reduced Ejection Fraction: DEFINE-HF" and the editorial "SGLT2 Inhibitors in Heart Failure: Targeted Metabolomics and Energetic Metabolism." Dr. Carolyn Lam: Welcome to Circulation On Run, your weekly podcast summary and backstage pass to the journal and its editors. We're your co-hosts, I'm Dr. Carolyn Lam, Associate Editor from the National Heart Center and Duke National University of Singapore. Dr. Greg Hundley: And I'm Dr. Greg Hundley, Associate Editor, Director of the Pauley Heart Center at VCU Health Richmond, Virginia. Dr. Carolyn Lam: In today's feature paper, we will be talking about the metabolomic profiling of the effects of dapagliflozin in heart failure, and this is from the DEFINE-HF trial. It's just such a cool paper with a lot of insights you have to hear from the authors. But, before we get there, let's talk about some of the other papers in today's issue. Shall we, Greg? Dr. Greg Hundley: You bet, Carolyn. Well, how about if I go first? Dr. Carolyn Lam: Please. Dr. Greg Hundley: Thank you, Carolyn. My first paper comes to us from Professor Paulus Kirchhof from the Universitäres Herzzentrum in Hamburg. Carolyn, in the randomized EAST-AFNET 4 study, so the early treatment of atrial fibrillation for stroke prevention, these trial investigators demonstrated that systematic initiation of early rhythm control reduced adverse cardiovascular outcomes in patients with recently diagnosed atrial fibrillation and stroke risk factors. However, the effectiveness and safety of early rhythm control in patients with multiple cardiovascular comorbidities is not known. Carolyn, in this study, it was a prespecified sub-analysis of the EAST-AFNET 4 trial and it compared the effectiveness and safety of early rhythm control with usual care stratified into patients with high CHA2DS2-VASc scores of greater than or equal to 4. Dr. Carolyn Lam: Nice. Okay. Important question, what did they find? Dr. Greg Hundley: Right, Carolyn. Quite a bit of data in this study, so let's walk through it carefully. First, in regards to the study population, the EAST-AFNET 4 randomized 1093 patients with CHA2DS2-VASc scores of greater than or equal to 4, these were predominantly women, 61% female, and then also 1,696 patients with CHA2DS2-VASc of less than four, and these were predominantly men, so only 37% women. Now let's get to the date. Early rhythm control reduced the composite primary efficacy outcome of cardiovascular death, stroke, or hospitalization for worsening heart failure or for acute coronary syndrome in patients with high CHA2DS2-VASc scores of greater than 4, but not in patients with CHA2DS2-VASc scores of less than 4. Second, now Carolyn, the primary safety outcome, so death, stroke, or serious adverse events of rhythm control therapy, was not different between study groups in patients with high CHA2DS2-VASc scores of greater than 4, but occurred more often in patients with low CHA2DS2-VASc scores randomized to early rhythm control. Now Carolyn, life threatening events or death were not different between the groups. When female sex was ignored for the creation of high and lower groups, the interaction P was not significant for the primary efficacy outcome, but remained significant for the primary safety outcome. Dr. Carolyn Lam: Oh, you are right. A lot of interesting data here. What's a take home message? Dr. Greg Hundley: Right, Carolyn. So the take home message is the following. Patients with recently diagnosed atrial fibrillation and multiple cardiovascular comorbidities should be considered to have priority access to early rhythm control to reduce cardiovascular outcomes, and a specific trial of early rhythm control in these patients is really needed as a next step. Dr. Carolyn Lam: Oh, thank you, Greg. The next paper focuses on arrhythmogenic right ventricular cardiomyopathy, which we know is characterized by a high propensity to life threatening arrhythmias and progressive loss of heart muscle. More than 40% of reported genetic variants linked to arrhythmogenic right ventricular cardiomyopathy, or ARVC, reside in a gene called plakophilin-2, or PKP2. In today's paper, Dr. Delmar and Lundby from NYU Grossman School of Medicine and University of Copenhagen, respectively, and their colleagues, described a comprehensive characterization of the ARVC molecular landscape using a multidisciplinary approach including human samples from ARVC patients with PKP2 mutations and left ventricular ejection fraction above 45%, as well as PKP2-deficient murine and human induced pluripotent stem cell-derived cardiomyocytes. They studied all of these with comprehensive proteomics and functional analysis. Dr. Greg Hundley: Wow, Carolyn, another great study in circulation combining both preclinical murine models as well as data from human subjects. So, what did they find? Dr. Carolyn Lam: Precisely, Greg. Here's what they found. Loss of nuclear envelope integrity and subsequent DNA damage is a key substrate in the molecular pathology of AR VC. The authors further showed transcriptional down regulation of proteins of the electron transcript chain as an early event in the molecular pathophysiology of the disease prior to an ejection fraction falling below 45%. This associates with increased oxidant production, with the clinical message being, therefore, that the authors propose therapies that limit oxidant formation may be a possible intervention to restrict DNA damage in ARVC. Dr. Greg Hundley: Very nice, Carolyn. Okay, our next paper comes from Dr. Donald Lloyd-Jones from Northwestern University, the Feinberg School of Medicine. Carolyn, you can tell the change in inflection of my voice because it's time for another Carolyn's quiz. Carolyn, open-ended question. Can you remind us of life's essential eight? Dr. Carolyn Lam: Oh boy, Greg. It's like asking me to name the dwarfs. I know I'm going to forget one, but here you go. Diet, exercise, cholesterol, weight, smoking, sugar must be there, diabetes, blood pressure. You see, I got seven. What's the eighth? Dr. Greg Hundley: Yeah. Remember seven dwarfs, Sleepy. Dr. Carolyn Lam: Sleep. Dr. Greg Hundley: Very good. Great job, Carolyn. Dr. Carolyn Lam: Thank you. Dr. Greg Hundley: Recently, the American Heart Association recently published an updated algorithm for quantifying cardiovascular health, the Life's Essential 8 score. In this study, the investigative team quantified US levels of cardiovascular health using the new score. They included non-pregnant, non-institutionalized individuals aged 2 through 79 years who were free of cardiovascular disease from the National Health and Nutrition Examination Surveys that were conducted between 2013 and 2018. Now, for all participants, they calculated the overall cardiovascular health score, and it ranged from 0, which is really low, to 100, which is the highest, as well as the score for each component. And Carolyn, yes, you are very close. Remember the eight? Diet, physical activity, nicotine exposure, sleep duration, body mass index, blood lipids, blood glucose, and blood pressure, and they used published American Heart Association definitions of these. The cardiovascular health scores were assessed across strata of age, sex, race, ethnicity, family income, and depression. Dr. Carolyn Lam: Okay, Greg. What did they find? Dr. Greg Hundley: Right, Carolyn. There were 23,400 plus participants, representing 201,728,000 adults and 74 million children. The overall mean cardiovascular health score was 64.7 among adults using all eight metrics, and it was 65.5 for the three metrics available of diet, physical activity, and BMI among the children and adolescents that were aged 2 through 19 years. Now, for the adults there were significant differences in mean cardiovascular health scores by sex, age, and racial ethnic group. Mean scores were lowest for diet, physical activity, and the BMI metrics. There were large differences in mean scores across demographic groups for diet, nicotine exposure, blood glucose, and blood pressure. In children, diet scores were low, 40.6, and were progressively lower in higher age groups. Large differences were also noted in mean physical activity and BMI by sociodemographic group. Carolyn, this study basically identifies wide ranges of scores across multiple domains of the essential eight, and thus, this new Life's Essential 8 score helps identify large group and individual differences in cardiovascular health. Additionally, overall, cardiovascular health in the US population remains well below optimal levels, and there are both broad and targeted opportunities to monitor, preserve, and improve cardiovascular health across the life course in both individuals, as well as the population at large. Dr. Carolyn Lam: Wow. Thanks, Greg. Truly really interesting. Everyone's going to have to pick up that paper and all the other papers in this issue, because there's also an In Depth paper by Dr. Whelton on “Harmonization of the ACC/AHA and ESC/ESH Blood Pressure Hypertension Guidelines, Comparisons, Reflections, and Recommendations. There's a Research Letter by Dr. Munshi on the accurate classification of cardiomyopathy etiology by chromatin accessibility. Dr. Greg Hundley: Carolyn, I have got to report an exchange of letters from Professor Sun and Weng regarding the article, “Legumain Is an Endogenous Modulator of Integrin αvβ3 Triggering Vascular Degeneration, Dissection, and Rupture.” And then Carolyn, lastly, there's a Perspective piece from Professor Vidal-Petiot entitled, “Thresholds for Hypertension Definition, Treatment Initiation, and Treatment Targets: Recent Guidelines at a Glance.” Well, Carolyn, how about we get on to that feature discussion? Dr. Carolyn Lam: Yes, let's go Greg. Wow, we have a star stud cast for today's feature discussion, and on a star studied topic, if I may. It's on the SGLT2 inhibitors, this time in the DEFINE-HF study and really going into the mechanism of action of SGLT2 inhibitors. Now, that's one question I personally get all the time. How do these things work? Today's paper brings us one step closer, for sure, in the understanding. I'm so grateful to have the first author, Dr. Senthil Selvaraj from University of Pennsylvania, as well as the corresponding author of the paper, Dr. Svati Shah, associate editor, as well as the corresponding author from Duke Molecular Physiology Institute. We also have Dr. Manuel Mayr who was both the guest editor and editorialist for this paper, and Dr. Mayr is from Kings College London, British Heart Foundation Center. Welcome, everyone. Senthil, get us started here. The DEFINE-HF study, just a quick summary, what that was about and then what you did, what you found. Dr. Senthil Selvaraj: Absolutely. Good morning, everyone, or maybe good evening for your time, Carolyn, but we were very excited about this study and the ability to do targeted metabolomic profiling in DEFINE. This audience is well familiar with the fact that SGLT2 inhibitors are foundational therapy in heart failure reduced ejection fraction, and the interesting thing is, despite a lot of literature, we still don't know why. Whether it relates to change in inflammation or endothelial function, but given the mechanism of action, metabolism is sort of at its core. So in this study we sought to identify metabolic pathways that were associated with dapagliflozin treatment using this targeted metabolomics platform in which we assayed 63 metabolites, acylcarnitine, which are markers of fatty acid oxidation, several amino acids, and ketone-related metabolites. To do this, we studied 234 participants from DEFINE, which is a 12-week placebo-controlled trial of dapagliflozin in this population, and we perform principal components analysis for dimensionality reduction techniques. In this study, briefly we found that, first, our principal components analysis yielded 13 different factors that accounted for the substantial proportion in the variation of the data, and that two in particular, ketone-related metabolites and short acylcarnitines in factor 6, as well as medium-chain acylcarnitines in factor 7 were differentially associated with dapagliflozin treatment. Specifically, there were increases in several ketone-related metabolites and short acylcarnitines, as well as several medium-chain acylcarnitines, really speaking to, potentially, changes in fatty acid as well as ketone biology with dapagliflozin treatment. The second aim of our study was to look at changes in metabolites and changes in endpoint studying DEFINE, which included NT-proBNP as well as KCCQ scores. We found that dicarboxylate long-chain acylcarnitines and aromatic amino acids really related to worsening heart failure endpoints there. So, a lot to impact, a lot that we found, and appreciative about the opportunity. Dr. Carolyn Lam: Oh, wow. Thank you so much for that amazing summary. Svati, I've heard you speak so many times on metabolomics on our calls, but this is really so important. First, I think the question is, congratulations for thinking ahead of time to collect the samples and to do all of this. Congratulations on that. Could I ask if you went in with any specific hypothesis or were you surprised by these findings, Svati? Dr. Svati Shah: Yeah, Carolyn, thank you so much. It was such a pleasure to work with Senthil on this and I really want to highlight what an incredible early career investigator he is. He's really going to set the metabolism world on fire. I also wanted to say thank you to the PI of the clinical trial, the parent clinical trial DEFINE-HF Mikhail Kosiborod, who did the really hard work of collecting the samples along with the clinical trial itself. To me, what's really cool is to be able to take a clinical trial like this with really important clinical outcomes well adjudicated and to be able to dig into the mechanism at a metabolic level of what might be going on with SGLT2 inhibitors. Going into this, Carolyn, we suspected that ketone-related biology was at play. There have been studies in other populations, non-HFrEF populations, that have shown that SGLT2 inhibitors have what appears to be beneficial impacts on ketone biology and induced ketosis. So, going into this, we suspected that this ketone pathway was going to come up. I think what's exciting is, not only did we find that the ketone pathway was differential modified by dapagliflozin, but that it wasn't at the level of severe ketosis that we would be concerned about. And then secondly, we found pathways of fatty acid oxidation. Some related to the effects of the medication and some related to changes in functional outcome. So it really enhanced beyond what we already knew about ketone biology, expanded our understanding of potential mechanisms of SGLT2 inhibitors, and expanded this into the HFrEF space, Carolyn. Dr. Carolyn Lam: Oh, that's so nice. I'm bursting with questions, but I really, really have to ask Dr. Manuel Mayr, first, could you put these findings into context for us and tell us what they mean clinically? Dr. Manuel Mayr: Yeah, Carolyn. First of all, I want to join you in congratulating the authors to this important study. As Svati mentioned, previous studies have reported effects of SGLT2 inhibitors on ketone bodies, but the present study really adds to the literature because it uses the state of the art metabolomic techniques. It uses a technique called mass spectrometry, but they also have a rating of, I think, in total, 63 metabolites in over 200 patients. Mass spectrometry is becoming increasingly important for cardiovascular precision medicine because we can use it in clinical trials to provide an unbiased assessment of metabolites and proteins. So it's a very versatile technology. I think this study really adds to the rapidly growing literature that SGLT2 inhibition is a principle of unloading the failing heart from metabolic stress. Dr. Carolyn Lam: Wow, I really like that and your editorial is just beautiful. I love that you say, "After the serendipitous findings of improved heart failure outcomes with SGLT2 inhibitors, mechanisms were postulated, but studies, such as the one we're discussing, are needed to really uncover what's the real thing." Now, I know this may sound really oversimplified and so on, but I'd really love for Senthil or Svati to just bear with me as I ask, what are you going to say to people who go, "Okay, then we should just be downing ketones," Or, "We should be Working on the fatty acid parts of it," Or taking conclusions like that. What would you say to something like that? Dr. Senthil Selvaraj: I'm happy to go first. It's a really wonderful question and I do think that this study raises the question of whether we should be exogenously increasing ketone levels to provide some sort of benefit. I would say the jury's still out there. I think it's a hot topic right now. But there are also differences between how we raise key tone levels, whether you do that endogenously in the body, or whether you give something like a ketone supplement, so exogenous ketone supplementation. And I think that there are completely different physiologies there. So more to come. I think there are a lot of studies in this space. The ketogenic diet is something that I'm often asked as well, whether that might provide benefit to heart failure. There are a lot of ways that I can, but one thing that we need to be mindful of is the fact that it will reduce glycogen stores as well, which may impact exercise capacity. So, we need more data. I would say the other thing that we found in our studies, while they were increased in ketone levels and markers of fatty acid oxidation with dapagliflozin treatment, we aren't necessarily sure that those mediate the benefits of SGLT2 inhibitors. DEFINE has important clinically relevant endpoints, but it is not an event-based trial. And so we don't know and we can't link the changes in metabolites with changes in outcomes quite yet. Dr. Svati Shah: Carolyn, just to add to the wonderful response that Senthil just gave, I think we do have to be careful. We don't know whether these are direct effects of SGLT2 inhibitors or whether these are related to the caloric loss that we know happens with these medications. I think it's important to point out that we're looking in the blood, we don't actually know what's happening at the tissue level, so we do have to be a little bit careful. We have made inferences that this is reporting on substrate fuel selection in the heart, but we also suspect that skeletal muscle and other organs are heavily involved in some of the pathways we're seeing. So I just wanted to make those important caveat to the epidemiologic work that we do. Dr. Carolyn Lam: And those are so important, so thank you Senthil and Svati. Manuel, I'd love to invite your thoughts because you did sort of point out some of these points in your editorial. Could you maybe discuss a bit of those and raise any questions, perhaps? Dr. Manuel Mayr: Yes. I think Svati and Senthil have nicely mentioned already that these measurements are performed in plasma. So the changes in plasma could be due to, for example, increased production in the liver due to decreased consumption in other tissues. So I guess the next step would be, and I would be really interested on what the authors want to pursue, is to provide direct evidence for the energetic hypothesis, that really the heart is consuming these keto bodies and what type of measurements could be performed to provide direct evidence in humans for these metabolic hypothesis. Dr. Senthil Selvaraj: That's a really great question, Manuel. There was a really nice study that was published about a year or two ago in Science in which the authors did coronary sinus sampling. So really to get arterial venous gradients, measure substances in the arterial system as well as the coronary sinus venous system and get extraction. I think that that study would be very interesting to understand. You take patients on SGLT2 inhibitors, those who are not, and to understand what is the heart chewing on. Obviously more invasive than some other approaches, but other studies that I think would be really interesting in those space would be flux studies and stable isotope studies. Again, as Svati really nicely mentioned, these are systemic physiology snapshots whenever we do less localized techniques like that, but they're still very important because heart failure is a systemic process. Dr. Carolyn Lam: Anything to add, Svati? Dr. Svati Shah: No, I think you said it beautifully. I'll just say on the sort of epidemiologic side, to be able to link this to harder outcomes, DEFINE-HF wasn't really designed to be able to do that. So as we expand our understanding of SGLT2 inhibitors, understand different populations, and to link these pathways to more objective outcomes, I think, will be really useful, also. Dr. Carolyn Lam: Indeed. Manual, in your editorial, you actually discuss some of your own work, which may be the ones that Senthil is actually talking about. What is your view? Dr. Manuel Mayr: Well, I think I'm very excited that beyond fatty acid metabolism and glucose metabolism, ketones have extracted increasing attention. Ketone body metabolism, I think, has long been underappreciated. We still need to understand to what extent it really acts as a fuel and that it can help to overcome the energy deficit that creates heart failure. I think, as mentioned by Svati and Senthil, we need more studies in this area, and of course other trials are ongoing where they're going to measure, for example, the phosphocreatine to ATP ratio by using phosphor-NMR spectroscopy. So we get direct evidence whether there really is an energetic improvement upon SGLT2 inhibition. I think this will be studies to look forward to and to add to the growing literature that metabolism is important as a therapeutic target for heart failure. Dr. Carolyn Lam: Oh, such exciting times. You mentioned the EMPA-VISION trial in your editorial. I think I'm trying to tell everybody, you have to pick up the paper and the editorial. You're going to learn so much. This is so cool. Thank you so, so much all of you for being on this podcast, for sharing your thoughts. I'm sure everyone has learned a lot and enjoyed it just as I have. On behalf of Greg and I, thank you for being here, thank you for joining us today, and don't forget to tune in again next week. Thank you. Dr. Greg Hundley: This program is copyright of the American Heart Association 2022. The opinions expressed by speakers in this podcast are their own and not necessarily those of the editors or of the American Heart Association. For more, please visit ahajournals.org.
This week on Pharm5: Rapid-acting Auvelity (bupropion/dextromethorphan) for MDD USPSTF's updated statin recommendations Post flu vaccination hyperglycemia in type 2 diabetes Twice annual HIV treatment lenacapavir approved in Europe; awaiting FDA approval Student loan forgiveness Connect with us! Listen to our podcast: Pharm5 Watch us on TikTok: @LizHearnPharmD Follow us on Twitter: @LizHearnPharmD References: Saro Arakelians PD. Daily medication pearl: Dextromethorphan and bupropion (Auvelity). Pharmacy Times. https://bit.ly/3QPIRY8. Published August 24, 2022. Accessed August 24, 2022. Auvelity (dextromethorphan and bupropion). Package insert. Axsome Therapeutics, Inc; 2022. @DrWestling15. “FDA just approved Auvelity (Dextromethorphan-Bupropion) for Major Depressive Disorder! What should a pharmacist know about this?” https://bit.ly/3R4WKkX. Published August 22, 2022. Accessed August 24, 2022. Mangione CM, Barry MJ, Nicholson WK, et al. Statin use for the primary prevention of cardiovascular disease in adults. JAMA. 2022;328(8):746. doi:10.1001/jama.2022.13044. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;140(11). doi:10.1161/cir.0000000000000678 Blood sugars higher for flu vaccine recipients with diabetes. U.S. Pharmacist – The Leading Journal in Pharmacy. https://bit.ly/3PKbDrH. Published August 24, 2022. Accessed August 24, 2022. Hulsizer AL, Witte AP, Attridge RL, Urteaga EM. Hyperglycemia Post-Influenza vaccine in patients with diabetes. Annals of Pharmacotherapy. June 2022:106002802210981. doi:10.1177/10600280221098101 Kansteiner F. Gilead HIV prospect escapes FDA hold after glass compatibility glitch triggered regulatory setbacks. Fierce Pharma. https://bit.ly/3R3h3yY. Published May 17, 2022. Accessed August 24, 2022. Gilead announces first global regulatory approval of Sunlenca® (Lenacapavir), the only twice-yearly HIV treatment option. Gilead Announces First Global Regulatory Approval of Sunlenca® (Lenacapavir), the Only Twice-Yearly HIV Treatment Option. https://bit.ly/3dXZd2t. Accessed August 24, 2022. Duster C. How to qualify for Biden's new student loan forgiveness plan. CNN Politics. https://cnn.it/3ALjKjF. Published Wednesday August 24, 2022. Accessed August 24, 2022. Occupational Employment and Wages, May 2021 - Pharmacists. U.S. Bureau of Labor Statistics. https://bit.ly/3PObHXm. Published March 31, 2022. Accessed August 24, 2022. Smoot C. What is the average pharmacy school debt in 2022? SuperMoney. https://bit.ly/3PHqZNK. Published April 26, 2022. Accessed August 24, 2022.
The following question refers to Section 4.3 of the 2021 ESC CV Prevention Guidelines. The question is asked by CardioNerds Academy Intern Dr. Maryam Barkhordarian, answered first by pharmacy resident Dr. Anushka Tandon and then by expert faculty Dr. Kim Williams. Dr. Williams is Chief of the Division of Cardiology and is Professor of Medicine and Cardiology at Rush University Medical Center. He has served as President of ASNC, Chairman of the Board of the Association of Black Cardiologists (ABC, 2008-2010), and President of the American College of Cardiology (ACC, 2015-2016). The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association. Question #15 Your patient mentions that she drinks “several” cups of coffee during the day. She also describes having a soda daily with lunch and occasionally a glass of wine with dinner. Which of the following recommendations is appropriate? A. Coffee consumption is not harmful and may even be beneficial, regardless of the number of drinks per day. B. Drinking two glasses of wine/day is safe from a cardiovascular prevention standpoint. C. Soft drinks (and other sugar-sweetened beverages) must be discouraged. D. None of the above Listen to this podcast episode! Answer #15 The correct answer is C. Soft drinks (and other sugar-sweetened beverages) must be discouraged. Sugar-sweetened beverages have been associated with a higher risk of CAD and all-cause mortality. The ESC guidelines give a class I recommendation for restriction of free sugar consumption (in particular sugar-sweetened beverages) to a maximum of 10% of energy intake. This is a class IIa recommendation in the ACC/AHA guidelines. Choice A is incorrect because: the consumption of nine or more drinks a day of non-filtered coffee (such as boiled, Greek, and Turkish coffee and some espresso coffees) may be associated with an up to 25% increased risk of ASCVD mortality. Moderate coffee consumption (3-4 cups per day) is probably not harmful, and perhaps even moderately beneficial. Choice B is incorrect: It is a class I recommendation to restrict alcohol consumption to a maximum of 100 g per week. The standard drink in the US contains 14 g of alcohol, so 100 mg of alcohol translate to: o 84 ounces of beer (5% alcohol) o Or 56 – 63 ounces of malt liquor (75% alcohol) or o Or 35 ounces of wine (12% alcohol) or ONE 5 fl oz glass of wine/day. o Or 31.5 ounces of distilled spirits (40% alcohol). The ACC/AHA guidelines recommended limiting alcohol consumption only for the management of hypertension to: ≤2 drinks daily for men and: ≤1 drink daily for women. Main Takeaway The main takeaway: ASCVD risk reduction can be achieved by restricting sugar-sweetened beverages to a maximum of 10% of energy intake. Guideline Location Section 4.3.2, Page 3271 CardioNerds Decipher the Guidelines - 2021 ESC Prevention Series CardioNerds Episode Page CardioNerds Academy Cardionerds Healy Honor Roll CardioNerds Journal Club Subscribe to The Heartbeat Newsletter! Check out CardioNerds SWAG! Become a CardioNerds Patron!
The following question refers to Sections 3.3-3.4 of the 2021 ESC CV Prevention Guidelines. The question is asked by student Dr. Adriana Mares, answered first by early career preventive cardiologist Dr. Dipika Gopal, and then by expert faculty Dr. Allison Bailey. Dr. Bailey is a cardiologist at Centennial Heart. She is the editor-in-chief of the American College of Cardiology's Extended Learning (ACCEL) editorial board and was a member of the writing group for the 2018 American Lipid Guidelines. Dr. Bailey, thank you so much for joining us! The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association. Question #14 Ms. Soya M. Alone is a 70-year-old woman of Bangladeshi ethnicity with a history of anxiety and depression. She currently lives at home by herself, does not have many friends and family that live nearby, and has had a tough year emotionally after the passing of her husband. She spends most of her time in bed with low daily physical activity and has experienced more weakness and exhaustion over the past year along with loss of muscle mass. Which of the following are potential risk modifiers in this patient when considering her risk for CVD?A. Bangladeshi ethnicity B. Psychosocial factorsC. Frailty D. History of anxiety and depressionE. All of the above Answer #14 The correct answer is E – All of the above.Traditional 10-year CVD risk scores do not perform adequately in all ethnicities. Therefore, multiplication of calculated risk by relative risk for specific ethnic subgroups should be considered (Class IIa, LOE B). Individuals from South Asia have higher CVD rates. The ESC guidelines recommend using a correction factor by multiplying the predicted risk by 1.3 for Indians and Bangladeshis, and 1.7 for Pakistanis. These correction factors are derived from data from QRISK3. In the UK, the QRISK calculator algorithm has been derived and validated in 2.3 million people to estimate CVD risk in different ethnic groups and unlike other calculators, it counts South Asian origins as an additional risk factor. The reasons for such differences remain inadequately studied, as do the risks associated with other ethnic backgrounds. Barriers to developing accurate risk prediction tools include the wide heterogeneity amongst the population.The 2019 ACC/AHA guidelines also list high-risk race/ethnicities such as South Asian ancestry as a risk-enhancing factor. However, there is no separate pooled cohort equation for different ethnicities, and consideration should be given that the pooled cohort equations will underestimate ASCVD risk in South Asians.Psychosocial stress including loneliness and critical life events are associated, in a dose-response pattern, with the development and progression of ASCVD, with relative risks between 1.2 and 2.0. Conversely, indicators of mental health, such as optimism and a strong sense of purpose, are associated with lower risk. While there is not a specific way proposed by the guidelines for psychosocial factors to improve risk classification, it is important to screen patients with ASCVD for psychological stress, and clinicians should attend to somatic and emotional causes of symptoms as well. The ESC guidelines give a Class IIa (LOE B) recommendation for assessment of stress symptoms and psychosocial stressors.This patient should also be formally screened for frailty, which is not the same as aging but includes factors such as slowness, weakness, low physical activity, exhaustion and shrinking, and makes her more vulnerable to the effect of stressors and is a risk factor for both high CV and non-CV morbidity and mortality. However, the ability of frailty measures to improve CVD risk prediction has not been formally assessed, so the guidelines do not recommend integrating it into formal...
CardioNerds (Amit Goyal and Daniel Ambinder), Dr. Ahmed Ghoneem (CardioNerds Academy Chief of House Taussig and medicine resident at Lahey Hospital), and Dr. Gurleen Kaur (Director of CardioNerds Internship and medicine resident at Brigham and Women's Hospital) discuss family history of premature ASCVD with Dr. Ann Marie Navar, Preventive Cardiologist and Associate Professor in the Departments of Internal Medicine and Population and Data Sciences at UT Southwestern Medical Center. They discuss the art of soliciting a nuanced family history, refining cardiovascular risk using risk models and novel markers, counseling patients with elevated risk, and more. Show notes were drafted by Dr. Ahmed Ghoneem and reviewed by Dr. Gurleen Kaur. Audio editing was performed by CardioNerds Intern, student Dr. Adriana Mares. For related teaching, check out this Tweetorial about CAC by Dr. Gurleen Kaur, the Family History of Premature ASCVD Infographic by Dr. Ahmed Ghoneem, and the CardioNerds Cardiovascular Prevention Series. CardioNerds Cardiovascular Prevention PageCardioNerds Episode Page Show notes - Family History of Premature ASCVD with Dr. Ann Marie Navar Patient summary: Mr. B is a 51-year-old gentleman who is referred to CardioNerds Prevention Clinic by his PCP. He does not have a significant past medical history. He is a former smoker but quit 2 years ago. His BP in clinic today is 138/84; he is not on any antihypertensives. His most recent lipid profile 2 weeks prior showed a total cholesterol level of 250 mg/dL, a TG level of 230 mg/dL, an LDL cholesterol of 174 mg/dL, and an HDL cholesterol of 30 mg/dL. He tells us that his father had a “heart attack” at the age of 52, and he would like to further understand his own risk. We calculate his ASCVD risk score, and it is 9.8%. 1. What constitutes a positive family history (FHx) of premature ASCVD? What is an approach to the art of soliciting the FHx from our patients? Definition of family history of premature ASCVD: the history of an atherosclerotic event (e.g., myocardial infarction or stroke) in a male first degree relative before the age of 55 or a female first degree relative before the age of 65. Dr. Navar's approach to soliciting a family history:Lead with a general question such as “what do you know about any medical conditions that run in your family?”.Then ask more specific questions about the parents and siblings, such as “Is your mother still alive? How long did she live? Has she ever had a heart attack or stroke?”If the answer is yes, ask about how old they were at the time of the event.A challenging aspect of the FHx can be eliciting the difference between atherosclerotic events and sudden cardiac death. While atherosclerotic diseases are a much more common cause of unexplained sudden death, it's important that we don't miss the opportunity to identify inherited cardiomyopathies, channelopathies, inherited aortopathies or other heritable SCD syndromes. 2. Is the “dose” of family history important (for example: the number of affected relatives, the closeness of those relationships, the age of onset)? While conducting studies to test this may be difficult, the few studies that have looked at the number of affected relatives have found a dose-response type relationship, where increasing number of relatives affected increases the risk of heart disease.1,2 3. How does a family history affect cardiovascular risk stratification? FHx of premature ASCVD does not improve the predictive ability of the Pooled Cohort Equations (PCE) at a population level. Therefore, it does not factor into the ASCVD risk calculation utilizing the PCE. However, it enhances the patient's risk at an individual level. The ACC/AHA guidelines recognize FHx of premature ASCVD as a risk-enhancing factor [together with CKD, chronic inflammatory conditions such as psoriasis, primary hypercholesterolemia, high-risk ethnicity such as South Asian ancestry...
The following question refers to Section 4.3 of the 2021 ESC CV Prevention Guidelines. The question is asked by Dr. Maryam Barkhordarian, answered first by pharmacy resident Dr. Anushka Tandon, and then by expert faculty Dr. Noreen Nazir. Dr. Noreen Nazir is Assistant Professor of Clinical Medicine at the University of Illinois at Chicago, where she is the director of cardiac MRI and the preventive cardiology program. The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association. Question #9 Mr. A is a 28-year-old man who works as an accountant in what he describes as a “desk job” setting. He shares that life got “a little off-track” for him in 2020 between the COVID-19 pandemic and a knee injury. His 2022 New Years' resolution is to improve his overall cardiovascular and physical health. He has hypertension and a family history of premature ASCVD in his father, who died of a heart attack at age 50. Prior to his knee injury, he went to the gym 3 days a week for 1 hour at a time, split between running on the treadmill and weightlifting. He has not returned to the gym since his injury and has been largely sedentary, although he is trying to incorporate a 20-minute daily walk into his routine. Which of the following exercise-related recommendations is most appropriate? A. A target of 75-150 minutes of vigorous-intensity or 150-300 minutes of moderate-intensity aerobic physical exercise weekly is recommended to reduce all-cause mortality, CV mortality, and morbidity. B. Bouts of exercise less than 30 minutes are not associated with favorable health outcomes. C. Exercise efforts should be focused on aerobic activity, since only this type of activity is associated with mortality and morbidity benefits. D. Light-intensity aerobic activity like walking is expected to have limited health benefits for persons with predominantly sedentary behavior at baseline. Answer #9 The correct answer is A. There is an inverse relationship between moderate-to-vigorous physical activity and CV morbidity/mortality, all-cause mortality, and incidence of type 2 diabetes, with additional benefits accrued for exercise beyond the minimum suggested levels. The recommendation to “strive for at least 150-300 min/week of moderate-intensity, or 75-150 min/week of vigorous-intensity aerobic physical activity, or an equivalent combination thereof” is a Class 1 recommendation per the 2021 ESC guidelines, and a very similar recommendation (at least 75 minutes of vigorous-intensity or 150 minutes of moderate-intensity activity) is also Class 1 recommendation per 2019 ACC/AHA primary prevention guidelines. Both the ESC and ACC/AHA provide examples of activities grouped by absolute intensity (the amount of energy expended per minute of activity), but the ESC guidelines also offer suggestions for measuring the relative intensity of an activity (maximum/peak associated effort) in Table 7, which allows for a more individualized, customizable approach to setting activity goals. Importantly, individuals who are unable to meet minimum weekly activity recommendations should still be encouraged to stay as active as their abilities and health conditions allow to optimize cardiovascular and overall health. Choice B is incorrect, as data suggests physical activity episodes of any duration, including
CardioNerds (Amit Goyal, Daniel Ambinder) and special co-host Dr. Mark Belkin, join the Journal of Cardiac Failure Family to discuss the 2022 ACC/AHA/HFSA Guideline for The Management of Heart Failure. The JCF Editor-In-Chief Dr. Robert Mentz, Deputy Editor Dr. Anu Lala, and FIT editors -- Dr. Vanessa Bluemer, Dr. Ashish Corrhea, and Dr. Quinton Youmans -- share their hot takes and practical takeaways from the guidelines. At JCF, we're privileged to share this important document that will support improved care for those living with heart failure,” stated Editor-in Chief Dr. Robert J. Mentz and Deputy Editor Anu Lala. “The 2022 guidelines convey patient-centered updates regarding the language we use to communicate disease considerations (e.g., stages of HF) and practice-changing guidance around the diagnosis and management of HF including newer therapeutics (e.g., SGLT2i). There is an emphasis not only on managing HF but also on how to treat important comorbidities as part of the holistic care for patients living with HF." 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure Executive Summary A Clinician's Guide to the 2022 ACC/AHA/HFSA Guideline for the Management of Heart Failure by Dr. Michelle Kittleson CardioNerds Heart Success Series PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Guideline Top 10 Take-Home Messages - Guideline for The Management of Heart Failure 1. Guideline-directed medical therapy (GDMT) for heart failure (HF) with reduced ejection fraction (HFrEF) now includes 4 medication classes that include sodium-glucose cotransporter-2 inhibitors (SGLT2i). 2. SGLT2i have a Class of Recommendation 2a in HF with mildly reduced ejection fraction (HFmrEF). Weaker recommendations (Class of Recommendation 2b) are made for ARNi, ACEi, ARB, MRA, and beta blockers in this population. 3. New recommendations for HFpEF are made for SGLT2i (Class of Recommendation 2a), MRAs (Class of Recommendation 2b), and ARNi (Class of Recommendation 2b). Several prior recommendations have been renewed including treatment of hypertension (Class of Recommendation 1), treatment of atrial fibrillation (Class of Recommendation 2a), use of ARBs (Class of Recommendation 2b), and avoidance of routine use of nitrates or phosphodiesterase-5 inhibitors (Class of Recommendation 3: No Benefit). 4. Improved LVEF is used to refer to those patients with previous HFrEF who now have an LVEF >40%. These patients should continue their HFrEF treatment. 5.Value statements were created for select recommendations where high-quality, cost-effectiveness studies of the intervention have been published. 6. Amyloid heart disease has new recommendations for treatment including screening for serum and urine monoclonal light chains, bone scintigraphy, genetic sequencing, tetramer stabilizer therapy, and anticoagulation. 7. Evidence supporting increased filling pressures is important for the diagnosis of HF if the LVEF is >40%. Evidence for increased filling pressures can be obtained from noninvasive (e.g., natriuretic peptide, diastolic function on imaging) or invasive testing (e.g., hemodynamic measurement). 8. Patients with advanced HF who wish to prolong survival should be referred to a team specializing in HF. A HF specialty team reviews HF management, assesses suitability for advanced HF therapies, and uses palliative care including palliative inotropes where consistent with the patient's goals of care. 9. Primary prevention is important for those at risk for HF (stage A) or pre-HF (stage B). Stages of HF were revised to emphasize the new terminologies of “at risk” for HF for stage A and pre-HF for stage B. 10.Recommendations are provided for select patients with HF and iron deficiency, anemia, hypertension, sleep disorders,
The following question refers to Section 4.3 of the 2021 ESC CV Prevention Guidelines. The question is asked by CardioNerds Academy Intern Dr. Maryam Barkhordarian, answered first by medicine resident CardioNerds Academy House Chief Dr. Ahmed Ghoneem, and then by expert faculty Dr. Kim Williams. Dr. Williams is Chief of the Division of Cardiology and is Professor of Medicine and Cardiology at Rush University Medical Center. He has served as President of ASNC, Chairman of the Board of the Association of Black Cardiologists (ABC, 2008-2010), and President of the American College of Cardiology (ACC, 2015-2016). The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association. Question #3 Mrs. B is a 56-year-old African American woman with a past medical history significant for type 2 diabetes (HbA1C 7.6) and hypercholesterolemia. Her calculated ASCVD risk score today is 12.5% and her BMI is 24kg/m2. She is concerned about her high cholesterol levels despite being on a statin and feels that her diet is “not healthy enough.” She is interested in making dietary changes to help reduce her ASCVD risk. Which of the following recommendations is appropriate?A. Sodium restriction to
The following question refers to Section 3.3 of the 2021 ESC CV Prevention Guidelines. The question is asked by CardioNerds Academy Intern student Dr. Adriana Mares, answered first by Brigham & Women's medicine intern & Director of CardioNerds Internship Dr. Gurleen Kaur, and then by expert faculty Dr. Allison Bailey.Dr. Bailey is an advanced heart failure and transplant cardiologist at Centennial Heart. She is the editor-in-chief of the American College of Cardiology's Extended Learning (ACCEL) editorial board and was a member of the writing group for the 2018 American Lipid Guidelines. The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association. Question #2 Mr. Early M. Eye is a 55-year-old man with a history of GERD who is seeing you in clinic as he is concerned about his family history of early myocardial infarction and would like to discuss if he should be taking a statin for cardiovascular prevention. He has never smoked tobacco. His 10-year CVD risk is estimated to be 8%. Which imaging modality is recommended by the ESC guidelines to reclassify his CVD risk?A. Coronary Artery Calcium (CAC) scoringB. Echocardiography C. Ankle brachial index D. Contrast enhanced computed tomography coronary angiography (CCTA)E. None of the above Answer #2 The correct answer is A.Coronary artery calcium (CAC) scoring can reclassify CVD risk upwards and downwards and should specifically be considered in patients with calculated risk scores that are around decision thresholds. CAC scores which are high-than-expected for age and sex increase estimated future CVD risk. Notably, CAC scoring may also be used to “de-risk” if CAC is absent or lower-than-expected. The 2021 ESC Prevention Guidelines give a Class IIb (LOE B) recommendation to consider CAC scoring to improve risk classification around treatment decision thresholds. However, one limitation of CAC is that it does not provide direct information on total plaque burden or stenosis severity. In addition, there is also a Class IIb (LOE B) recommendation to use plaque detection by carotid ultrasound as an alternative when CAC scoring is unavailable or not feasible. Plaque assessed through carotid ultrasound is defined as presence of wall thickening that is >50% greater than the surrounding vessel wall or a focal region with intima-media thickness measurement >1.5mm that protrudes into the lumen.Similar to the ESC Prevention Guidelines, the 2019 ACC/AHA guidelines on primary prevention of CVD also have a Class IIa recommendation for using CAC score, and explicitly mention its use for adults at intermediate risk (>7.5% to 100 Agatson units to reclassify risk upwards and CAC of 0 to reclassify risk downwards. However, the guidelines also mention that clinicians should not down-classify risk in patients who have CAC of 0 if they are current smokers, have diabetes, have a family history of ASCVD, or have chronic inflammatory conditions. Furthermore, the 2018 ACC/AHA Cholesterol guidelines have a Class IIa recommendation that if CAC is 0, it is reasonable to withhold statin therapy and reassess risk in 5 to 10 years, as long as higher risk conditions that we just discussed are absent. If CAC is 1-99, it is reasonable to initiate statin therapy for patients ≥ 55 years of age.Choice B is incorrect. Echocardiography is not recommended to improve CV risk prediction due to lack of convincing evidence that it improves CVD risk reclassification.Choice C is incorrect. While the 2013 ESC guidelines mentioned that ABI may be considered as a risk modifier in CVD risk estimation, the newer 2021 guidelines state that ankle brachial index has limited potential in terms of reclassification risk, though an individual patient data meta-analysis showed th...
This question refers to Sections 3.2 and 3.3 of the 2021 ESC CV Prevention Guidelines. The question is asked by CardioNerds Academy Intern, student Dr. Hirsh Elhence, answered first by Ohio State University Cardiology Fellow Dr. Alli Bigeh, and then by expert faculty Dr. Eugene Yang.Dr. Yang is professor of medicine of the University of Washington where he is medical director of the Eastside Specialty Center and the co-Director of the Cardiovascular Wellness and Prevention Program. Dr. Yang is former Governor of the ACC Washington Chapter and current chair of the ACC Prevention of CVD Section.The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelinesrepresents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association. Question #1 A 48-year-old Pakistani woman with rheumatoid arthritis comes to your clinic asking how she can reduce her risk of ASCVD. Her mother died of an MI at age 45, her father is healthy at age 79. Her calculated 10-year risk based on SCORE2 is 3%. SBP is 120 mmHg, LDL is 120 mg/dL. What is the next best step? A. Order an echocardiogram B. Schedule a follow-up appointment in 1 year C. Discuss initiating a statin D. Repeat lipid panel in 3-5 years Answer #1 Answer: C. Discuss Initiating a statin The absolute benefit derived from risk factor modification depends on the absolute risk of CVD and the absolute improvements in each risk factor category. Risk factor treatment recommendations are based on categories of CVD risk (“low-to-moderate”, “high”, and “very high”). The cut-off risk levels for these categories are numerically different for various age groups to avoid undertreatment in the young and to avoid overtreatment in the elderly. As age is a major driver of CVD risk, but lifelong risk factor treatment benefit is higher in younger people, the risk thresholds for considering treatment are lower for younger people as per the ESC guidelines. Treatment decisions should be made with shared decision-making valuing patient preference. Option A is INCORRECT- there is a lack of convincing evidence that echocardiography improves CVD risk reclassification, and it is NOT recommended to improve CV risk prediction. (Class III, LOE B) Option B is INCORRECT- simply doing nothing is not appropriate for this patient with elevated CVD risk. Option C is CORRECT- This patient has a seemingly low 10-year CVD risk based on SCORE 2 of 3% and her SBP is controlled; however, given her age she is considered as having high CVD risk, therefore treatment should be considered. Stepwise approach involves targeting LDL
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