Podcasts about Heart Rhythm Society

Orthostatic vitals are taught throughout medical training as a quick and easy way to assess patient volume status objectively. We also frequently see these documented in MCHD charts. Is there any evidence that orthostatics help our clinical decision-making? Has anyone ever evaluated their use in EMS? Could standing a patient to check their heart rate actually be harmful? Join the podcast crew as they address these questions and more. REFERENCES 1. White, JL, Hollander, JE, Chang, AM, et al. (2019). Orthostatic vital signs do not predict 30-day serious outcomes in older emergency department patients with syncope: A multicenter observational study. The American journal of emergency medicine, 37(12), 2215–2223. 2. Shen W, Sheldon R, Yancy C, et al. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Journal of The American College Of Cardiology. August 1, 2017;70(5):e39-e110. Available from: MEDLINE, Ipswich, MA. Accessed May 1, 2018. 3. Cohen E, Grossman E, Sapoznikov B, et al. Assessment of orthostatic hypotension in the emergency room. Blood Press. 2006;15(5):263-267. 4. Aronow WS, Lee NH, Sales FF, Etienne F. Prevalence of postural hypotension in elderly patients in a long-term health care facility. Am J Cardiol. 1988;62(4):336. 5. Ooi WL, Barrett S, Hossain M, et al. Patterns of orthostatic blood pressure change and their clinical correlates in a frail, elderly population. JAMA. 1997;277(16):1299-1304.

Click here for the Revenue Recovery cheat sheet: https://hubs.ly/Q03hvhqw0 Welcome to the seventh episode of our HeartTalk podcast series, Revenue Recovery. Host Melanie Lawson, MS, speaks with Linda Gates-Striby, CCS-P, ACS-CA, Revenue Cycle Solutions consultant. They dive into how to appropriately capture Prolonged Care services and offer practical examples for your organization.  Guest Bio:Linda Gates-Striby, CCS-P, ACS-CAMedAxiom Consultant, Revenue Cycle Solutions Linda Gates-Striby has worked in the medical field for over 30 years and has specialized in cardiology coding and revenue cycle for 25 years. Her clinical experience includes work in the heart stations and coronary intensive care units as well as working as an EMT for a level one trauma center. As a MedAxiom Revenue Cycle Solutions consultant, Linda provides cardiovascular programs across the country with operational expertise, implementation strategies and simplification for often complex initiatives to minimize risk and maximize revenue. Linda, who has spent the past 30 years working as a specialist in compliance, revenue cycle and quality with a large cardiology and multi-specialty practice, is also the director of quality assurance with Ascension Medical Group in Indiana. Linda is a sought-after speaker and consultant and has conducted numerous national educational sessions focused on documentation, coding, auditing and revenue cycle improvement for clinicians, coders and administrators across the nation. Linda serves as a non-physician member of the American College of Cardiology's coding work group and publications subcommittee and has also served on the coding committee for the Heart Rhythm Society. Linda served as the cardiology chair on the Board of Advanced Medical Coding, lead the development of the Advanced Cardiology and Specialty Cardiology Certification examinations, and was the technical editor for cardiology-focused newsletters. Linda has served as an Independent Review Organization auditor for Office of Inspector General Corporate Integrity Agreements, and as an expert witness on behalf of cardiology practices.

Rural America is a vital part of our nation—rich in culture, community, and resilience. But potential Medicaid cuts coupled with the impending expiration of enhanced tax credits further threatens rural communities' access to health care and puts the strength of rural communities at risk. In this episode, Chip Kahn is joined once again by Alan Morgan, CEO of the National Rural Health Association, to explore the impacts of Medicaid cuts and Americans' loss of health coverage on rural hospitals and what is at stake for patient care if lawmakers fail to protect these institutions.Key topics include: The current state of rural health care and why it matters to all Americans;What hospital closures mean for rural patients;The policy levers that could make or break the future of rural hospitals; and,Why Medicaid and the enhanced tax credits are essential to access care.References: Washington Post “Republican Medicaid cuts could shutter rural hospitals, maternity care” (https://www.washingtonpost.com/health/2025/03/08/medicaid-cuts-rural-hospitals/)About: Alan Morgan joined NRHA staff in 2001 and currently serves as Chief Executive Officer of the association.  Recognized as among the top 100 most influential people in health care by Modern Healthcare Magazine, Alan Morgan serves as Chief Executive Officer for the National Rural Health Association. He has more than 30 years experience in health policy at the state and federal level, and is one of the nation's leading experts on rural health policy.Mr. Morgan served as a contributing author for the publications, “Policy & Politics in Nursing and Health Care,” “The Handbook of Rural Aging” and for the publication, “Rural Populations and Health.” In addition, his health policy articles have been published in: The American Journal of Clinical Medicine, The Journal of Rural Health, The Journal of Cardiovascular Management, The Journal of Pacing and Clinical Electrophysiology, Cardiac Electrophysiology Review, and in Laboratory Medicine. Mr. Morgan served as staff for former US Congressman Dick Nichols and former Kansas Governor Mike Hayden. Additionally, his past experience includes tenures as a health care lobbyist for the American Society of Clinical Pathologists, the Heart Rhythm Society, and for VHA Inc.He holds a bachelor's degree in journalism from University of Kansas, and a master's degree in public administration from George Mason University.

EBR Systems Inc Senior Vice President Andrew Shute talked with Proactive at the AIM maSmall and Midcap Conference about the company's upcoming FDA decision for its leadless CRT pacemaker system. The device is designed to treat heart failure and represents the only leadless option in a market currently dominated by three players—with no direct competitor. Shute said, “We've developed the world's only leadless pacemaker to treat heart failure. And we're on track to receive FDA approval within the next two and a half weeks.”* The product already holds FDA Breakthrough Device designation, and has shown strong clinical results, including a 16.4% reduction in left ventricular end systolic volume—well above the target goal of 9.3%. Shute outlined the company's go-to-market plan, emphasizing that reimbursement is expected to begin from October 1st under the NTAP and TPT schemes, enabling an ASP of USD 45,000. The company only needs to sell around 2,200 units annually to reach USD 100 million in revenue. “We've got no direct competition,” he said. He also highlighted the successful completion of the FDA's pre-approval inspection with no observations—an uncommon achievement in the medical device industry. The device, supported by data published in JAMA Cardiology, was also featured at the Heart Rhythm Society meeting in 2023. During the interim, the US commercial team will establish purchasing agreements, prepare technology committee engagements, and begin physician training for a limited market release. #EBRSystems #MedicalDevices #HeartFailureTreatment #LeadlessPacemaker #CardiacTech #FDAApproval #CRTDevice #InvestingInHealthcare #BreakthroughDevice #MedTechInnovation #JAMACardiology #HeartRhythmSociety

Updates from the 2024 ESC and AHA Scientific Statements on Cardiac Sarcoidosis   Guest: Leslie T. Cooper Jr., M.D. Host: Kyle W. Klarich, M.D.   Cardiac sarcoidosis is a systemic, chronic inflammatory disorder characterized by non-caseating, epithelioid cell granulomas that may involve many tissues and organs. The Heart Rhythm Society criteria for diagnosis of cardiac sarcoidosis require a biopsy-proven diagnosis of extra-cardiac sarcoidosis. If extra-cardiac sarcoidosis is confirmed, CS is highly probable when there is evidence of the following: (a) rhythm abnormalities in either ECG or Holter monitoring such as advanced AVB (Mobitz type II second-degree or third-degree AVB), sustained VT, and (b) LV dysfunction on echocardiography or CMR (LVEF

Contributor: Taylor Lynch MD Supraventricular tachycardias (SVTs) arise above the bundle of His The term SVT includes AV nodal reentrant tachycardia (AVNRT), atrioventricular reentrant tachycardia (AVRT), atrial tachycardia, atrial fibrillation, atrial flutter, and multifocal atrial tachycardia  AVNRT is the most common form of SVT Paroxysmal Spontaneous or provoked by exertion, coffee, alcohol, or thyroid disease More common in women (3:1 women:men ratio) HR 160-240 Narrow complex with a normal QRS Unstable patients receive synchronized cardioversion at 0.5-1 J/kg Valsalva maneuver is attempted before pharmaceutical interventions Increases vagal tone at the AV node to slow conduction and prolongs its refractory period to normalize the conduction Traditionally, patients are asked to bear down, but this only works in 17% of patients REVERT trial assessed a modified valsalva that worked in 43% of patients Adenosine Slows conduction at the AV node by activating potassium channels and inhibiting calcium influx Extremely uncomfortable for most patients Not commonly used anymore Nondihydropyridine calcium-channel blockers are preferred A 2009 RCT investigated low-infusion CCBs compared with adenosine bolus The study found a conversion rate of 98% in the CCB group vs. adenosine group at 86.5% The main adverse effect of CCB is hypotension, which a slow infusion rate can mitigate Diltiazem dose is 0.25 mg/kg/2min and repeat at 0.35 mg/kg/15 minutes or slow infusion at 2.5 mg/min up to a conversion or 50 mg total References 1. Appelboam A, Reuben A, Mann C, et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): A randomised controlled trial. Lancet. 2015;386(10005):1747-1753. doi:10.1016/S0140-6736(15)61485-4 Belz MK, Stambler BS, Wood MA, Pherson C, Ellenbogen KA. Effects of enhanced parasympathetic tone on atrioventricular nodal conduction during atrioventricular nodal reentrant tachycardia. Am J Cardiol. 1997;80(7):878-882. doi:10.1016/s0002-9149(97)00539-0 Lim SH, Anantharaman V, Teo WS, Chan YH. Slow infusion of calcium channel blockers compared with intravenous adenosine in the emergency treatment of supraventricular tachycardia. Resuscitation. 2009;80(5):523-528. doi:10.1016/j.resuscitation.2009.01.017 Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society [published correction appears in Circulation. 2016 Sep 13;134(11):e234-5. doi: 10.1161/CIR.0000000000000448]. Circulation. 2016;133(14):e506-e574. doi:10.1161/CIR.0000000000000311 Summarized & Edited by Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

It's becoming increasingly important to ensure your care team stays up to date with best practices for managing patients with cardiac implantable electronic devices (CIED) in the device clinic. On this MedAxiom HeartTalk, host Melanie Lawson, MS, speaks with James Allred, MD, FACC, CEO and co-founder of CV Remote Solutions; Austin Reed, vice president of Business Development, Strategy and Innovation, at CV Remote Solutions; and Nicole F. Knight, LPN, CPC, CCS-P, executive vice president of Revenue Cycle Solutions and Care Transformation at MedAxiom. They discuss the unique challenges related to highly technical roles and complex workflows in the device clinic. They also offer educational solutions to enhance your care team's understanding of function, programming and troubleshooting CIEDs. GUEST BIOS  James Allred, MD, FACC CEO and Co-Founder, CV Remote SolutionsAs Chief Executive Officer and Co-Founder of CV Remote Solutions, Dr. Allred partners with clinicians nationwide to ensure optimal care for patients with cardiac implanted electrical devices. Before launching CV Remote Solutions, Dr. Allred previously served as chief of Electrophysiology Services and medical director of the Atrial Fibrillation (AF) Clinic at Cone Health in Greensboro, NC. After establishing the world-class AF Clinic in Greensboro, he consults with individual clinicians, clinics and hospitals on starting or improving their AF clinic efforts and programs. He has also served on advisory boards for the Heart Rhythm Society and the American Heart Association. Dr. Allred completed an internal medicine residency at Duke University and fellowships in cardiovascular disease and electrophysiology at the University of Alabama at Birmingham, AL. In addition to partnering with MedAxiom to create educational material for clinicians, he has authored several published manuscripts on AF clinical efficiencies and healthcare savings. Austin Reed, MBA Vice President of Business Development, Strategy, and Innovation, CV Remote Solutions. In his role, Austin is responsible for sculpting strategic growth initiatives, pioneering innovative solutions, and driving business development efforts to help CV Remote Solutions continue to be at the forefront of the industry. In his previous role as vice president of Operations, he managed multiple business areas, including operations, marketing and human resources. Austin was instrumental in developing brand strategies and initiatives that responded to the needs and projected future of the healthcare industry. Before his time at CV Remote Solutions, Austin served as a director of Physician Services for HCA Healthcare, one of the nation's top providers. With over 15 years of healthcare industry experience spanning multi-site operations in primary care, cardiology, oncology and pulmonology, his robust understanding of the healthcare landscape is a key pillar of his strategic approach. Austin obtained his Bachelor of Science degree in health care administration from Western Kentucky University and a Master of Business Administration from Murray State University. His commitment to healthcare extends beyond his role at CV Remote Solutions as he continues to serve on the Nashville Health Care Leadership Council and the Medical Group Management Association, contributing valuable insights and leadership.  Nicole F. Knight, LPN, CPC, CCS-PExecutive Vice President, Revenue Cycle Solutions and Care Transformation ServicesAs the Executive Vice President of Revenue Cycle Solutions and Care Transformation Services at MedAxiom, Nicole provides guidance to MedAxiom's membership in cardiovascular operations, LEAN process improvement and the revenue cycle. Nicole applies her decades of healthcare experience in cardiovascular and neurology practice operations, clinical management, business office management and consulting to leading the Revenue Cycle Solutions team at MedAxiom. 
  
Prior to joining MedAxiom, Nicole served as a practice administrator for Baptist Neurology and Northeast Florida Cardiology and director of operations for Jacksonville Heart Center and Louisiana Cardiology Associates. She has extensive expertise in coding, compliance and education for various specialties including cardiology, neurology, radiology, hematology/oncology, orthopedic, ENT, gastroenterology and internal medicine. Nicole has delivered physician and staff coding and compliance education sessions nationally. 
  
Nicole has completed numerous education hours towards a Bachelor of Science in health care administration. In addition, she maintains her licensed practical nurse credential in Florida. She is a member of the American Academy of Professional Coders (AAPC) and the American Health Information Management Association. She received her Advanced Cardiovascular Coding Certification with the Board of Medical Specialty Coding and completed the AAPC inpatient coding and reimbursement course. Nicole is a certified American Health Information Management Association (AHIMA) ICD-10-CM Trainer and completed a LEAN Healthcare training course at Johns Hopkins University. She has also served on the Physician Practice Council for AHIMA.Areas of Expertise: • Cardiology and neurology practice operations • Clinical and business office management • LEAN process improvement • Office-based cath lab implementation • Revenue cycle performance and metrics • Coding, compliance audits and education in numerous specialties, including cardiovascular • Documentation and implementation guidelines • Complex procedure coding education • Risk adjustment coding • Cardiovascular service line integration • Cath and electrophysiology lab optimization, revenue cycle services and facility coding 

Click here for the Revenue Recovery cheat sheet:
https://hubs.ly/Q02yqht40Welcome to the next episode of our HeartTalk podcast series, Revenue Recovery. Host Melanie Lawson, MS, speaks with MedAxiom's Nicole F. Knight, LPN, CPC, CCS-P, executive vice president of Revenue Cycle Solutions and Care Transformation, and Linda Gates-Striby, CCS-P, ACS-CA, Revenue Cycle Solutions consultant. They discuss the coverage eligibility for Interprofessional Consultation services and share specific examples your practice can use to capture those services, all while improving patient care.Guest Bios:Nicole F. Knight, LPN, CPC, CCS-PExecutive Vice President, Revenue Cycle Solutions and Care Transformation ServicesAs the Executive Vice President of Revenue Cycle Solutions and Care Transformation Services at MedAxiom, Nicole provides guidance to MedAxiom's membership in cardiovascular operations, LEAN process improvement and the revenue cycle. Nicole applies her decades of healthcare experience in cardiovascular and neurology practice operations, clinical management, business office management and consulting to leading the Revenue Cycle Solutions team at MedAxiom. 
  
Prior to joining MedAxiom, Nicole served as a practice administrator for Baptist Neurology and Northeast Florida Cardiology and director of operations for Jacksonville Heart Center and Louisiana Cardiology Associates. She has extensive expertise in coding, compliance and education for various specialties including cardiology, neurology, radiology, hematology/oncology, orthopedic, ENT, gastroenterology and internal medicine. Nicole has delivered physician and staff coding and compliance education sessions nationally. 
  
Nicole has completed numerous education hours towards a Bachelor of Science in health care administration. In addition, she maintains her licensed practical nurse credential in Florida. She is a member of the American Academy of Professional Coders (AAPC) and the American Health Information Management Association. She received her Advanced Cardiovascular Coding Certification with the Board of Medical Specialty Coding and completed the AAPC inpatient coding and reimbursement course. Nicole is a certified American Health Information Management Association (AHIMA) ICD-10-CM Trainer and completed a LEAN Healthcare training course at Johns Hopkins University. She has also served on the Physician Practice Council for AHIMA. 
  
Areas of Expertise: • Cardiology and neurology practice operations Linda Gates-Striby, CCS-P, ACS-CAMedAxiom Consultant, Revenue Cycle SolutionsAs a Revenue Cycle Solutions Consultant at MedAxiom, Linda provides cardiovascular programs across the country with operational expertise, implementation strategies and recommendations for simplifying often complex initiatives to minimize risk and maximize revenue.  Linda has worked in the medical field for over 30 years and has specialized in cardiology coding for 25 years. Her clinical experience includes working in the heart stations and coronary intensive care units and serving as an emergency medical technician for a level-one trauma center. As a coding specialist, she focuses on compliance, revenue cycle and quality for a large cardiology and multispecialty practice. She is also the director of quality assurance at the Ascension Medical Group in Indiana. Linda is a sought-after speaker and consultant and has conducted numerous national educational sessions focused on documentation, coding, auditing and revenue cycle improvement for clinicians, coders and administrators across the nation. Linda serves as a non-physician member of the American College of Cardiology's coding work group and publications subcommittee and has also served on the coding committee for the Heart Rhythm Society. Linda served as the cardiology chair on the Board of Advanced Medical Coding, led the development of the Advanced Cardiology and Specialty Cardiology Certification examinations, and acts as a technical editor for cardiology-focused newsletters. Linda has served as an independent review organization auditor for the Office of Inspector General Corporate Integrity Agreements and as an expert witness on behalf of cardiology practices. 

Click here for the Revenue Recovery cheat sheet:https://hubs.ly/Q02x7ncv0Welcome to the next episode of our HeartTalk podcast series, Revenue Recovery. Host Melanie Lawson, MS, speaks with MedAxiom's Nicole F. Knight, LPN, CPC, CCS-P, executive vice president of Revenue Cycle Solutions and Care Transformation, and Linda Gates-Striby, CCS-P, ACS-CA, Revenue Cycle Solutions consultant. They discuss specific use cases for CPT code 99211 and give implementation tips to help ensure your practice leaves no dollar on the table.Guest Bios:Nicole F. Knight, LPN, CPC, CCS-PExecutive Vice President, Revenue Cycle Solutions and Care Transformation ServicesAs the Executive Vice President of Revenue Cycle Solutions and Care Transformation Services at MedAxiom, Nicole provides guidance to MedAxiom's membership in cardiovascular operations, LEAN process improvement and the revenue cycle. Nicole applies her decades of healthcare experience in cardiovascular and neurology practice operations, clinical management, business office management and consulting to leading the Revenue Cycle Solutions team at MedAxiom.Prior to joining MedAxiom, Nicole served as a practice administrator for Baptist Neurology and Northeast Florida Cardiology and director of operations for Jacksonville Heart Center and Louisiana Cardiology Associates. She has extensive expertise in coding, compliance and education for various specialties including cardiology, neurology, radiology, hematology/oncology, orthopedic, ENT, gastroenterology and internal medicine. Nicole has delivered physician and staff coding and compliance education sessions nationally. 
 Nicole has completed numerous education hours towards a Bachelor of Science in health care administration. In addition, she maintains her licensed practical nurse credential in Florida. She is a member of the American Academy of Professional Coders (AAPC) and the American Health Information Management Association. She received her Advanced Cardiovascular Coding Certification with the Board of Medical Specialty Coding and completed the AAPC inpatient coding and reimbursement course. Nicole is a certified American Health Information Management Association (AHIMA) ICD-10-CM Trainer and completed a LEAN Healthcare training course at Johns Hopkins University. She has also served on the Physician Practice Council for AHIMA. 
  
Areas of Expertise: • Cardiology and neurology practice operations Linda Gates-Striby, CCS-P, ACS-CAMedAxiom Consultant, Revenue Cycle SolutionsAs a Revenue Cycle Solutions Consultant at MedAxiom, Linda provides cardiovascular programs across the country with operational expertise, implementation strategies and recommendations for simplifying often complex initiatives to minimize risk and maximize revenue.  Linda has worked in the medical field for over 30 years and has specialized in cardiology coding for 25 years. Her clinical experience includes working in the heart stations and coronary intensive care units and serving as an emergency medical technician for a level-one trauma center. As a coding specialist, she focuses on compliance, revenue cycle and quality for a large cardiology and multispecialty practice. She is also the director of quality assurance at the Ascension Medical Group in Indiana. Linda is a sought-after speaker and consultant and has conducted numerous national educational sessions focused on documentation, coding, auditing and revenue cycle improvement for clinicians, coders and administrators across the nation. Linda serves as a non-physician member of the American College of Cardiology's coding work group and publications subcommittee and has also served on the coding committee for the Heart Rhythm Society. Linda served as the cardiology chair on the Board of Advanced Medical Coding, led the development of the Advanced Cardiology and Specialty Cardiology Certification examinations, and acts as a technical editor for cardiology-focused newsletters. Linda has served as an independent review organization auditor for the Office of Inspector General Corporate Integrity Agreements and as an expert witness on behalf of cardiology practices. 

Commentary by Dr Mingfang Li

Welcome to Episode 30 of “The 2 View,” the podcast for EM and urgent care nurse practitioners and physician assistants! Show Notes for Episode 30 of “The 2 View” – oral phenylephrine, visual diagnosis plans, and NSVT. Oral Phenylephrine Myers Z. FDA panel: Many oral allergy meds don't work. WTTV CBS4Indy. Published October 15, 2023. Accessed October 17, 2023. https://cbs4indy.com/news/fda-panel-many-oral-allergy-meds-dont-work/ Neurosyphilis Review Hamill MM, Ghanem KG, Tuddenham S. State of the art review: neurosyphilis. Clin Infect Dis. Published August 18, 2023. Accessed November 1, 2023. doi: 10.1093/cid/ciad437 Visual Diagnosis - Behcet's Disease Behcet's Disease. Vasculitis Foundation. Published July 18, 2012. Accessed October 17, 2023. https://www.vasculitisfoundation.org/education/behcets-disease/ ACEP Clinical Policy on Ischemic Stroke Clinical Policies – Acute Ischemic Stroke. ACEP. Published May 2023. Accessed November 2, 2023. https://www.acep.org/patient-care/clinical-policies/acute-ischemic-stroke The VAN Assessment to Identify Large Vessel Occlusion Strokes. Core EM. Published May 17, 2018. Accessed November 2, 2023. https://coreem.net/journal-reviews/the-van-assessment/ Los Angeles Motor Scale (LAMS). MDCalc. Accessed November 2, 2023. https://www.mdcalc.com/calc/3959/los-angeles-motor-scale-lams Rapid Arterial oCclusion Evaluation (RACE) Scale for Stroke. MDCalc. Accessed November 2, 2023. https://www.mdcalc.com/calc/3941/rapid-arterial-occlusion-evaluation-race-scale-stroke NSVT: Non-Sustained Ventricular Tachycardia Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. Published August 1, 2018. Accessed October 17, 2023. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000549 Farzam K, Tivakaran VS. QT Prolonging Drugs. StatPearls Publishing; 2023. Accessed October 17, 2023. https://www.ncbi.nlm.nih.gov/books/NBK534864/ Foth C, Gangwani MK, Ahmed I, Alvey H. Ventricular Tachycardia. StatPearls Publishing; 2023. Accessed October 17, 2023. https://www.ncbi.nlm.nih.gov/books/NBK532954/ Ep 1 Lady G and Courage Under Fire. Burnt. Published January 27, 2021. Accessed November 2, 2023. https://podcasts.apple.com/us/podcast/ep-1-lady-g-and-courage-under-fire/id1551194920?i=1000506903956 Glaucomflecken. Will and Kristin's Cardiac Arrest Story with Paramedic Lieutenant Aaron Gregg. Published August 22, 2023. Accessed October 17, 2023. https://www.youtube.com/watch?v=CQtYoKPNsrM Laslett DB, Cooper JM, Greenberg RM, et al. Electrolyte Abnormalities in Patients Presenting With Ventricular Arrhythmia (from the LYTE-VT Study). Am J Cardiol. PubMed. NIH: National Library of Medicine: National Center for Biotechnology Information. Published August 15, 2020. Accessed October 17, 2023. https://pubmed.ncbi.nlm.nih.gov/32565090/ Nonsustained ventricular tachycardias. Bmj.com. BMJ Best Practice. Accessed October 25, 2023. https://bestpractice.bmj.com/topics/en-us/831 PVCs and Nonsustained VT: When to Worry? How to Treat? - Penn Physician VideoLink.; 2015. Published January 7, 2015. Accessed October 17, 2023. https://videolink.pennmedicine.org/videos/pvcs-and-nonsustained-vt-when-to-worry-how-to-treat TualatinValleyFire. Dr. Will Flanary - Cardiac Arrest Survivor. Published February 16, 2021. Accessed October 17, 2023. https://www.youtube.com/watch?v=wu9uAwnSrJU Recurring Sources Center for Medical Education. Ccme.org. http://ccme.org The Proceduralist. Theproceduralist.org. http://www.theproceduralist.org The Procedural Pause. Emergency Medicine News. Lww.com. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx The Skeptics Guide to Emergency Medicine. Thesgem.com. http://www.thesgem.com Trivia Question: Send answers to 2viewcast@gmail.com Be sure to keep tuning in for more great prizes and fun trivia questions! Once you hear the question, please email us your guesses at 2viewcast@gmail.com and tell us who you want to give a shout-out to. Be sure to listen in and see what we have to share!

Michael S. Lloyd, MD, FHRS, of Emory University is joined by guests T. Jared Bunch, MD, FHRS, of University of Utah School of Medicine, and Amit Shah MD, MSCR, of Emory University to discuss Atrial Fibrillation Catheter Ablation vs Medical Therapy and Psychological Distress - A Randomized Clinical Trial.   https://www.hrsonline.org/education/TheLead https://jamanetwork.com/journals/jama/article-abstract/2809419   Host Disclosure(s): M. Lloyd: Honoraria/Speaking/Consulting Fee: Medtronic, Baylis Medical Company, Boston Scientific Contributor Disclosure(s): T. Bunch: Honoraria/Speaking/Consulting Fee: Pfizer, Inc., Heart Rhythm Society; Research (Contracted Grants for PIs and Named Investigators Only): Boehringer Ingelheim, Altathera, Abbott; Other Financial Relationships: Biosense Webster, Inc.  A. Shah: No relevant financial relationships with ineligible companies to disclose. 

Click here for the Revenue Recovery cheat sheet: https://hubs.ly/Q02531_L0 Welcome to the fourth episode of our HeartTalk podcast series, Revenue Recovery. Host Melanie Lawson, MS, speaks with MedAxiom's Nicole F. Knight, LPN, CPC, CCS-P, executive vice president of Revenue Cycle Solutions and Care Transformation, and Linda Gates-Striby, CCS-P, ACS-CA, Revenue Cycle Solutions consultant. Together, they discuss the challenges and benefits of capturing home health certification and recertification services and share some top implementation tips your practice can use.Guest Bios: Nicole F. Knight, LPN, CPC, CCS-PExecutive Vice President, Revenue Cycle Solutions and Care Transformation Nicole's decades of healthcare experience include cardiovascular and neurology practice operations, clinical management, business office management, and consulting. The most recent years have been devoted to cardiovascular consulting in operations, LEAN process improvement, and the revenue cycle. Prior to joining MedAxiom, Nicole served as practice administrator for Baptist Neurology and Northeast Florida Cardiology and director of operations for Jacksonville Heart Center and Louisiana Cardiology Associates. She has extensive expertise in coding, compliance, and education for various specialties including cardiology, neurology, radiology, hematology/oncology, orthopedic, ENT, gastroenterology and internal medicine. Nicole has provided physician and staff coding and compliance education sessions nationally. Nicole has completed numerous education hours toward a B.S. in Health Care Administration. In addition, she maintains her LPN licensure in Louisiana and Florida. She is a member of the American Academy of Professional Coders and the American Health Information Management Association. She received her Advanced Cardiovascular Coding Certification with the Board of Medical Specialty Coding and completed the AAPC inpatient coding and reimbursement course. Nicole is a certified AHIMA ICD-10-CM Trainer and completed a LEAN Healthcare training course at Johns Hopkins University. She also serves on the Physician Practice Council for AHIMA. Linda Gates-Striby, CCS-P, ACS-CAMedAxiom Consultant, Revenue Cycle Solutions Linda Gates-Striby has worked in the medical field for over 30 years and has specialized in cardiology coding and revenue cycle for 25 years. Her clinical experience includes work in the heart stations and coronary intensive care units as well as working as an EMT for a level one trauma center. As a MedAxiom Revenue Cycle Solutions consultant, Linda provides cardiovascular programs across the country with operational expertise, implementation strategies and simplification for often complex initiatives to minimize risk and maximize revenue. Linda, who has spent the past 30 years working as a specialist in compliance, revenue cycle and quality with a large cardiology and multi-specialty practice, is also the director of quality assurance with Ascension Medical Group in Indiana. Linda is a sought-after speaker and consultant and has conducted numerous national educational sessions focused on documentation, coding, auditing and revenue cycle improvement for clinicians, coders and administrators across the nation. Linda serves as a non-physician member of the American College of Cardiology's coding work group and publications subcommittee and has also served on the coding committee for the Heart Rhythm Society. Linda served as the cardiology chair on the Board of Advanced Medical Coding, lead the development of the Advanced Cardiology and Specialty Cardiology Certification examinations, and was the technical editor for cardiology-focused newsletters. Linda has served as an Independent Review Organization auditor for Office of Inspector General Corporate Integrity Agreements, and as an expert witness on behalf of cardiology practices.

Take 1 minute to tell us what you think about this episode: pcna.net/PSVTevalGuest Mary Janette Sendin, MSN, APRN-CNS, CCNS, PCCN describes traditional pharmacologic and non-pharmacologic treatment options for PSVT such as vasovagal technique. Janette also discusses current research into treatment options.ESC Guideline: Brugada J, Katritsis DG, Arbelo E, et al. 2019 ESC Guidelines for the management of patients with supraventricular tachycardia The Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J. 2020;41(5):655-720.AHA Guideline: Page RL, et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2016;133(14):e506-e574. Etripamil study: Brugada J, Katritsis DG, Arbelo E, et al. 2019 ESC Guidelines for the management of patients with supraventricular tachycardia The Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J. 2020;41(5):655-720.See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

Click here for the Revenue Recovery cheat sheet: https://hubs.ly/Q023rDk50Welcome to the third episode of our new HeartTalk podcast series, Revenue Recovery. Host Melanie Lawson, MS, speaks with MedAxiom's Nicole F. Knight, LPN, CPC, CCS-P, executive vice president of Revenue Cycle Solutions and Care Transformation, and Linda Gates-Striby, CCS-P, ACS-CA, Revenue Cycle Solutions consultant. They discuss the challenges of capturing Advanced Care Planning services and share some practical tips to take back to your organization.Guest Bios: Nicole F. Knight, LPN, CPC, CCS-PExecutive Vice President, Revenue Cycle Solutions and Care Transformation Nicole's decades of healthcare experience include cardiovascular and neurology practice operations, clinical management, business office management, and consulting. The most recent years have been devoted to cardiovascular consulting in operations, LEAN process improvement, and the revenue cycle. Prior to joining MedAxiom, Nicole served as practice administrator for Baptist Neurology and Northeast Florida Cardiology and director of operations for Jacksonville Heart Center and Louisiana Cardiology Associates. She has extensive expertise in coding, compliance, and education for various specialties including cardiology, neurology, radiology, hematology/oncology, orthopedic, ENT, gastroenterology and internal medicine. Nicole has provided physician and staff coding and compliance education sessions nationally. Nicole has completed numerous education hours toward a B.S. in Health Care Administration. In addition, she maintains her LPN licensure in Louisiana and Florida. She is a member of the American Academy of Professional Coders and the American Health Information Management Association. She received her Advanced Cardiovascular Coding Certification with the Board of Medical Specialty Coding and completed the AAPC inpatient coding and reimbursement course. Nicole is a certified AHIMA ICD-10-CM Trainer and completed a LEAN Healthcare training course at Johns Hopkins University. She also serves on the Physician Practice Council for AHIMA. Linda Gates-Striby, CCS-P, ACS-CAMedAxiom Consultant, Revenue Cycle Solutions Linda Gates-Striby has worked in the medical field for over 30 years and has specialized in cardiology coding and revenue cycle for 25 years. Her clinical experience includes work in the heart stations and coronary intensive care units as well as working as an EMT for a level one trauma center. As a MedAxiom Revenue Cycle Solutions consultant, Linda provides cardiovascular programs across the country with operational expertise, implementation strategies and simplification for often complex initiatives to minimize risk and maximize revenue. Linda, who has spent the past 30 years working as a specialist in compliance, revenue cycle and quality with a large cardiology and multi-specialty practice, is also the director of quality assurance with Ascension Medical Group in Indiana. Linda is a sought-after speaker and consultant and has conducted numerous national educational sessions focused on documentation, coding, auditing and revenue cycle improvement for clinicians, coders and administrators across the nation. Linda serves as a non-physician member of the American College of Cardiology's coding work group and publications subcommittee and has also served on the coding committee for the Heart Rhythm Society. Linda served as the cardiology chair on the Board of Advanced Medical Coding, lead the development of the Advanced Cardiology and Specialty Cardiology Certification examinations, and was the technical editor for cardiology-focused newsletters. Linda has served as an Independent Review Organization auditor for Office of Inspector General Corporate Integrity Agreements, and as an expert witness on behalf of cardiology practices.

Click here for Revenue Recovery "Cheat Sheet" Welcome to the second episode of our new HeartTalk podcast series, Revenue Recovery, in which we aim to empower you to communicate effectively and ensure your organization does not leave any money on the table. Host Melanie Lawson, MS, speaks with MedAxiom's Nicole F. Knight, LPN, CPC, CCS-P, executive vice president of Revenue Cycle Solutions and Care Transformation, and Linda Gates-Striby, CCS-P, ACS-CA, Revenue Cycle Solutions consultant. They share tips for capturing counseling services for a low-dose CT scan and why shared decision-making with the patient is essential.Guest Bios:Nicole F. Knight, LPN, CPC, CCS-PExecutive Vice President, Revenue Cycle Solutions and Care TransformationNicole's decades of healthcare experience include cardiovascular and neurology practice operations, clinical management, business office management, and consulting. The most recent years have been devoted to cardiovascular consulting in operations, LEAN process improvement, and the revenue cycle.Prior to joining MedAxiom, Nicole served as Practice Administrator for Baptist Neurology and Northeast Florida Cardiology and Director of Operations for Jacksonville Heart Center and Louisiana Cardiology Associates. She has extensive expertise in coding, compliance, and education for various specialties including cardiology, neurology, radiology, hematology/oncology, orthopedic, ENT, gastroenterology and internal medicine. Nicole has provided physician and staff coding and compliance education sessions nationally.Nicole has completed numerous education hours toward a B.S. in Health Care Administration. In addition, she maintains her LPN licensure in Louisiana and Florida. She is a member of the American Academy of Professional Coders and the American Health Information Management Association. She received her Advanced Cardiovascular Coding Certification with the Board of Medical Specialty Coding and completed the AAPC inpatient coding and reimbursement course. Nicole is a certified AHIMA ICD-10-CM Trainer and completed a LEAN Healthcare training course at Johns Hopkins University. She also serves on the Physician Practice Council for AHIMA.Linda Gates-Striby, CCS-P, ACS-CAMedAxiom Consultant, Revenue Cycle SolutionsLinda Gates-Striby has worked in the medical field for over 30 years and has specialized in cardiology coding and revenue cycle for 25 years. Her clinical experience includes work in the heart stations and coronary intensive care units as well as working as an EMT for a level one trauma center.As a MedAxiom Revenue Cycle Solutions consultant, Linda provides cardiovascular programs across the country with operational expertise, implementation strategies and simplification for often complex initiatives to minimize risk and maximize revenue. Linda, who has spent the past 30 years working as a specialist in compliance, revenue cycle and quality with a large cardiology and multi-specialty practice, is also the director of quality assurance with Ascension Medical Group in Indiana.Linda is a sought-after speaker and consultant and has conducted numerous national educational sessions focused on documentation, coding, auditing and revenue cycle improvement for clinicians, coders and administrators across the nation.Linda serves as a non-physician member of the American College of Cardiology's coding work group and publications subcommittee and has also served on the coding committee for the Heart Rhythm Society. Linda served as the cardiology chair on the Board of Advanced Medical Coding and lead the development of the Advanced Cardiology and Specialty Cardiology Certification examinations, as well as the technical editor for cardiology focused newsletters. Linda has served as an Independent Review Organization auditor for Office of Inspector General Corporate Integrity Agreements, and as an expert witness on behalf of cardiology practices.

Click Here for Revenue Recovery "Cheat Sheet"While you may or may not be the person coding revenue cycle services, many of you are responsible for your program's overall success with revenue recovery and know all too well the challenges that come with it. Welcome to the first episode of our new podcast series, Revenue Recovery, where we aim to empower YOU – physicians, administrators and revenue cycle managers – to effectively communicate and ensure your organization does not leave any money on the table. On MedAxiom HeartTalk, host Melanie Lawson speaks with MedAxiom's Nicole F. Knight, LPN, CPC, CCS-P, executive vice president of revenue cycle solutions and care transformation, and Linda Gates-Striby, CCS-P, ACS-CA, revenue cycle solutions consultant. Together, they discuss some challenges, tips and solutions for capturing services involving smoking and tobacco cessation.Guest Bios:Nicole F. Knight, LPN, CPC, CCS-PExecutive Vice President, Revenue Cycle Solutions and Care TransformationNicole's decades of healthcare experience include cardiovascular and neurology practice operations, clinical management, business office management, and consulting. The most recent years have been devoted to cardiovascular consulting in operations, LEAN process improvement, and the revenue cycle.Prior to joining MedAxiom, Nicole served as Practice Administrator for Baptist Neurology and Northeast Florida Cardiology and Director of Operations for Jacksonville Heart Center and Louisiana Cardiology Associates. She has extensive expertise in coding, compliance, and education for various specialties including cardiology, neurology, radiology, hematology/oncology, orthopedic, ENT, gastroenterology and internal medicine. Nicole has provided physician and staff coding and compliance education sessions nationally.Nicole has completed numerous education hours toward a B.S. in Health Care Administration. In addition, she maintains her LPN licensure in Louisiana and Florida. She is a member of the American Academy of Professional Coders and the American Health Information Management Association. She received her Advanced Cardiovascular Coding Certification with the Board of Medical Specialty Coding and completed the AAPC inpatient coding and reimbursement course. Nicole is a certified AHIMA ICD-10-CM Trainer and completed a LEAN Healthcare training course at Johns Hopkins University. She also serves on the Physician Practice Council for AHIMA.Linda Gates-Striby, CCS-P, ACS-CAMedAxiom Consultant, Revenue Cycle SolutionsLinda Gates-Striby has worked in the medical field for over 30 years and has specialized in cardiology coding and revenue cycle for 25 years. Her clinical experience includes work in the heart stations and coronary intensive care units as well as working as an EMT for a level one trauma center.As a MedAxiom Revenue Cycle Solutions consultant, Linda provides cardiovascular programs across the country with operational expertise, implementation strategies and simplification for often complex initiatives to minimize risk and maximize revenue. Linda, who has spent the past 30 years working as a specialist in compliance, revenue cycle and quality with a large cardiology and multi-specialty practice, is also the director of quality assurance with Ascension Medical Group in Indiana.Linda is a sought-after speaker and consultant and has conducted numerous national educational sessions focused on documentation, coding, auditing and revenue cycle improvement for clinicians, coders and administrators across the nation.Linda serves as a non-physician member of the American College of Cardiology's coding work group and publications subcommittee and has also served on the coding committee for the Heart Rhythm Society. Linda served as the cardiology chair on the Board of Advanced Medical Coding and lead the development of the Advanced Cardiology and Specialty Cardiology Certification examinations, as well as the technical editor for cardiology focused newsletters. Linda has served as an Independent Review Organization auditor for Office of Inspector General Corporate Integrity Agreements, and as an expert witness on behalf of cardiology practices.

In this episode, we are highlighting some of the presentations from Heart Rhythm 2023, the Heart Rhythm Society's annual meeting, which took place May 19-21, 2023. Included here are onsite interviews with Doug Darden, MD, Pamela Mason, MD, Marco Perez, MD, and Monica Pammer Austin, PAC.

ABOUT THE AUTHOR:  Dr. Arif Ahmad is a Fellow of the American College of Cardiology and a Fellow of the Heart Rhythm Society and practices cardiology and electrophysiology in southern Wisconsin. He is a mid-Westerner with pride for where he came from – Pakistan, his faith – Muslim, and most of all, for the county he now calls home – America. Born in Lahore, Pakistan, he has lived in New York City, Milwaukee, and Iron Mountain, MI, and now resides in Madison, WI. He also has a farm 20 minutes from his home.  Dr. Arif Ahmad lived his first 30 years of life in Pakistan. After coming to America in the 1990s, he has been in the United States for almost 30 years. Through his experiences and optimistic outlook, he shares an encouraging vision for America in his debut book, A Piece of Me: An Arrangement of Words To Inspire Reflection. Written over a decade the 2010s, his book offers provocative thoughts on a wide variety of topical areas, including unity, diversity, news media, faith, and health. It became a best-seller on Amazon and earned the 2022 Bronze Medal Award in the Poetry/ Verse category for the Global Book Awards. Though it is his debut book, his writings have been published in the Associated Press and CNN.com. What we can learn from the Muslim-American experienceHow he uses award-winning poetry to get his points acrossExploring our nation through the eyes of a well-educated Pakistani immigrantHow can we shape society for the future right nowWhy we should feel optimism — but what we can do to bridge our cultural divide Which moments of the past decade are defining America.

This week, please join authors Hanna-Kaisa Nordenswan and Jukka Lehtonen, as well as Associate Editor Mark Link as they discuss the article "Incidence of Sudden Cardiac Death and Life-Threatening Arrhythmias in Clinically Manifest Cardiac Sarcoidosis With and Without Current Indications for an Implantable Cardioverter Defibrillator." Dr. Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. 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, VCU Health in Richmond, Virginia. Dr. Peder Myhre: And I'm Dr. Peder Myhre, Social Media Editor in Circulation from Akershus University Hospital, and University of Oslo, Norway. Dr. Carolyn Lam: Oh, I am so excited about our feature paper today. It is about a condition that may not be as commonly encountered, but this paper can change clinical practice. It's about cardiac sarcoidosis and the indications for an ICD. Listen up. Very important stuff and discussion coming right up. But first, let's grab coffees and discuss the other papers in today's issues. Shall we? Dr. Greg Hundley: Right. So Carolyn, Peder, how about I go first? And so, both of you... we start with a really interesting, very practical study. It's somewhat unclear whether replacing an oral glucose tolerance test with just a hemoglobin A1C measurement for diagnosing diabetes is justified. And so these authors led by Adam Tabák, from University College of London in the United Kingdom, aimed to assess proportion of oral glucose tolerance tests, diagnosed diabetes cases that can be confirmed with hemoglobin A1C measures. And to examine whether individuals with oral glucose tolerance test diagnoses, but non-diagnostic hemoglobin and A1C are at higher risk of macro and microvascular disease. So the study included 5,773 men and women from the population based Whitehall II prospective of cohort study in the United Kingdom. New oral glucose tolerance tests, diabetes cases diagnosed in clinical examinations between the years of 2002 and 2004. And again, in 2007 and 2009 were assessed for hemoglobin A1C confirmation of a value greater than 6.5% in these. And then again, so in those years, and then again, in subsequent clinical examinations in the periods of 2012 to 2013 and 2015 to 2016, now all participants were followed for major cardiovascular events via linkage to electronic health records until the year of 2017. And for incident chronic kidney disease by an estimated glomerular filtration blade of less than 60 mLs per minute per meter squared, until the last clinical examination. Dr. Peder Myhre: Thank you, Greg. That is such an important study with direct clinical implications. And I'm so curious to know what did they find? Dr. Greg Hundley: Right, Peder. Right, Carolyn. Carolyn's in the background, it's like a mind meld with Peder. She's going to keep pounding me with these same questions. Okay. So in this population based cohort study, with five yearly repeated oral glucose tolerance tests and hemoglobin A1C measurements, only 59.3% of the oral glucose tolerance tests diagnosed diabetes cases were confirmed by hemoglobin A1C at the same or a subsequent examination during 4.1 years of follow up. Incident oral glucose tolerance test diagnosed diabetes cases with hemoglobin A1C confirmation, and preexisting diabetes cases had similarly increased risks of cardiovascular disease and chronic kidney disease. While notably unconfirmed oral glucose tolerance test cases had a similar risk as the diabetes free population. Dr. Peder Myhre: Wow. That is really remarkable, Greg. Thank you for that summary. But can you please just give us, from this complicated paper, can you just give us some take-home points for the listeners. Dr. Greg Hundley: Right, Peder. So first, in this study, people with oral glucose tolerance tests diagnosed diabetes without diagnostic hemoglobin A1C have a risk of cardiovascular disease and chronic kidney disease, similar to the diabetes free population. And therefore, replacement of oral glucose tolerance tests with hemoglobin A1C based diagnoses appears justified. Second, there seems to be no need to consider oral glucose tolerance testing when hemoglobin A1C and fasting glucose levels are apparently inconclusive. Fasting glucose tests are needed only in exceptional circumstances where hemoglobin A1C results are felt to be unreliable. And then, finally, these findings lend confidence to widespread use of hemoglobin A1C for diagnosing diabetes in the vast majority of clinical settings. Dr. Peder Myhre: Wow. Greg, thank you so much. This was so helpful. Well, I'm going to move on to the second original research article. And that is from the DAPA-HF trial, that I know Carolyn has been quizzing you throughout the years about. So I'm not going to quiz you, but I'm just going to ask you. Did you know that SGLT-2 inhibitors increase hematocrit and that it has been identified as one of the key mediators of the clinical benefits on this class of drugs. Dr. Greg Hundley: So Peder, they're really interesting. And the second week of this you're popping out with these quizzes. I didn't do this to Carolyn. It was like a couple months. So anyway, but- Dr. Carolyn Lam: Way to go, Peder. Way to go. Dr. Greg Hundley: Yeah. Well, the good news is, I can just say yes. I did know that. Dr. Peder Myhre: That's nice. And in this paper, we're going to learn even more. Because the authors are taking this further by looking into the iron metabolism and assessing iron deficiency in the DAPA-HF trial. So just to remind you, although, you are familiar with it at this point, Greg, and of course, Carolyn, the DAPA-HF trial was large RCT testing efficacy and safety of the SGLT-2 inhibitor compared to placebo in patients with heart failure and a reduced ejection fraction. And in this post talk analysis, the authors examine the prevalence and consequences of iron deficiency and the effect of dapagliflozin on markers of iron metabolism. They also analyze the effect dapagliflozin on outcomes according to iron status at baseline. Dr. Greg Hundley: Oh, wow, Peder. So what did they find? Dr. Peder Myhre: So in total, 44% of patients in DAPA-HF were defined as iron deficient. And that was defined as having less than 100 nanogram per milliliter of ferritin or a key set of less than 20% and a ferritin level between 100 and 299 nanogram per milliliter. So the rate of the primary outcome was higher in patients with iron deficiency compared to those without. That was 16 versus 10 per 100% years. And the effect of dapagliflozin on the primary outcome was consistent in iron deficient compared to iron replace patients with a fever interaction of 4.59. And similar findings were observed for cardiovascular death, heart failure hospitalizations and all-cause mortality. And finally, and very importantly, ferritin, T cell, and hepcidin were reduced with dapagliflozin versus placebo. So the authors conclude that iron deficiency was common in DAPA-HF. And associated with worse outcomes. Dapagliflozin, appeared to increase iron utilization, but improved outcomes, irrespective of iron status at baseline. Dr. Greg Hundley: Very nice, Peder. Wow. Just another important piece of information that we're learning about SGLT-2 inhibition. Well, Peder, my next paper comes from the world of preclinical science and it's from a group of authors led by Dr. Osamu Takeuchi from Kyoto University. Primary pulmonary arterial hypertension, Peder, is often characterized by obliterative pulmonary vascular remodeling, resulting in right heart failure. And although, the pathogenesis of pulmonary arterial hypertension is not fully understood. Inflammatory responses and cytokines have been shown to be associated with pulmonary arterial hypertension, particularly with connective tissue disease. So in this sense, Regnase-1 and RNAs, which regulates mRNAs in coding genes related to immune reactions was investigated in relationship to the pathogenesis of pulmonary hypertension. Dr. Peder Myhre: Wow, Greg. Pulmonary arterial, a hypertension and mRNA degradation of IL-6. So what did they find, Greg? Dr. Greg Hundley: Right, Peder. So these investigators examined the expression levels of Z3H12A in coding Regnase-1, in peripheral blood mononuclear cells from pulmonary hypertension patients classified under various types of pulmonary hypertension, searching for an association between the ZC3H12A expression and the clinical features associated with pulmonary hypertension. They then generated mice lacking Regnase-1 and myeloid cells, including alveolar macrophages and examined right ventricular systolic pressures, and histologic changes in the lung. They found that Regnase-1 maintains lung innate immune homeostasis via the control of IL-6 and PDGF in alveolar macrophages, thereby, suppressing the development of pulmonary arterial hypertension in mice. And furthermore, the decreased expression of Regnase-1 in various types of pulmonary hypertension implied its involvement in pulmonary hypertension pathogenesis. And then, therefore, may serve as a disease biomarker as well as a therapeutic target for pulmonary hypertension. Very, very interesting work from the world of preclinical science. So how about we jump and see what else is in the mail bag? Dr. Peder Myhre: So we have From the Literature by Dr. Tracy Hampton, and this time we get three summaries from preclinical science papers published on their journals. First, there is a summary of a paper suggesting that circadian and pluripotency networks control longevity related genes, and that was published in cell metabolism. There is also a summary from a paper on the varied responses to a high fat diet using mouse models published in high science. And finally, there is a summary related to Brugada syndrome and how gene therapy is a potential future therapy. And that was published in scientific translational medicine. So Greg, what did you have in the mail bag? Dr. Greg Hundley: Sure. Well, Peder, I've got a research letter from Professor Fang entitled “Mitochondrial Stress Induces HRIEIF2A Pathway that's Protective for Cardiomyopathy.” Dr. Peder Myhre: And finally, we have clinical implications of basic research from Dr. Garry and colleagues entitled “Cardiac Xenotransplantation, the Clinical Impact of Science and Discovery.” So let's move on the future discussion, Carolyn. Dr. Carolyn Lam: Absolutely. Thank you for excellent summary, Greg and Peder. Now, let's go the feature discussion on cardiac sarcoidosis. Dr. Greg Hundley: You bet. Dr. Carolyn Lam: Wow. Today's feature discussion is on a rare, but very important topic. And it's that of cardiac sarcoidosis. And you have to listen up because today's paper could actually change practice. So I'm very pleased and grateful to have the authors of this paper. The corresponding author, Dr. Hanna-Kaisa Nordenswan and coauthor, Dr. Jukka Lehtonen both from Helsinki University Hospital. As well as our associate editor, Dr. Mark Link, from UT Southwestern to discuss this very important paper. Hannah-Kaisa if you don't mind, could you start by just telling us about your paper and what you found? Dr. Hanna-Kaisa Nordenswan: Thank you so much for inviting us to the podcast. So cardiac sarcoidosis predisposes to sudden cardiac death. But how well the current guidelines for implantable cardioverter-defibrillators in CS issued by the Heart Rhythm Society in 2014 and the American College of Cardiology, American Heart Association and Heart Rhythm Society, consortium guidelines from 2017, discriminate high from low risk of sudden cardiac death is unknown. And this is what we wanted to examine. So our study is a nationwide study, including 398 patients with cardiac sarcoidosis. All patients had clinical cardiac manifestations and a histological diagnosis of sarcoidosis. The histological diagnosis was myocardial in nearly one half of the population. So patients with and without class 1 to 2A indications for an implantable cardioverting-defibrillator at presentation were identified from this population. The occurrence of fatal or aborted sudden cardiac death and sustained ventricular tachycardias in follow-up were recorded. We also noted ICD indications emerging first on, follow up. Dr. Carolyn Lam: Great. What did you find? Dr. Hanna-Kaisa Nordenswan: So, first of all, we found that by the current ICD guidelines, 85 to 100% of our patients had at least one strong to modest class 1 to 2a indication for an early ICD implementation. And we also found a 10%, five-year cumulative incidence of sudden cardiac death in our population of cardiac sarcoidosis patients. Further, we found that patients without an early indication for an ICD by the Heart Rhythm Society guidelines had nearly 5% cumulative risk of sudden cardiac death at five years. These patients further had a 53% cumulative risk of either developing an indication or suffering from a life-threatening ventricular arrhythmia at five years follow up. Finally, we also found that a diagnosis of cardiac sarcoidosis based on myocardial histology, IE definite CS. So definite cardiac sarcoidosis predicted twice higher combined five-year risk of sudden cardiac death and life-threatening ventricular arrhythmia than diagnosis based on extra cardiac histology, IE probable cardiac sarcoidosis. Dr. Carolyn Lam: Wow. Thank you so much, Hannah-Kaisa and congratulations on such impactful findings. 398 patients and if I read correctly, a cohort spanning 30 years. Jukka, could you tell us a little bit more on how these patients were identified? And I think this is important too, because it speaks to the generalizability of your findings. Dr. Jukka Lehtonen: Exactly. Yeah. So we have a very proactive approach to cardiac sarcoidosis. So basically, if I give you an example, so we screen all patients less than 60 years of age with MRI. And if the MRI shows that there's any signs of myocardial damage, we do endomyocardial biopsy. And then, if we do biopsy, once take 10 samples from the right ventricular septum. If that comes out negative, as it very often comes, then we do a PET study. And if there's an extra cardiac signal, then we do biopsy that side. So usually, it's lymph nodes very often. And that gives us a probable cardiac sarcoidosis. So probable cardiac sarcoidosis is the terminology that's used in Heart Rhythm Society, 2014 guidelines. It has the same prognosis, basically, the definite cardiac sarcoidosis that's based on endomyocardial biopsy. So if the PET shows no signal outside the heart, we usually repeat the biopsy either right or left side, depending where there's most signal. And we can do that up to three times. So we have a very proactive approach. And that explains why we have so many patients. So because you may end up taking 30 biopsy samples and you have one sample that's positive. So that explains why 5.3 million people can have such a huge number of sarcoid patients. We don't think that we are special. We just think that we are very active in biopsy area. And I know that this is something that differs in different places, and the different centers in the US have very different policies, and in Europe as well. So why I think this explains why we have such a large population and why they're all biopsy verified cases. Dr. Carolyn Lam: Thank you so much, Mark. I know that as editors we spotted immediately what a precious, valuable cohort in data we were looking at. Could you frame that for us? Take us behind the scenes a little bit on what you thought when this paper first crossed your desk. Dr. Mark Link: Yeah. This was a paper that caught our interest right away for a number of reasons. One, is the large number of sarcoid patients, nearly 400, that's one of the largest series that's ever been published. And two, is the systematic way in which sarcoid was approached. And what we found fascinating is that once you had a diagnosis of cardiac sarcoid, be it either probable or actual, there was a high risk of having ventricular arrhythmias. And this is something that in the guidelines, it's not so clear, because it's clear if the EF's less than 35%, you should get an ICD. But if your EF's greater than 35% by current guidelines, that's not a class 1 indication. So we thought this paper had the possibility to move guidelines and that perhaps we should think about an ICD and any patient that has diagnosis of cardiac sarcoid. Dr. Carolyn Lam: Wow. That's a brave postulation though. Exactly, as I said at the beginning, I think it may be practice changing. What do you think about that? Jukka and Hannah? Dr. Jukka Lehtonen: I think that's exactly what we have noticed that we have, most of the cardiac sarcoid patients are less than 50 years of age. So I think, the average age is 49 or something. And they're mostly females, so 70% are females. So it's pretty unique cardiac disease, that's more common in females than in males. And I think this population is benefiting tremendously from the ICD therapy, so that's something that we can see. It's not based on randomized data, it's follow up data, but these patients have lots of ICD events, events treated by an ICD. So we think that this is a major problem. Our previous papers have shown that the mortality in sarcoidosis is 90% is ventricle arrhythmia. So this conclusion fits with that previous findings as well. Dr. Carolyn Lam: Wow. Hannah has this impacted your personal clinical practice? I mean, do you now therefore think any patient, especially, if they've got confirmed cardiac sarcoidosis biopsy proven. Are you going to just, no matter what, regardless, anything else be more likely to put an ICD? Dr. Hanna-Kaisa Nordenswan: Yeah. Based on this study, we think that all cardiac sarcoidosis patients presenting with clinical cardiac manifestations and with histologically proven cardiac sarcoidosis should be considered for an ICD implantation. But with patients, with having non-definite cardiac sarcoidosis and without class 1 to 2A indications for an ICD in these patients, probably, the pros and cons of an ICD should be carefully discussed. Well, if an ICD is not implanted, at least repeated risk appraisal is needed regularly during follow up. Dr. Carolyn Lam: That's great comments. Mark, what do you think is going to be needed as future steps to get it to change practice? Or do you think this is it? Because, I mean, this is... the issue is, it's not easy to say let's just do a trial in cardiac sarcoidosis, right? Where are we going to find those patients and so on. What do you think, Mark? Dr. Mark Link: Yeah. That's a very good question. Because this isn't randomized trial data, and the strength of evidence is best with randomized trial data. And will we get a randomized trial in sarcoid? I doubt it. I really doubt it. So we're going to be left with registry data. And so where I would see this going is other registries coming out, showing their data. I think we do need confirmatory data from another large registry or two, and that's going to change practice, but are we there yet? I don't know. I don't know. Based on the lack of randomized trial data. Dr. Carolyn Lam: Thanks. If I could then for the last questions, if I could give it to the authors, what are your plans for next steps, if any. Maybe, Jukka, do you want to start first? Dr. Jukka Lehtonen: Well, I think cardiac sarcoidosis has lots of open questions. It has only open questions. I think the direction we are going is to go to the drug trial. So whether treatment of the inflammation by different agents would provide benefit in terms of arrhythmias and heart failure. So there's an idea that take patients with, for example, that's something that we haven't finalized yet, but take patients with normal ejection fraction, randomized them to cortisone and no cortisone and see how they do. Because we don't really know whether even corticosteroids actually make a huge difference. I think we have more than 200 cardiac sarcoid patients under follow up in our hospital. And I can see that there are patients that have very good prognosis and no events whatsoever over many years or even decade. And then we have other patients that have lots of events, arrhythmias and develop heart failure. So I think we need trials that help us to distinguish those patients and also trials that help us select right medications for each group. Dr. Carolyn Lam: Thank you, Hannah? Dr. Hanna-Kaisa Nordenswan: Based on this particular study, we think that also the next study should preferably be a larger multicenter study that would focus on the prognostic factors in cardiac sarcoidosis. Perhaps, a risk score could be developed by using more detailed information of the presenting manifestations and ventricular function and imaging findings, cardiac magnetic resonance and positron emission tomography. Dr. Mark Link: Yeah. And we at the editorial staff thought this was important enough paper to have an editorial, to comment on its usefulness and way forward in dealing with cardiac sarcoid patients. And this editorial is written by Rick Patton and will accompany the printed issue. Dr. Carolyn Lam: Thanks. And so, you heard it, everyone pick up that editorial, pick up that paper. This is an important topic, and so grateful that it was published with us. Thank you once again to the authors. Thank you once again, Mark, for managing this paper. So lovely. And thank you, audience for joining us today from Greg and I, you've been listening to Circulation on the Run. Don't forget to tune in again next week. 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.

Show Notes - All Things Afib - Episode 15: Dementia and Atrial Fibrillation with Dr. Jared Bunch As doctors, we often don't ask our patients (or their spouses) about “memory issues” or other signs of dementia, related to AFib. We usually ask about stroke, clots, and other heart functions but neglect to ask about the brain. My guest today is Dr. T. Jared Bunch, Head of Section for Heart Rythm Services at the University of Utah. Dr. Bunch specializes in the diagnosis and management of heart rhythm disorders. His current research involves defining mechanisms underlying the association between atrial fibrillation and dementia. He looks at therapeutic opportunities to lower the risk of cognitive decline, the integration of wearable and implantable devices to improve early diagnosis and treatment of arrhythmias, and improving mapping and catheter ablation of arrhythmias.Dr. Bunch is a section editor for Current Cardiology Risk Reports, Heart Rhythm Journal, and a guest editor for American Heart Journal. He is on the editorial boards of the Heart Rhythm Journal, Journal of Cardiovascular Electrophysiology, Heart, American Heart Journal, JACC electrophysiology, and the Journal of Innovations in Cardiac Rhythm Management. In addition, he is a Professor of Medicine at the University of Utah and Editor-in-chief of the Heart Rhythm Society.Join us for a discussion on the alarming connection between AFib and dementia, how to manage AFib and also assist in preventing brain decline, and the many exciting studies and trials, books and articles about the relationship between the two.All Things Afib is hosted by me, Dr. Armin Kiankhooy. As a board-certified cardiothoracic surgeon, my focus is on advanced treatments for heart and lung failure and minimally-invasive surgical treatments for atrial fibrillation such as the Hybrid Maze procedure. You can find me on staff at Adventist Health Heart and Vascular Institute in St. Helena California. Discussion points:Dr. T Jared Bunch intro and background What is dementia? Why should we care about its relation to AFib?An AFib/Dementia story– the salesman with AFib and “senior moments”Many times doctors neglect to ask patients about dementia and memory issues – only ask about stroke, clots, etc.Microbleeds, microclots, and hypoperfusionAssessing risk through blood panelsThe concussion/afib trialThe magnitude of risk for dementia is higher in younger patients – ages 60-70 vs. 70-90The impact of wearables and the Heartline TrialBenefits of anticoagulantsAppendage management, AFib, and dementiaCHADS VASC scores and AFib/dementiaWhat other tests/scores do you look at?The AFib Cure book and Dr. John DayClosing words: for anyone listening– Be your own advocate, ask questions, join the AFib online community, and find a doctor who will answer your questions/knows about AFib. There are treatments and ways to address Afib.Resources:Dr. T. Jared Bunch LinkedInDr. Bunch PublicationsJoin the Heartline Trial/Apple WatchThe Afib Cure BookStopAFib.orgDr. Kiankhooy LinkedInAll Things AFib WebsiteAll Things AFib TwitterAll Things AFib YouTube Channel

The "Community Outreach and COVID" topic was originally presented during National Minority Quality Forum's weekly webinar series. Listen now for a closer look at addressing existing disparities. Panelists: Jonathan Hsu, MD, MAS Heart Rhythm Society Dan Fagbuyi, MD Centers for Disease Control Kristen Hobbs, MPH Senior Project Manager, Quality Improvement and Equity NMQF - SHC (Moderator)

Welcome to the first episode of “All Things AFib.” I am your host, Dr. Armin Kiankhooy. As a board-certified cardiothoracic surgeon, my focus is on advanced treatments for heart and lung failure and minimally-invasive surgical treatments for atrial fibrillation such as the Hybrid Maze procedure. You can find me on staff at Adventist Health Heart and Vascular Institute in St. Helena California. For our inaugural episode, I'm thrilled to welcome Dr. James Cox, a legend in the field of cardiothoracic surgery, and inventor of the Cox maze surgery. The world is lucky that Dr. Cox decided to become a surgeon because he also had an offer to play professional baseball with the LA Dodgers. Dr. Cox was the Evarts A. Graham Professor of Surgery, vice-chairman of the department of surgery, and chief of the division of cardiothoracic surgery at Washington University School of Medicine and Barnes Hospital in St. Louis, MO. It was here in 1987 that he developed the eponymous “maze” procedure, which is still the gold standard in the world today. Dr. Cox was the 81st (and youngest) president of the American Association for Thoracic Surgery (AATS), a member of the editorial board of more than 20 scientific journals, and editor-in-chief of two AATS journals. Among the numerous awards and honors he has received throughout his illustrious career, Dr. Cox is the only surgeon to receive the Distinguished Scientist Award from the AATS, the Society of Thoracic Surgeons, and the Heart Rhythm Society. He is the only U.S. cardiac surgeon in the Russian Academy of Medical Sciences. Cox is dedicated to clinical excellence, the development of new techniques, and the training of the next generation of surgeons. Discussion points:What is Atrial Fibrillation (AFib)?The AFib word origins actually meant the appearance of a “sack of worms”The two types of Macro Re-Entry– Automaticity and micro/macro re-entryTreatment methods– Cardiothoracic Surgeons vs. ElectrophysiologistsThe technicalities of terms Maze III vs. Maze IV, the confusion, and even a lawsuitWhat are the confusing statistics around pacemaker implantation and the Cox maze procedure?Post-operative and medicinal damage to the sinus nodeAround 5% of patients may need pacemakers due to “sick” sinus nodes, not AFib surgeryA discussion of Left Atrial Appendage managementIs there a percentage of AFib patients that should have more than the Left Atrial closure procedure?Do we need to get more surgeons to do Left Atrial closure?Discussion of hybrid maze proceduresWill we still be doing maze procedures in 30 years?Imagining tools we may be using in the futureResources:Dr. James Cox Original Papers: The surgical treatment of atrial fibrillation. I. Summary of the current concepts of the mechanisms of atrial flutter and atrial fibrillation. The surgical treatment of atrial fibrillation. II. Intraoperative electrophysiologic mapping and description of the electrophysiologic basis of atrial flutter and atrial fibrillation. The surgical treatment of atrial fibrillation. III. Development of a definitive surgical procedure. Modification of the maze procedure for atrial flutter and atrial fibrillation. I. Rationale and surgical results. Modification of the maze procedure for atrial flutter and atrial fibrillation. II. Surgical technique of the maze III procedure.Dr. James Cox LinkedInDr. James Cox Receives Jacobson Innovation Award Dr. Kiankhooy LinkedInAll Things AFib WebsiteAll Things AFib TwitterAll Things AFib YouTube Channel

Warning: this talk contains graphic content describing medical practice. This talk was given on October 19, 2021 at Johns Hopkins University via Zoom. For more information on upcoming events, please visit our website at www.thomisticinstitute.org About the speaker: Joseph Marine, MD, MBA, FACC, FHRS, is a board-certified clinical cardiac electrophysiologist who practices primarily at the Johns Hopkins Hospital in Baltimore, Maryland. He is a Professor of Medicine at the Johns Hopkins University School of Medicine and holds appointments as Vice-Director of Operations for the Division of Cardiology and Section Chief of Cardiology for Johns Hopkins Community Physicians. He trained at UC San Francisco Medical School, Brigham and Women's Hospital/Harvard Medical School, Boston University Medical Center, and Beth Israel Deaconess Medical Center. Dr. Marine has lectured widely on a variety of arrhythmia topics and has served as a co-director of the American College of Cardiology (ACC) Cardiovascular Overview and Board Review Course for 10 years. He currently serves on the ACC Board of Governors and is co-editor of the ACC/HRS EP Self-Assessment Program. He also serves on other committees for the ACC, the Heart Rhythm Society, and MedChi. He is co-author of more than 130 original research and review articles and has served on writing committees for several national cardiology practice and training guidelines.

Episode 73: Anticoagulation in Afib. When should you start anticoagulation in atrial fibrillation? What medications are appropriate? Virginia Bustamante, Charizza Besmanos and Dr Arreaza discuss this topic.  By Charizza Besmanos, MS4; Virginia Bustamante, MS4; and Hector Arreaza, MDCharizza: Hello, welcome to today's episode of Rio Bravo qWeek Podcast. My name is Charizza Besmanos, a 4th year medical student from American University of the Caribbean and I am joined here today by Virginia Bustamante.  Virginia: I'm Virginia Bustamante, an incoming 4th year medical student from Ross University.  Arreaza: And I'll be here just to make sure that you guys behave during this episode. Charizza: Before we get started on our discussion, I have a quick patient case to share with you.  This is a 66-year-old woman who is brought to the ED with sudden onset of severe difficulty speaking and weakness while having breakfast. She has hypertension, hyperlipidemia, severe left atrial enlargement seen on previous ECHO, and is noncompliant with her medications. She is a lifetime nonsmoker and does not drink alcohol. On admission, her blood pressure is 152/90 and pulse is 124/min and irregularly irregular. She is awake and alert but has difficulty finding words while trying to speak. She has severe right lower facial droop and marked weakness and sensory loss in the right arm and mild weakness in right leg. Fingerstick glucose is at 105. ECG shows atrial fibrillation. Acute stroke management is started right away. CT shows occlusion of the left MCA. What management could have prevented this complication?  Virginia: This patient clearly has multiple risk factors for thromboembolism events but given her irregularly irregular pulse consistent with atrial fibrillation, she would've warranted long-term anticoagulation to prevent stroke, which she most likely had.  Charizza: Exactly. Today's topic is atrial fibrillation, specifically the use of anticoagulation. __________________This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it's sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. __________________ Virginia: Anticoagulation is indicated to decrease the risk of thromboembolic events such as ischemic stroke in patients with atrial fibrillation (A-fib). Not all patients receive anticoagulation. Like most things in medicine, you must decide to start anticoagulation when the benefits of decreasing the risk of stroke outweighs the risk of bleeding. So, for assessing the risk of stroke in A-fib, the American College of Cardiology along with American Heart Association and the Heart Rhythm Society published a guideline in the Journal of the American College of Cardiology in 2014 and was recently updated in 2019[1] detailing in which patients anticoagulation is recommended.  Charizza: Yes, according to the guideline, “high risk patients” are all patients with valvular A-fib, and those with nonvalvular A-fib with a CHADVASC score of >/= 2 in men or >/= 3 in women, and those with nonvalvular Afib and hypertrophic cardiomyopathy. Those with “medium risk” are patients with nonvalvular Afib with CHAD2VASc score of 1 in men or 2 in women. In these patients, anticoagulation is considered but the risk and benefits are discussed with the patient. Those with “low risk” are patients with CHAD2VASc score of 0 in men or 1 in women and anticoagulation is not routinely recommended in these patients. Can you tell us briefly what CHA2DVASc score is?  Virginia: CHA2DS2-VASc score is the stroke risk assessment tool of choice by the AHA/ACC/HRS guideline. It is great because it is a mnemonic. Each letter is assignment 1 point except for 2 criteria. C stands for congestive heart failure, H for HTN defined as >140/90, A2 is for or Age>75 which is for 2 points, D for diabetes, S2 is for stroke or TIA and it's for 2 points, V for vascular disease such as MI, A for age 65-74, S for female sex.  Charizza: That certainly makes it easy to remember. Not only that, but you can also find CHA2DS2-VASc score of MDCalc to make it even easier. Virginia: Now that we've established which patients should receive anticoagulation, how do we choose which anticoagulant?  Charizza: For this discussion today, I would like to focus on nonpregnant patients. There really are 2 main anticoagulants, DOACs (or the direct oral anticoagulants) and warfarin. DOACs are the direct thrombin INH (dabigatran) and the direct factor Xa INH (rivaroxaban, apixaban, and edoxaban). DOAC is recommended as first-line in the long-term management of nonvalvular afib as trials have shown DOACs are more successful at reducing risk of thromboembolic events and have a lower risk of bleeding than warfarin and warfarin requires INR monitoring with dose adjustments. Although, in patients with valvular Afib, warfarin is preferred. Arreaza: All of them are by mouth.  Virginia: Dosing of DOACs depends on the kidney function, so it is important to obtain the creatinine clearance. For dabigatran, the direct thrombin INH, the recommended dose for patients with CrCl >30 mL/min is 150mg PO twice daily based on the results from the RE-LY trial (2), which evaluated the efficacy and safety of dabigatran with warfarin in patients with Afib. For patients with CrCl of 15-30 mL/min, the recommended dose is 75mg PO BID. Those with CrCl 1.5, patient who is > 80years old or body weight

Today's guests are Kory Anderson, MD, CHCQM-PHYADV, medical director at Intermountain Physician Advisor Services and CDI, and Kearstin Jorgenson, MSM, CPC, COC, the system operations director for physician advisor services at Intermountain Healthcare. Today's show is co-hosted to Sharme Brodie, RN, CCDS, CCDS-O, CDI education specialist at HCPro/ACDIS in Middleton, Massachusetts. Today's show is supported by 3M Health Information Systems. 3M Health Information Systems, now with M*Modal, delivers innovative software and consulting services designed for a wide range of healthcare environments. From closing the loop between clinical care and revenue integrity, to computer-assisted coding, clinical documentation integrity and performance monitoring, 3M can help you reduce cost and provide more informed care. Featured solution: Today's featured ACDIS solution is the 2021 ACDIS national conference. After a year in which we had to cancel our 2020 event, ACDIS is stepping forward to make ourselves and the CDI profession stronger than ever. Join us October 24-28 in Dallas, Texas, for the return of the ACDIS national conference. We're offering cutting-edge education across more than 60 CDI-focused presentations in our first-ever hybrid event. Our in-person event at the Sheraton Dallas Hotel features four concurrent tracks focused on coding and clinical concerns, management and professional development, regulatory changes and challenges, outpatient CDI, and much more. In a new value-added supplement this year, we're offering online-only bonus presentations that participants can enjoy when they return home. Click here to learn more and register today! (http://ow.ly/7l3b30rLACx) In the News: “Kaiser Permanente researchers push the envelope with AI and NLP,” from Healthcare IT News (http://ow.ly/6ptz30rWW3N) “Large-scale identification of aortic stenosis and its severity using natural language processing on electronic health records” from the Heart Rhythm Society (http://ow.ly/kmrD30rWW6Y) ACDIS update: 2021 CDI Salary Survey open now! (http://ow.ly/z7wM30rWW76)

In this interview, Andrea Russo, MD, FACC; Marek Jastrzebski, MD, PhD; and Jeffrey Hsu, MD, PhD, focus on a Heart Rhythm Society late-breaking study on LBB optimized CRT, discussing its differences from traditional pacing and benefits to the patient, limitations of the alternative techniques, and a new method to more fully restore physiology of depolarization of the LV in patients with HF and broad QRS complex. Like what you hear? Get 20 episodes a month with CME/MOC credit at www.acc.org/ACCEL.

The COVID-19 surge, vaccine-induced myocarditis, Heart Rhythm news, the state of medical evidence, and doctors in unions are discussed by John Mandrola, MD, in this week's podcast. https://www.medscape.com/twic 1- COVID-19 Texas COVID-19 Wave Is Climbing More Steeply Than Past Waves https://www.medscape.com/viewarticle/956104 White House Says US Can Provide COVID-19 Boosters if Needed https://www.medscape.com/viewarticle/956016 2- Vaccine-Myocarditis Myocarditis Tied to COVID-19 Shots More Common Than Reported? https://www.medscape.com/viewarticle/956089 3- Heart Rhythm News The Three Big Stories from the Heart Rhythm Society's 2021 Meeting https://www.medscape.com/viewarticle/955989 4- Medical Evidence Despite Retraction, Study Using Fraudulent Surgisphere Data Still Cited https://www.medscape.com/viewarticle/956090 Ongoing Citations of a Retracted Study Involving Cardiovascular Disease, Drug Therapy, and Mortality in COVID-19 https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2782460 5- Doctors in Unions? Physicians Need to Unionize Now https://www.medscape.com/viewarticle/955888 You may also like: Medscape editor-in-chief Eric Topol, MD, and master storyteller and clinician Abraham Verghese, MD, on Medicine and the Machine https://www.medscape.com/features/public/machine The Bob Harrington Show with Stanford University Chair of Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact news@medscape.net

CardioNerd (Amit Goyal), cardioobstetrics series co-chair Dr. Natalie Stokes, Cardionerds Duke University CardioNerds Ambassador and episode lead fellow, Dr. Kelly Arps, join Dr. Andrea Russo, Director of Electrophysiology and Arrhythmia Services at Cooper Medical School of Rowan University and immediate past president Heart Rhythm Society, for a discussion about pregnancy and arrhythmia. Stay tuned for a message from Dr. Sharonne Hayes about WomenHeart. Audio editing by Gurleen Kaur. Claim free CME for enjoying this episode! Dr. Russo's disclosures: Johnson and Johnson, Medtronic, Inc., Boston Scientific Corporation, Kestra, Medilynx, Up-to-Date, and ABIM. Abstract • Pearls Notes • References • Guest Profiles • Production Team CardioNerds Cardio-Obstetrics Series PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Episode Abstract Pregnant patients may have exacerbation of underlying arrhythmic syndromes or unmasking of previously undiagnosed arrhythmic syndromes. Management of atrial and ventricular tachyarrhythmias should proceed with increased urgency in pregnant patients due to risk of adverse hemodynamic events in the mother and fetus. Cardioversion of atrial and ventricular arrhythmias is safe in pregnancy. Preferred antiarrhythmic agents in pregnant patients include metoprolol, propranolol, verapamil, flecainide, propafenone, sotalol, procainamide, and lidocaine. Management of arrhythmias in pregnancy should include collaboration with obstetrics and maternal-fetal medicine teams. Pearls Pre-conception counseling is a shared decision making process; include obstetrics and maternal-fetal medicine colleagues in challenging cases. Have a high sense of urgency for acute arrhythmias in pregnancy due to risk of impaired fetal perfusion. Goals of acute arrhythmic management should include rapid treatment while avoiding hypotension. In scenarios when beta blockers are indicated, metoprolol and propranolol are first choice. Avoid atenolol as this drug has the highest risk of fetal bradycardia and intra-uterine growth retardation in the class. Lidocaine or procainamide should be first line for ventricular arrhythmias in pregnancy. Amiodarone is potentially teratogenic and should not be used in pregnant patients unless all other options have been exhausted. Show notes 1. What are the expected electrophysiologic changes associated with pregnancy? Increase in resting heart rate which peaks in third trimesterPR shorteningECG axis shift leftward and upwardNon-specific ST and T wave changes These changes, along with increased cardiac output and volume with increased stretch in all chambers, increase the risk of re-entrant arrhythmias in those who are predisposed. ↑ atrial volume -> ↑ stretch -> ↑ ectopy -> ↑ risk for re-entrant arrhythmias 2. What is the approach to pre-conception counseling for patients with known arrhythmias or arrhythmic syndromes? Anticipate frequency and potential severity of adverse arrhythmic outcomes during pregnancy and post-partum periodConsider available options for rhythm control and anticoagulation therapy, as appropriate, during the pre-conception, pregnancy, and post-partum periodsConsider catheter ablation prior to pregnancy, particularly for curable arrhythmias such as Wolff-Parkinson-White (WPW) and AVNRT   Offer genetic counseling about hereditary risk to fetus for inherited arrhythmias such as Brugada syndrome and Long QT syndrome 3. What is the management of SVT in pregnancy? Consider the increased risk of tachyarrhythmias in pregnancy: Typically benign arrhythmias can lead to more rapid decompensation in mother due to increased baseline cardiac output. Typically benign arrhythmias can lead to rapid danger to the fetus due to maternal hypotension and shortened diastolic ...

We're talking Longevity today with our special guest, Dr. John D Day.  John D. Day, MD, graduated from medical school at Johns Hopkins University. He did his residency and cardiac electrophysiology fellowship training at Stanford University. Dr. Day is an electrophysiologist at the Intermountain Medical Center Heart Institute in Salt Lake City, Utah. He previously served as president of the Heart Rhythm Society and currently serves as the Utah Governor of the American College of Cardiology. He is recognized as an international thought leader on atrial fibrillation management. Dr. Day is board certified in cardiology, and cardiac electrophysiology. He has published more than 100 manuscripts, abstracts, and book chapters and regularly lectures both nationally and internationally on heart rhythm disorders. Dr. Day is the former editor-in-chief of the Journal of Innovations in Cardiac Rhythm Management. In 2017, Dr. Day published The Longevity Plan: Seven Life-Transforming Lessons from Ancient China, with HarperCollins as publisher. The Longevity Plan was an Amazon number one bestseller and was named best books of 2017 by the Huffington Post and won the Nautilus Book Award Gold Medal for the best book of 2017. 1:49 About The Longevity Plan Book 4:37 Longevity belt in China 6:04 Bluezones 7:45 Seven things discovered that centenarians had in common 11:43 Aging can be beautiful  14:26 Routines and aging 18:18 Advice for people 30-40 to increase longevity 22:20 Fasting 24:20 How did your experiences change the way you practice medicine?   You can learn more about Dr. John D Day:  https://drjohnday.com/ Buy the book: https://www.amazon.com/Longevity-Plan-Life-Transforming-Lessons-Ancient/dp/0062319817   Website: StayYoungAmerica.com  Twitter: @StayYoungPod  Facebook: @Stay Young America!  Join us next time as we always bring you information you can use 

We're talking Atrial Fibrillation today with our special guest, Dr. John D Day.  John D. Day, MD, graduated from medical school at Johns Hopkins University. He did his residency and cardiac electrophysiology fellowship training at Stanford University. Dr. Day is an electrophysiologist at the Intermountain Medical Center Heart Institute in Salt Lake City, Utah. He previously served as president of the Heart Rhythm Society and currently serves as the Utah Governor of the American College of Cardiology. He is recognized as an international thought leader on atrial fibrillation management. Dr. Day is board certified in cardiology, and cardiac electrophysiology. He has published more than 100 manuscripts, abstracts, and book chapters and regularly lectures both nationally and internationally on heart rhythm disorders. Dr. Day is the former editor-in-chief of the Journal of Innovations in Cardiac Rhythm Management. In 2017, Dr. Day published The Longevity Plan: Seven Life-Transforming Lessons from Ancient China, with HarperCollins as publisher. The Longevity Plan was an Amazon number one bestseller and was named best books of 2017 by the Huffington Post and won the Nautilus Book Award Gold Medal for the best book of 2017. 2:07 What is Atrial Fibrillation? 2:58 How does someone develop Atrial Fibrillation? 6:33 How is Atrial Fibrillation treated? 9:43 Biomarkers 12:13 Anti-Inflammatory drugs and Atrial Fibrillation 13:50 Gut Microbiome and Atrial Fibrillation 15:15 More about The AFib Cure “Executive Medicine Moment” At Executive Medicine of Texas we understand that true health can only be found when you treat the patient as a whole. That’s why our Executive Physical Exams are second to none in the amount of testing and information we gather prior to making a wellness plan for our patients. Learn more about how you can take charge of your health at http://www.EMTexas.com    You can learn more about Dr. John D Day:  https://drjohnday.com/ Buy the book: https://www.amazon.com/AFib-Cure-Medications-Control-Health-ebook/dp/B089FK6W3D/ref=pd_rhf_dp_p_img_5?_encoding=UTF8&psc=1&refRID=4N3DNN35XSP1FN2DCB56   Website: StayYoungAmerica.com  Twitter: @StayYoungPod  Facebook: @Stay Young America!  Join us next time as we always bring you information you can use 

Episode 45: Osteoporosis Update. Dr Linares (endocrinologist) explains the basics of screening and treatment of osteoporosis, referring frequently to the updated guidelines of osteoporosis by AACE and ACE (2020). A new group of residents is introduced. Congratulations to our new group of residents:  Amelia Martinez Lopez, Amardeep Singh Chetha, Cecilia Selena Covenas, Funmilayo Helen Idemudia, Licet Imbert Matos, Su Myat Hlaing, Timiiye Dawn Yomi, and Young Na Sung. This group of residents will start in July 2021 and will graduate in July 2024. We hope you enjoy your time with us.Today is March 22, 2021.Implanted pacemakers and defibrillators are equipped with a switch that responds to magnetic forces to stop them when needed. Magnetic interference between these cardiac implantable electronic devices (CIEDs) and mobile devices have been investigated for years. It has been established that magnetic fields stronger than 10 gauss can deactivate these cardiac devices, causing pacemakers to give asynchronous pacing and ICDs to stop tachyarrhythmia detection.The Heart Rhythm Society journal, published in October 2009 (that was 11 years ago), an association between portable headphones and significant electromagnetic interference (EMI) in patients with implantable cardioverter-defibrillators (ICD) and pacemakers (PM). 100 patients with implanted devices were tested with different portable headphones. Headphones effectively deactivated implanted devices when held less than 2 cm from skin on the left side of chest. There was not interference when headphones were placed farther than 3 cm. In this study, normal functioning of the devices was restored in 29 out of 30 cases when the headphones were removed from the patient’s chest. The recommendation from that study was to recommend patients to keep their portable headphones at least 3 cm away from their implanted device.More recently, in January 2021, the same journal posted the effect of iPhone 12 on ICDs deactivation. iPhone 12 and MagSafe technology, which allows faster wireless charging, contain strong magnets. iPhone 12 successfully deactivated a Medtronic Inc. ICD when tested by a group of investigators in a patient[2]. The official Apple Support website posted on February 25, 2021, “To avoid any potential interactions with these devices, keep your iPhone and MagSafe accessories a safe distance away from your device (more than 6 inches / 15 cm apart or more than 12 inches / 30 cm apart if wirelessly charging)”[3]. Other devices such as fitness tracker wristbands, and even e-cigarettes have been involved in deactivation of ICDs.Bottom line: Make sure your patient discusses with you or their cardiologist before buying wearable or mobile technology that may interfere with their implanted cardiovascular devices.This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. “The secret of getting ahead is getting started” —Mark Twain.Osteoporosis UpdateDuring this conversation, we discussed some parts of the guidelines from the American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE)[2], updated in 2020. This is not a complete analysis of those guidelines. For a comprehensive explanation of the guidelines, visit the AACE or ACE websites. The recommendations from these organizations may be different than the ones given by the American Academy of Family Physicians (AAFP) or the United States Preventive Services Taskforce (USPSTF), which are organizations we are more familiar with as family physicians.The questions analyzed during this conversation includes:When would you consider a DEXA scan to screen a woman younger than 65 for osteoporosis? What to do when the report says Osteopenia (T score -1.0 to -2.5)? Let’s mention the recommended dose of Vitamin D and Calcium. What is the FRAX score?  What is an easy work up we can do to rule out a secondary cause of osteoporosis before sending patient to you? The new guidelines divide patients in two categories: “High risk/no risk of fractures” and “VERY High risk/prior fractures”, What’s the difference in management between those two categories? (alendronate in high risk vs abaloparatide in very high risk). How can you tell the patient has a good response after 1 year of treatment (Dexa scan, bone turnover markers)? What is a drug holiday? ___________________________Now we conclude our episode number 45 “Osteoporosis Update”. Dr Linares explained what the FRAX score is and mentioned the different options we have for treatment of osteoporosis. DEXA scan continues to be the gold standard for screening, diagnosis and monitoring of osteoporosis. We will announce the winner of the question of the month about polyarthralgia next week, and we wish our new group of residents a great start in July 2021. Remember, even without trying, every night you go to bed being a little wiser.Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Maria Linares, and Claudia Carranza. Audio edition: Suraj Amrutia. See you next week! _____________________References:Lee S, Fu K, Kohno T, Ransford B, Maisel WH. Clinically significant magnetic interference of implanted cardiac devices by portable headphones. Heart Rhythm. 2009 Oct;6(10):1432-6. doi: 10.1016/j.hrthm.2009.07.003. Epub 2009 Jul 8. PMID: 19968922. https://www.heartrhythmjournal.com/article/S1547-5271(09)00740-1/fulltextGreenberg, Joshua C.; Mahmoud R. Altawil; Gurjit Singh; Letter to the Editor—Lifesaving Therapy Inhibition by Phones Containing Magnets, Heart Rhythm, January 04, 2021. DOI:https://doi.org/10.1016/j.hrthm.2020.12.032.  https://www.heartrhythmjournal.com/article/S1547-5271(20)31227-3/fulltext“About the magnets inside iPhone 12, iPhone 12 mini, iPhone 12 Pro, iPhone 12 Pro Max, and MagSafe accessories”, Apple Support, https://support.apple.com/en-us/HT211900, accessed on March 2, 2021. AACE Releases 2020 Clinical Practice Guidelines for Postmenopausal Osteoporosis, Physician Weekly, September 11, 2020, https://www.physiciansweekly.com/aace-releases-2020-update-clinical-practice-guidelines-for-postmenopausal-osteoporosis/

CardioNerds (Amit Goyal and Daniel Ambinder) join Dr. Christine Albert (Professor of Medicine, Founding Chair of the Department of Cardiology at Cedars-Sinai, and President of Heart Rhythm Society) and Dr. Rachita Navara (FIT at Washington University, soon to be EP fellow at UCSF) for a Narratives in Cardiology episode. We learn from their experiences as physician scientists and women in cardiology, and specifically in electrophysiology. Claim free CME just for enjoying this episode! Cardionerds Narratives in Cardiology PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll Subscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Show notes 1. Over the last several decades, what have we learned about the contribution of lifestyle factors to atrial fibrillation? Particularly in women, the development of obesity (BMI > 30 kg/m2) is associated with a 41% increase in the risk of developing atrial fibrillation (AF). Even short-term weight gains are associated with a 18% increased risk of developing AF. Fortunately, losing weight could modify or even reverse this elevated risk [1]Exercise is beneficial for reducing the risk of AF, but higher frequency of vigorous exercise is actually associated with an increased risk of developing AF in young men and joggers. This risk decreases with age, and is offset by the other benefits of vigorous exercise on AF risk factors [2]The link between alcohol consumption and AF was first described in 2008: for healthy middle-aged women, consuming two or more alcoholic drinks is associated with a statistically increased risk of developing AF [3]The recent VITAL trial is the largest and longest randomized trial on primary prevention of AF, following over 25,000 men and women over five years. As recently presented at AHA 2020, Dr. Christine Albert and her study team found that neither vitamin D nor fish oil prevents the development of AF [4] 2. What is some practical advice on giving presentations and preparing research grants from Dr. Albert, renowned physician-scientist, and leader in electrophysiology? Whenever possible, Dr. Albert recommends memorizing your presentation to avoid referencing notes frequently, and to allow for continued eye contact with the audience. Practice delivering your presentation multiple times prior to the scheduled talk.When preparing a grant, start early and seek feedback and edits from those in and out of your field.In many cases, a grant review involves individuals who may not be in your exact scientific field, so the priority is to interest the grant readers regardless of their scientific background. 3. Whether in research or clinical care, what are the common features of a well-oiled clinical team? In an ideal team, every individual adds value and has a clear role. Team members show mutual respect and provide the autonomy for other team members to demonstrate their expertise.Don’t be intimidated by the individuals on your team who are extremely talented or experienced in a given domain – this in turn elevates you by being on the same team!Leaders are most successful when they enable others to succeed. The spirit of collaboration and respect comes from the top, so leaders need to demonstrate respect for every team member and give each person a role, eliminating the need for team members to compete with each other. 4. What is some advice for female trainees navigating a male-dominated field (e.g. electrophysiology)? What makes a good mentor and mentee? It is very important to seek female or otherwise relatable role models in your field. While representation increases, it can also be valuable to seek female mentors outside your specific field.It is just as important for male mentors to continue to support female trainees, especially in fields where females are underrepresented.Often, as a mentee you may change your area of interest or seek a new area of specializ...

Happy New Year! We’re kicking off 2021 with a conversation with Alan Morgan, CEO of the National Rural Health Association. Alan shares how the COVID-19 pandemic has made an impact on rural health, the good and the bad, and talks about the opportunities the new year presents. “The pandemic really has been an accelerant for change.” ~Alan Morgan Alan Morgan is recognized as among the top 100 most influential people in healthcare by Modern Healthcare Magazine. Alan serves as Chief Executive Officer for the National Rural Health Association.  He has more than 30 years experience in health policy at the state and federal level and is one of the nation’s leading experts on rural health policy. Alan served as a contributing author for the publication, “Policy & Politics in Nursing and Health Care,” and for the publication, “Rural Populations and Health.”  In addition, his health policy articles have been published in: The American Journal of Clinical Medicine, The Journal of Rural Health, The Journal of Cardiovascular Management, The Journal of Pacing and Clinical Electrophysiology, Cardiac Electrophysiology Review, and in Laboratory Medicine.   Alan served as staff for former US Congressman Dick Nichols and former Kansas Governor Mike Hayden. Additionally, his past experience includes tenures as a health care lobbyist for the American Society of Clinical Pathologists, the Heart Rhythm Society, and for VHA Inc. He holds a bachelor's degree in journalism from the University of Kansas, and a master's degree in public administration from George Mason University. 

Anne Curtis, MD, is the Charles and Mary Bauer Professor and Chair of the Department of Medicine at the Jacobs School of Medicine and Biomedical Sciences and SUNY Distinguished Professor at the University at Buffalo. Dr. Curtis completed her medical school at Columbia University, her residency in internal medicine at the Columbia Presbyterian Medical Center, and then she went on to Duke University to pursue fellowships in cardiovascular disease and clinical cardiac electrophysiology. Dr. Curtis maintains an active clinical practice, with a focus on cardiac electrophysiology, and she has been involved in the development of national guidelines for the treatment of atrial fibrillation and ventricular arrhythmias. She has been involved in clinical trials for over 25 years with over 300 publications, and she serves as an associate editor for the Journal of the American College of Cardiology. At a national level, she has held numerous leadership roles, including serving as the President of the Association of University Cardiologists, President of the Heart Rhythm Society, and Chairing the ACC's Clinical Electrophysiology Committee and the FDA's Circulatory System Devices Panel. How can we become our own best advocate? Today, Dr. Anne Curtis explains that the best way to find more opportunities is to go after them with all the enthusiasm we've got. She shares stories throughout her career and recalls that she's always felt highly motivated to work hard, get things done, and prove herself in a career in medicine. She advises us to take the opportunities we are presented with, even if they seem daunting at first. It is when we prove ourselves to our mentors and show them that we're willing to do the work, that they build more trust in us—and offer us more and more opportunity. Dr. Curtis explains that—especially in these early years of training—our one job is to become good physicians. She leaves us with this: “If you want to do anything that involves patient care and research, you better be a darn good doctor.” Pearls of Wisdom: 1. Be your own best advocate. Opportunities may or may not come—it's up to you to seek them out. 2. Find role models for potential. Look for the mentors that you can see yourself in, and realize that their potential also exists in you. When you follow in their footsteps, you'll achieve greater and greater things. 3. The mark of a good mentee is when a supervisor trusts you when they're not there. Develop trust and prove that you can handle things on your own, that you know what you're doing, and that you're willing to do things the right way.

On September 27, 2020, our host Dr. Marianne Ritchie was joined by Dr. Hugh G. Calkins for a discussion about atrial fibrillation.Dr. Hugh Calkins is the Catherine Ellen Poindexter Professor of Cardiology and Director of the Electrophysiology Laboratory and Arrhythmia Service at the Johns Hopkins Hospital. He is also the former President of the Heart Rhythm Society.Each week we highlight the #RealChampions in your life! Your family, friends, or colleagues who go the extra mile to help others in their community. For this week, Your Real Champion was Karen Coyle! Karen is a 28 year veteran of the US Postal Service who has worked in settings large and small. Despite the threats posed by anthrax, September 11th and now COVID, she has remained faithful in her role of serving the public even when she faced medical challenges.

Buying as much loperamide as you possibly can Loperamide history1969- Synthesized (1)1976 FDA Approved as schedule V (2)Jaffe trial of "abuse potential"- https://pubmed.ncbi.nlm.nih.gov/7438696/1982- Descheduled (3)2010-Annually Increasing in # of poison center calls, cases of arrhythmia and hospitalization (4,5,6)2016- Submission to DEA for rescheduling of loperamide denied (7)2019- FDA works with manufactures to reduce package size to 48 tablets (8)Pharmacist knowledge of abuse remains low https://pubmed.ncbi.nlm.nih.gov/32641253/Toxic MechanismFun theories about co evolution of PGP and CYP https://pubmed.ncbi.nlm.nih.gov/10837556/Inhibition of sodium channels, and to a higher affinity, Human Ether a Go-Go Related (HERG) channel leads to prolonged repolarization (9)IC50 for HERG Ikr ~ 40 nm/l (1908 ng/dl), inhibits as low as 10 nm/l (10)Case reports of conduction disturbance with level of 22 ng/ml (14)Levels in fatalities vary but  reported as high as 270 ng/ml in some studies  (15)Prolonged re polarization leads to torsadesEarly after depolarizations may trigger, which are then propagated torsades via re entrant rhythms (11)TreatmentACMT loperamide guidelines (12)Supportive careArrhythmia managementTorsades (13)Electrical cardioversion (terminates re entrant rhythm)Magnesium (prevents early after depolarization)Target Mg >2 and K >4Lidocaine-> Recommended in 2006 Sudden cardiac death guidlines, not mentioned in 2017, however one of the only VT recommended antiarryhtmics that do not prolong QTc (others, sotalol, amiodarone, and procainamide, do)If preceded by bradycardia, Overdrive pacing with isoproterenol to target HR~ 100Beta blockers are recommended in patients with LQTSSodium channel blockade induced wide QRS complex tachycardia (12)Hypertonic sodium to over whelm sodium channel blockade (1-2 amps of 8.4% Sodium Bicarbonate given IV)Where do we go in the future?More research will help us understand the true incidence of how often this occurs and what impact the FDA decisions will haveAny concerned citizen can submit for rescheduling of loperamide. Interested? Reach out at toxtalk1@gmail.comDrug Enforcement Agency. The Controlled Substances Act. Available at: https://www.dea.gov/controlled-substances-act.Florey, Klaus (1991). Profiles of Drug Substances, Excipients and Related Methodology, Volume 19. Academic Press. p. 342. ISBN9780080861142."IMODIUM FDA Application No.(NDA) 017694". U.S. Food and Drug Administration (FDA). 1976.https://www.deadiversion.usdoj.gov/schedules/orangebook/orangebook.pdf.Miller H, Panahi L, Tapia D, Tran A, Bowman JD. Loperamide misuse and abuse. J Am Pharm Assoc (2003). 2017;57(2S):S45eS50.Feldman R, Everton E. National assessment of pharmacist awareness of loperamide abuse and ability to restrict sale if abuse is suspected [published online ahead of print, 2020 Jul 5]. J Am Pharm Assoc (2003). 2020;S1544-3191(20)30264-8. doi:10.1016/j.japh.2020.05.021Eggleston W, Marraffa JM, Stork CM, et al. Notes from the Field: Cardiac Dysrhythmias After Loperamide Abuse — New York, 2008–2016. MMWR Morb Mortal Wkly Rep 2016;65:1276–1277. DOI: http://dx.doi.org/10.15585/mmwr.mm6545a7https://www.chpa.org/PDF/09_05_17_CommentsCitizenPetitionLoperamide.aspxhttps://www.fda.gov/drugs/drug-safety-and-availability/fda-limits-packaging-anti-diarrhea-medicine-loperamide-imodium-encourage-safe-useKang J, Compton DR, Vaz RJ, Rampe D. Proarrhythmic mechanisms of the common anti-diarrheal medication loperamide: revelations from the opioid abuse epidemic. Naunyn Schmiedebergs Arch Pharmacol. 2016;389(10):1133-1137. doi:10.1007/s00210-016-1286-7Klein MG, Haigney MCP, Mehler PS, Fatima N, Flagg TP, Krantz MJ. Potent Inhibition of hERG Channels by the Over-the-Counter Antidiarrheal Agent Loperamide. JACC Clin Electrophysiol. 2016;2(7):784-789. doi:10.1016/j.jacep.2016.07.008https://www.sciencedirect.com/science/article/pii/S1880427611800050Eggleston W, Palmer R, Dubé PA, et al. Loperamide toxicity: recommendations for patient monitoring and management. Clin Toxicol (Phila). 2020;58(5):355-359. doi:10.1080/15563650.2019.1681443Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society [published correction appears in J Am Coll Cardiol. 2018 Oct 2;72(14):1760]. J Am Coll Cardiol. 2018;72(14):e91-e220. doi:10.1016/j.jacc.2017.10.054Marraffa JM, Holland MG, Sullivan RW, et al. Cardiac conduction disturbance after loperamide abuse. Clin Toxicol (Phila). 2014;52(9):952-957. doi:10.3109/15563650.2014.969371Miller H, Panahi L, Tapia D, Tran A, Bowman JD. Loperamide misuse and abuse. J Am Pharm Assoc (2003). 2017;57(2S):S45-S50. doi:10.1016/j.japh.2016.12.079

Mark Bogdansky is the Vice President of Meetings and Events for the Auto Care Association. Bogdansky oversees all trade shows for the Auto Care Association, its segments, committees, and managed associations, including the AAPEX and HDAW shows. His responsibilities include strategic planning, trade show management, partner and vendor relationships, contract negotiation, and on-site logistics. Prior to joining the Auto Care Association in November 2016, Bogdansky worked on the conventions for the National Retail Federation and Heart Rhythm Society. Prior to that, Mark was a high school teacher and college basketball coach. He is an active member of the International Association of Exhibitions and Events, and currently serves on its Advocacy Committee. He has also served on multiple industry advisory boards and committees and spoken at several industry events. Raised in Boston, Bogdansky graduated from Yeshiva University in New York, with a bachelor of arts in mathematics and a minor in business. He lives with his wife and son in Maryland. What you’ll learn about in this episode: Mark discusses the work of the Auto Care Association, representing every business in the supply chain that keep cars on the road How the Auto Care Association has assisted member organizations with navigating the challenges posed by the pandemic How Mark and the team at the International Association of Exhibitions and Events successfully pulled off their 2020 Exhibitions Day virtual event What future advocacy efforts IAEE will be pursuing going forward relating to the COVID-19 crisis and its impact on the industry Why part of the IAEE’s role is to educate lawmakers and policymakers on the industry’s concerns and needs What key lessons Mark and the team at IAEE learned when taking their annual event to a virtual space Why safety is at the heart of what Auto Care Association and IAEE are doing, and why they are working to support their members through keeping everyone safe as well What big wins and upsides Mark has noticed from the switch to virtual events, and why hybrid virtual/in-person events are going to be powerful going forward How the Auto Care Association’s AAPEX 2020 trade show is evolving into an entirely new experience, both in response to COVID and due to new innovations and opportunities Why the secret to creating an experience for your attendees is to focus on creating engaging, interactive concepts Additional resources: Website: www.autocare.org Website: www.aapexshow.com LinkedIn: www.linkedin.com/in/markbogdansky/

This month on Episode 13 of the Discover CircRes podcast, host Cindy St. Hilaire highlights three featured articles from the June 5 issue of Circulation Research and gives listeners an inside scoop on the cutting-edge ideas in the June 19th Compendium on Atrial Fibrillation. This episode also features an in-depth conversation with Dr David McManus on emerging technologies for identifying AFib.    Article highlights:   Zhang, et al. ACEI/ARB on COVID-19 in patients with hypertension Sakamoto, et al. ERR Signaling and Cardiac Maturation Xie, et al. CIRP Governs the Heart Rate Response to Stress Cindy St. Hilaire:           Hello and welcome to Discover CircRes, the podcast for the American Heart Association's journal, Circulation Research. I'm your host, Dr Cindy St. Hilaire, from the Vascular Medicine Institute at the University of Pittsburgh. Today, I'm going to share with you three articles selected from the June 5th issue of Circulation Research as well as give you an overview of the Compendium on Atrial Fibrillation also coming out in June. We'll follow that by having a discussion with Dr David McManus regarding his review on the emerging technologies for identifying AFib in the general population. So first, the highlights. The first article I'm sharing with you is titled Association of Inpatient Use of Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers with Mortality Among Patients with Hypertension Hospitalized with COVID-19. The first author is Peng Zhang and the corresponding author is Hongliang Li and they're from Wuhan University in Wuhan, China. Patients with hypertension have increased risk of death from COVID-19. While the high blood pressure itself is likely to contribute to this, concerns have been raised that medications used to treat hypertension, specifically ACE inhibitors and Angiotensin II receptor blockers may worsen coronavirus infection. Research in animals showed that these drugs increased expression of ACE-2, the protein on lung epithelial cells that is used by the virus to gain entry into the host cell where it can then replicate. However, other conflicting evidence has shown that these drugs might reduce lung injury in pneumonia patients, which is also a complication of COVID. To weigh up the benefits and risks of ACE inhibitors and Angiotensin II receptor blockers, Zhang and colleagues performed a retrospective analysis of 1,128 patients with COVID-19 and hypertension who are treated at nine hospitals in Hubei Province, China. Of the patients, 188 took the hypertensive medicine during their hospital stay and 940 did not. The ages, sexes and comorbidities of the two groups were very similar. After 28 days of follow up, 99 of the patients had died, seven from the group taking the hypertensive medications, equivalent to 3.7% and 92 from the group that did not or 9.8%. The team concludes that treatment of hypertension patients with hypertension medications does not increase risk of COVID-19 mortality and may even reduce the threat. However, a much larger sample size would be necessary to fully confirm. The second article I want to highlight is titled A Critical Role For Estrogen Related Receptor Signaling and Cardiac Maturation. The first authors are Tomoya Sakamoto and Timothy Matsuura and the corresponding author is Daniel Kelly from the University of Pennsylvania.  From fetal to postnatal development, the human heart goes through significant changes, including the expansion of mitochondrial numbers, a change in fuel utilization within the mitochondria and replacement of fetal contractile proteins for the adult ones. Further, there is increases in ion uptake and release. Transcription factor estrogen-related receptor was known to drive postnatal mitochondrial biogenesis and now this group has shown that it also drives these developmental changes. They developed a genetic model to knock down expression of estrogen-related receptor in early postnatal mice. When the animals were five weeks old, they performed transcriptomic analysis. In mice lacking estrogen-related receptor, there was a reduction in expression of genes involved in ion channeling in handling, fatty acid oxidation, which is the major metabolic process in the adult heart, as well as adult versions of the contractile proteins. By contrast, expression of genes and coding field contractile proteins and factors, specifically those involved in glycolysis, was upregulated. In heart failure, cardiomyocytes can revert to fetal-like cells. The authors, therefore, suggest that boosting estrogen-related receptor might be a way to counteract such pathology as well as a way to induce and study cardiomyocyte maturation and cultured progenitor cells. The next article I want to share with you is titled Cold-Inducible RNA-Binding Protein Prevents the Excessive Heart Rate Response to Stress by Targeting Phosphodiesterase. The first authors are Duanyang Xie and Li Geng and the corresponding author is Yi-Han Chen and they're from the China Ministry of Education. During a fight-or-flight situation, also known as the acute stress response, the heart rate increases rapidly due to the effects of adrenergic signaling on the cells in the sinoatrial node, which is the heart's pacemaker. Within sinoatrial node cells, levels of the signaling factor, cyclic AMP, ramp up and this, in turn, increases the cell's calcium handling and contraction rate, but excessive or prolonged racing heartbeat can be damaging and it is unclear what keeps the system in check. This group has now shown that cold-induced RNA-binding protein or CIRP puts the brakes on the heart by regulating cyclic AMP levels. The team showed that while baseline rates between wild-type and CIRP-deficient rats were the same, triggering the adrenergic signaling via treatment with isoproterenol caused CRP-deficient rat hearts to beat faster for longer than in the wild-type counterparts. Cardiac tissue from the CIRP-lacking rats showed higher than usual levels of cyclic AMP after isoproterenol treatment. This was due to lower than usual levels of phosphodiesterase, the enzyme that normally degrades cyclical AMP. The team went on to show that CIRP normally binds and stabilizes phosphodiesterase's messenger RNA and sharing a ready supply of the enzyme to restrain cyclic AMP signaling. As well as revealing this crucial control mechanism, the work highlights CIRP as a potential new target for future heart rate lowering medications. The last thing I want to share with you before we switch to our interview is our Atrial Fibrillation Compendium. Atrial fibrillation, or AFib, is a major cause of morbidity and mortality globally. There have been significant advances in the detection, management and treatment of AFib over the past two decades. However, the burden of the disease continues to increase. This Compendium on AFib features articles on epigenetics and transcriptional networks underlying atrial fibrillation, inflammasomes and proteostasis, novel molecular mechanisms associated with atrial fibrillation, emerging technologies with the identification of atrial fibrillation, epidemiology of atrial fibrillation in the 21st century, how will genetics inform the critical care of AFib, how will machine learning inform the clinical care of AFib, population-based screening for AFib, the molecular basis of AFib pathophysiology and therapy, the genetics of AFib in 2020, GWAS genome sequencing, polygenetic risk and beyond, is there hope for animal models of AFib and ablating AFib in 30 minutes, new technologies for safer and more efficient pulmonary vein isolation. Okay. So we're now going to switch over to the interview portion of the podcast. I have with me, Dr David McManus, who is a professor of medicine in the Division of Cardiology and the Department of Medicine at UMass Medical Center in Worcester, Mass and he's also a cardiac electrophysiologist. And today, we're going to be discussing his recent Review on the emerging technologies for identifying atrial fibrillation, also known AFib, So thank you so much for taking the time to speak with me today. David McManus: My pleasure. Thanks for inviting me. Cindy St. Hilaire: Yeah, so before we dig into the review and about the emerging technologies for AFib, can you maybe give me a brief explanation of what is AFib, who gets it and what's the spectrum of disease severity in the patients that do get AFib? David McManus: Sure, so atrial fibrillation is the world's most common sustained heart rhythm problem. It is associated with a number of different health conditions in terms of risk factors. The biggest risk factor for getting this rhythm problem is age, so it's most common in people over the age of 40 and it increases ... in fact, it doubles in terms of the incidents with each decade of life. So as you get into your 80s and 90, it's really quite common. The additional risk factors are kind of common things that you might imagine and a few things you might not, things like diabetes and high blood pressure that are also risk factors forgetting plaque in your heart arteries are also risk factors for AFib, but some other risk factors that are a little more controversial with respect to heart artery disease, things like alcohol consumption, even if it's red wine, which otherwise might seem to have some benefit, is actually a risk factor too for AFib. In fact, in the old days, some doctors used to refer to AFib as holiday heart because of its association with acute alcohol intake around the holidays. So, the fact is that AFib is related to some health behaviors like drinking. It's also related to a condition called sleep apnea or sleep-disordered breathing. Weight is associated with getting AFib. So all these things combined with your genetics, your family history and your age to contribute to getting this disease, so those are the most common risk factors. The question about why it is important to diagnose? It was a disease that people sort of treated like gray hair for a long time. Something that you might not want to have, but is not particularly impactful, but some really important studies, especially in the 70s and 80s, started to establish a link between atrial fibrillation and clot-based strokes and so that is a very strong relationship that exists between people who get AFib and a much higher risk of having a clot form in the heart and traveling to the brain. Cindy St. Hilaire: Which is obviously very dangerous. So how often does AFib go undetected? Because I think that's kind of at the core of using this new technology. Once you get AFib, do you know you have it right away? David McManus: So, that's exactly right. The fact is that we don't truly know, right? Because by definition it's undiagnosed. We don't really know how long your average person goes before they're diagnosed and I think it varies a lot, but it's important to know a couple of things about AFib to sort of talk around the perimeter of this answer and try to kind of hone in a bit.  So first off, some people who develop AFib don't feel it or they have very minimal symptoms or they have symptoms that come and go so quickly. By the time they get in for an evaluation, the arrhythmia is gone so it can be what's called paroxysmal in its early stages, which means it can come and go. The duration of that AFib can be minutes or hours or even in some cases, seconds, and therefore elude a diagnosis. The other thing is symptoms from AFib, when they do exist, are not always the sensation of palpitation, a sensation of an irregularity. Some people just feel short of breath when they go up a flight of stairs and- Cindy St. Hilaire: Which you can associate with age. David McManus:  ... they may attribute that symptom to being older. Yeah. Right. They may just think "I'm getting tired because I'm older," or "I'm out of shape." And so the simple answer is, I guess, I'd start with this statistic. A significant minority of patients with atrial fibrillation present with a stroke as their first clear manifestations, so they come in with stroke. The estimates on that vary considerably, but at least one in five patients who present with a stroke have a first diagnosis of AFib at the time of that stroke and about 5% of patients with AFib overall present with stroke as their first manifestation. Those are two different statistics to kind of come at it different ways and that's what you're trying to prevent. You want to make the diagnosis of AFib before the stroke because we have a lot of really good treatments that can prevent stroke if you know you have it. Cindy St. Hilaire: Right and so I think that gets to this idea of maybe screening patients of a certain age. I don't know what that age cutoff would be. But when you look at the guidelines right now, there is no clear guideline. The US Preventative Task Force says there's no good data to screen patients beforehand. I think the AHA and the ACC just don't have any guidelines regarding screening. But yet in Europe and Australia, they do perform opportunistic screening for AFib patients and this is in the clinic. This is now with ECGs. They screen for patients over 65. So based on this statistic you said that 20% of stroke patients had undetected AFib, why is there not a specific guideline? Where does that come from? David McManus: I think you're spot on that there's a lot of controversy about this right now and that's good because the reason I think it's controversial is there's some emerging technologies and opportunities that didn't exist before. Because pretty clearly, before doing a conventional 12-lead EKG in the office, did not offer sufficient benefit over and above usual care to demonstrate to groups like the US Preventative Service Task Force, which issues the guidance around things like breast cancer screening and colon cancer screening, so they have to weigh costs, financial costs, harms from false-positive tests. And so, the reason there's controversy is because what we had previously was a pretty suboptimal situation for screening. We had intermittent tests, which were of significant costs and they were spaced so far apart and required coming in for clinical care that there was really no benefit to doing them over and above taking someone's pulse in the office. But there's no question that there are groups. There's a group called the AF-SCREEN Group, for example, that is really challenging the research community and clinicians to revisit some of these assumptions about screening, given new technologies and how we might thoughtfully use them in a pharmacy, for example, or in a clinic or at home with commercial technologies to study that. Because, really, to make a recommendation that screening is clearly beneficial, you have to do some kind of a study or studies that show that not only can you diagnose more of the arrhythmia, but that by diagnosing it, you can do something about it and that that action, in this case, anticoagulation, leads to a reduction in stroke and without a significant increase in harm from that treatment and that's somewhat controversial because this is a disease…the technologies that we have now are creating new diseases, right? So in a sense, we've created the new disease, undiagnosed AFib. And so, okay, we found it. Now, is it kind of like cancer where finding it earlier maybe has a different prognosis than finding it later in terms of risk? Some people think so. And in that case, you really have to prove that finding it early and treating that early form with the treatment that you have for the late form works as well and doesn't cause harm. So that's kind of where we are right now is there a number of really big studies going on that are hoping to help inform this more, which is pretty cool. Cindy St. Hilaire: Yeah. And so on that note, my parents got new supplemental insurance. They're both retired and this new insurance came with a nurse that dropped by your house and just kind of did a wellness check. And that nurse came and checked my mom's pulse, asked her how she was feeling and checked it again and said, "You're going to your doctor. You're in AFib," and she had no symptoms of that. She's 69, she's very healthy, she's active. And essentially in the course of a couple of months, she went from what she thought was normal to not being able to take one step up one stair because her AFib got so bad and she obviously saw a cardiologist and they got her on blood thinners. And eventually, after two cardioversions, things stuck and it's now in control, but one of the things that we did was we immediately bought her an at-home KardiaMobile heart monitor. That is essentially what you're reviewing now and I'm wondering if you could maybe give us a little bit of information about this. So, there's multiple devices out there. There's the KardiaMobile. There's also the Apple Watch and the Fitbit that are starting to get these kinds of technologies. And so for us, it was at least reassuring to see her heart rate was something and now it's getting more normal with the medicine. And now even after the cardioversion, it's been a couple of months, she checks it once a day to make sure it's still functioning as it should. So can you tell us a little bit about these and about what this might mean for the future of AFib and clinical management? David McManus: Sure. So you are using an FDA-cleared technology. You've referenced the AliveCor KardiaMobile. It's in a recent survey that the Heart Rhythm Society did. One of the most common ones that's purchased or advised to patients to buy by their cardiologists and healthcare providers and I think it was cleared about 2015. And what it is is it's a credit card-sized device that gets you a 1-lead EKG and it records about 30 seconds. And then that data, it can be transmitted directly to your cardiologist. Cindy St. Hilaire: She actually would bring her phone in and show them, "Look at my last week." David McManus: Yeah, you can do it that way or, like many of my patients are, just constantly emailing them or putting them in their electronic health record, which speaks to a whole other ball of wax. But that is a very valuable tool for people who are at risk for AFib or know they have it and want to monitor themselves for things like recurrences, to check their rhythm, check their rate, so that's an FDA-cleared device. And it also provides an automated read so that she is able to see at the top of the EKG what the computer thinks her heart rhythm is and that is a really nice technology that's been fairly well studied in a variety of different settings, including people like your mom who have had a prior cardioversion, to look for recurrences. So that's one approach that exists, which is for intermittent monitoring. And that's also in essence, the same approach that one of the two tools that an Apple Watch has embedded in it. So the Apple Watch 4 and 5 are also FDA-cleared for similar analysis. So the Apple Watch has a EKG on the bevel of the watch. The thing you turn to change the time, not really in an Apple Watch, but in an old-fashioned watch. And so you can kind of put your finger on it and again, create that same circuit in your body to record a single-lead EKG and that similarly can present a 30-second EKG strip, so it's very similar to what AliveCor's KardioMobile does. Just in the watch. But again, that's an EKG-based approach and those approaches are not the only technologies that are out there. There are a number of other devices that have CE marking designation in Europe. Other devices that are starting to become available in the US and we go through some of the performance of those devices in our review. And generally speaking, the ECG approach, the advantage is it's one of the more accurate approaches to AFib detection, but it does require, at least right now, that you intermittently check yourself.  In contrast, there's a movement afoot, and Apple has a separate  FDA clearance, to use the lens and video camera on the back of the watch, that was previously used to measure your heart rate, to analyze the skin color changes that happen when your blood is flowing in and out of your wrist, to your hand. It looks at that skin color change, records it and analyzes it for irregularity. So it's an essence, like someone checking your pulse and it's called pulse plethysmography and that recording is similar to what other groups are analyzing. For example, there's something called FibriCheck, which is an app that is FDA cleared for AFib detection. But again, you put your finger on the camera of your iPhone or Android and it analyzes the pulse. Cindy St. Hilaire: So a patient has to actively say, "I'm going to check this right now," as opposed to a background assessment? David McManus: Yeah, so just to be clear. The background assessment is the automated sort of pulse check that the Apple Watch is doing and then it can prompt you to perform your own EKG, so that's the difference between kind of an intermittent-check approach versus a more near-continuous ... it's not truly continuous, but it's a near-continuous approach Cindy St. Hilaire: So are there any drawbacks to people more regularly performing these in their kitchen? As a clinician, what are the drawbacks? David McManus: It really is exciting and I think there are a lot of good reasons to pursue this. As you know, I'm sort of an early adopter of this idea and so I definitely would side with you that I think there were a lot of good reasons to be using these technologies. I just want to highlight though that there are a couple of issues. So when commercial technology companies build medical-grade tech intended to diagnose or detect rhythm problems, those rhythm problems come to the clinics in a very different way and from a different type of patient, so they're not necessarily contextualized the same way a workup would happen if you came into the doctor, they prescribed a medical-grade patch monitor or a traditional monitor or did another type of medical test on you. You're kind of on your own. And so when you get the diagnosis or you get the possible diagnosis, you have very little information,  and it can be anxiety-provoking. In many cases, especially in younger people ... in fact, the majority of people who have Apple Watches are at really low risk from having a complication from AFib. So now, you're making an upstream diagnosis and you may not do anything about it other than introduce a word onto their chart. And so, yeah, I do think there's some things that warrant further study and evaluation about some of the unintended downstream consequences of making diagnoses earlier and worrying people about a condition. David McManus: Now, some have argued that an early diagnosis, even if you wouldn't put someone on a blood thinner, as you call it or an anticoagulant ... Like for example, maybe you change your health behaviors, maybe you lose some weight or you get more active or you stopped drinking so much. So I happen to think that early diagnosis is a good thing, but I do think that we don't really have robust care-management systems across the country that can support people who are at home. It's really hard right now for your doctor to, on top of seeing 30 patients in the office, to find the time to respond to your new test that he didn't order or she didn't order. Cindy St. Hilaire: I got this blip on my strips. David McManus: Yeah, what do I do about this? Well, okay, now I got to see you, what tests are ordered, what's the process and I think there's a lot of opportunity for us to, especially in the COVID era, redesign how we're delivering heart care and integrating these technologies become a facilitator as opposed to a burden, so I think there's a lot of interest in incorporating them. But right now, at least, they're kind of separate from your chart, in the electronic chart and your doctor has to sort of find a way of reviewing on your smartphone, in the office, finding extra time to do that. They're not really paid to do that, how do you protect the safety of that information and et cetera, et cetera. So there are all these sort of little, but they seem little, but they're actually kind of important downstream implications. So we talk a little bit about, and this is kind of a unique part of this Review, the clinical actionability of device-detected AFib. There's no debating the fact that AFib is bad, but the real impact of device-detected AFib remained something that we really need to define and so there's a lot of interesting work going on in this area. Cindy St. Hilaire: And so, because we're still all at home because of the COVID epidemic, there's been some things in the news regarding some of these wearable technologies being able to detect or track trends in swaths of patient health. Where do you see this going in terms of either things like COVID and epidemics or even things regarding AFib and we always see those maps from the AHA with hotspots of diabetes, things like that, so how do you think that this kind of technology can help transition the future of medical care, specifically in the US? David McManus: I think it's really exciting because everybody has a smartphone and that crosses age, sex, race, occupation, religion and I think people are increasingly understanding the connections between health behaviors and their heart health. And I think, for example, just using your heat map example, that there's a stroke belt and a diabetes belt and different areas in the United States, also tremendous rural health disparities, that mobile devices have a really remarkable opportunity to help us understand what is going on, what is driving these sort of risks? Is it stress, is it alcohol, food consumption, nutrition, activity, sleep, all the things we talked about? And whether it be AFib or other cardiovascular conditions, these wearable devices and mobile devices and digital technologies allow for quantifying different health behaviors and mood and opinion and activity in ways that our  regular in-person exams that we do, when we see you for an hour or two every 365 days, we just really don't quantify. And I look forward to a time in the near future where your vital signs that are presented for your visit with your doctor over the internet is your activity, your blood pressure from your watch or heart rate from your watch or EKG, your oxygen levels at any of a myriad of other things that these devices can impact or will in the near future. Cindy St. Hilaire: Yeah, I agree. I think it's great. And I think also it helps to empower the patient. David McManus: Oh, for sure. I mean, if done well, it really connects you as a patient to your health more and it also, if done well, could connect you better to your healthcare team. I mean, a lot of people are afraid in the healthcare community of this technology replacing them, but that only will happen if we don't incorporate it as a tool into our relationships with our patients. I think if it's done in that way, it's a facilitator. It actually makes your mom maybe feel more connected to her cardiologist to be able to kind of run that list. Cindy St. Hilaire: Yeah and she understands what she's looking at more, so it's been wonderful. Well, thank you so much. This was an excellent Review; it was really timely and thank you again for the contribution and for taking the time to speak with me today. David McManus: My pleasure and thanks for the invitation and I hope people will read the Review. Cindy St. Hilaire: Great. Wonderful. Well, thank you so much, David. David McManus: Good luck to you and your mom. Cindy St. Hilaire: So that's it for the highlights from our June issues of Circulation Research and our compendium on atrial fibrillation. Thank you for listening. Please check out the Circulation Research Facebook page and follow us on Twitter and Instagram with the handle @CircRes and #DiscoverCircRes. Thank you to our guests, Dr David McManus. This podcast is produced by Rebecca McTavish and Ishara Ratnayaka, edited by Melissa Stoner and supported by the editorial team of Circulation Research. Some of the copy text for highlighted articles is provided by Ruth Williams. I'm your host, Dr Cindy St. Hilaire And this is Discover CircRes, you're on-the-go source for the most up-to-date and exciting discoveries in basic cardiovascular research.  

This episode, we hear from ASAE President & CEO Susan Robertson, CAE, Pat Blake, FASAE, CAE, CEO of the Heart Rhythm Society and Steve Caldeira, President and CEO of the Household & Commercial Products Association, Angel M. Royal, PhD, Chief of Staff, American Association of Community Colleges, and Margarita L. Valdez, Assistant Director of Congressional Relations, American Society for Radiation Oncology (ASTRO) about their associations’ work related to COVID-19. We learn about the association community’s efforts to keep America healthy and safe, as well as re-open and recover. Plus, we share another Great Moment in Association History.

Author: Jared Scott, MD Educational Pearls: Differentiating symptomatic bradycardia from asymptomatic may be essential in determining workup and treatment Airway, breath, circulation always hold true Symptoms may  include dizziness, syncope, or weakness An EKG is essential in the majority of cases Complete heart block can be a cause of symptomatic bradycardia and requires immediate attention Complete heart block can be caused by drugs (beta-blockers, calcium channel blockers), Lyme disease, infiltrative disease, or degeneration of the conduction system References: Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2019;74(7):e51. Epub 2018 Nov 6.  Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Jane Ferguson:                Hello. Welcome to episode 33 of Getting Personal: Omics Of The Heart, your podcast from Circulation: Genomic and Precision Medicine. I'm Jane Ferguson. This episode is from October 2019. Let's get started.                                            First up is a paper from Sébastien Thériault, Yohan Bossé, Jean-Jacques Schott and colleagues from Laval University, Quebec and INSERM in Mont. They published on genetic association analyses, highlight IL6, ALPL and NAV1 as three new susceptibility genes underlying Calcific Aortic Valve Stenosis.                                            In this paper, they were interested in finding out whether they could identify novel susceptibility genes for Calcific Aortic Valve Stenosis, or CAVS, which is a severe and often fatal condition with limited treatment options other than surgical aortic valve replacement. They conducted a GWAS meta-analysis across four European ancestry cohorts comprising over 5,000 cases and over 354,000 controls. They identified four loci at genome-wide significance, including two known loci in LPA and PALMD as well as two novel loci, IL6 which encodes the interleukin six cytokine, and ALPL, which encodes an alkaline phosphatase. They then integrated transcriptomic data from 233 human aortic valves to conduct the transcriptome wide association study and find an additional risk locus associated with higher expression of NAV1 encoding neuron navigator one. Through fine mapping, integrating conservation scores, and methylation peaks, they narrowed down the putative causal variants at each locus identifying one snip in each of PALMD and IL6 as likely causal in addition to two candidates snips at ALPL and three plausible candidate snips in NAV1.                                            Phenome-Wide Association Analysis, or PheWAS of the top candidate functional snips found that the IL6 risk variant associated with higher eosinophil count, pulse pressure and systolic blood pressure. Overall, this study was able to identify novel loci associated with CAVS potentially implicating inflammation and hypertension in CAVS etiology. Additional functional studies are required to further explore these potential mechanisms.                                            Next up is a paper from Elisavet Fotiou, Bernard Keavney and colleagues from the University of Manchester. Their paper entitled Integration of Large-Scale Genomic Data Sources With Evolutionary History Reveals Novel Genetic Loci for Congenital Heart Disease explored the genetic etiology of sporadic non syndromic congenital heart disease using an evolution informed approach. Ohnologs are related genes that have been retained following ancestral whole genome duplication events which occurred around 500 million years ago. The authors hypothesized that ohnologs which were retained versus duplicated genes that were lost were likely to have been under greater evolutionary pressure due to the need to maintain consistent gene dosage. For example, as could occur when the resulting proteins form complexes that require stochiometric balance.                                            Thus, ohnologs may be enriched for genes that are sensitive to dosage. The group analyzed copy number variant data from over 4,600 non syndromic coronary heart disease patients as well as whole exome sequence data from 829 cases of Tetralogy of Fallot. Compared to control data obtained from public databases, there was evidence for significant enrichment in CHD associated variants in ohnologs but not in other duplicated genes arising from small scale duplications. Through this and various other filtering steps to prioritize likely variants, the group was able to identify 54 novel candidate genes for congenital CHD highlighting the utility of considering the evolutionary origin of genes in the search for disease relevant biology.                                            Next, we have a clinical letter entitled Pathological Overlap of Arrhythmogenic Right Ventricular Cardiomyopathy and Cardiac Sarcoidosis from Ashwini Kerkar, Victoria Parikh and colleagues at Stanford University. They describe a case of a 50 year old woman previously healthy and a long distance runner who presented with tachycardia. She was found to have normal left ventricular size but severe right ventricular enlargement and systolic dysfunction. Genetic testing using an Arrhythmogenic Right Ventricular Cardiomyopathy or ARVC panel identified a variant in DSG2. through cascade testing it was found that two of the patient's three children also carried this variant. The patient experienced worsening RV failure and subsequently underwent heart transplantation at age 55. Pathology of the heart showed evidence of cardiac sarcoidosis. There have been some previous reports of overlap in ARVC and cardiac sarcoid pathology but not in cases with a high confidence genetic diagnosis such as this one.                                            This case raises the possibility of shared disease mechanisms underlying ARVC and cardiac sarcoidosis and suggests that therapies aimed at immune modulation may also have utility in ARVC. However, further work is required to test this hypothesis. Our next paper is a perspective piece from Babken Asatryan and Helga Servatius from Bern University Hospital. In Revisiting the Approach to Diagnosis of Arrhythmogenic Cardiomyopathy: Stick to the Arrhythmia Criterion!, they outline the challenges in defining diagnostic criteria for a Arrhythmogenic Right Ventricular Cardiomyopathy or ARVC, given the variable presentation of the disease. Given recent advances in knowledge, particularly in recognizing disease overlap with Arrhythmogenic Left Ventricular Cardiomyopathy or ALVC and Biventricular Arrhythmogenic Cardiomyopathy, a new clinical perspective was warranted. The Heart Rhythm Society updated their recommendations this year to introduce a new umbrella term that better encompasses the spectrum of disease, Arrhythmogenic Cardiomyopathy or ACM. This recommends the arrhythmia criterion Should be used as a first line screening criteria for ACM.                                            This is a broad criteria and a definitive diagnosis of ACM requires exclusion of systemic disorders such as sarcoidosis, amyloidosis, mild carditis, Chagas disease, and other cardiomyopathies. Implementation of this new approach to diagnosis may require more extensive investigation of arrhythmias including the use of ambulatory ECG monitors or cardiac loop recorders. These changes may also affect who's referred for genetic testing, potentially shifting diagnoses towards genotype rather than phenotype based disease classifications. Despite challenges and adopting new approaches, it is hoped that these changes will ultimately serve to improve risk stratification and allow for improved disease management and intervention to prevent sudden cardiac death.                                            We end with a scientific statement chaired by Sharon Cresci and co-chaired by Naveen Pereira with a writing group representing the AHA Councils on Genomic and Precision Medicine, Cardiovascular and Stroke Nursing and Quality of Care and Outcomes Research entitled Heart Failure in the Era of Precision Medicine: A Scientific Statement From the American Heart Association. This paper provides a comprehensive overview of the current state of omics technologies as they relate to the development and progression of heart failure and considers the current and potential future applications of these high throughput data for precision medicine with respect to prevention, diagnosis and therapy of heart failure. They discuss advances in genomics, pharmacogenomics, epigenomics, proteomics, metabolomics, and the microbiome, and integrate the findings from this rapidly developing field as they pertain to new methods to diagnose, treat, and prevent heart failure.                                            And that's it for October. I hope to see many of you at AHA Scientific Sessions in Philadelphia in November and look forward to bringing you more of the best new science next month. Thanks for listening. This podcast was brought to you by Circulation: Genomic and Precision Medicine and the American Heart Association Council on Genomic and Precision Medicine. This program is copyright American Heart Association 2019.  

Dr. Oussama Wazni, Section Head, Electrophysiology and Pacing at Cleveland Clinic and Dr. Dan Cantillon, Director of Research in Electrophysiology and Pacing discuss the highlights from the recent Heart Rhythm Society Meeting. Research discussed includes bariatric surgery and afib ablation; digital health in electrophysiology; central monitoring unit outcomes; HIS bundle CRT pacing and pulse field ablation.

The founder of crazysocks4docs movement. Dr. Geoff Toogood is a Cardiologist and specialist consulting Aviation Cardiologist who has practiced for 20 years on the Mornington Peninsula. He has held The Director of Cardiology position at Frankston Hospital and is a Fellow of the College of Physicians, Cardiac Society and the prestigious Heart Rhythm Society. He has lived experience of both depression and anxiety. He faced stigma and discrimination at many levels and was determined that once recovered he would create awareness movement to break down the stigma faced by health professionals. He wants to reduce Doctors suicide round the world.CRAZYSOCKS4DOCS DAY IS 7 JUNE POST YOUR CRAZY SOCK PHOTOS & TAG #CrazySocs4DocsIf you are a Doctor needing help know there is help available, below are only some of the options available: See your GPAMA ANONYMOUS PEER SUPPORT line 1300 853 338 (Note you do not need to be a member to access this line)RACGP GP support 1800 331 626 / membership@racgp.org.auVictorian Doctors Health Program (03) 9495 6011 / vdhp@vdhp.org.auLifeline 13 11 14

Dr Carolyn Lam:                Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to The Journal and it's editors. We're your co-hosts. I'm Carolyn Lam, Associate Editor from the National Heart Center and Duke National University of Singapore. Dr Greg Hundley:             And I'm Greg Hundley, also Associate Editor from the Pauley Heart Center in Richmond, Virginia, VCU Health Sciences. Dr Carolyn Lam:                How well are we doing with guideline-directed stroke prevention therapy in atrial fibrillation? Well, there are going to be very important results that you need to hear about from Get With the Guidelines Atrial Fibrillation. That's our feature paper coming right up in a future discussion. But first, you've got Greg and I discussing really important papers that we've spotted in The Journal. Greg. Dr Greg Hundley:             Absolutely, Carolyn. And my favorite kind of follows from that 'cause it's really about left atrial electromechanical remodeling following two years of high intensity exercise training in sedentary middle-aged adults, kind of like me. The studies from Ben Levine at University of Texas Southwestern Medical Center in Dallas. So, what he's driving at here are moderate-intensity exercises associated with a decrease in incidents of atrial fibrillation. However, extensive training in competitive athletes is associated with an increased atrial fibrillation risk.                                                 So, in this study, they're looking at the effects of 24 months of high-intensity exercise training on left atrial mechanical as well as electrical remodeling in sedentary, healthy, middle-aged adults. So, he had 61 individuals, their average age was 53.5 years, quite young, who were randomized to 10 months of exercise training followed by 14 months of maintenance exercise and some stretching or stretching and balance control. He also had another group of 14 master's athletes that were added for a comparison and he looked at three of the echocardiograms to assess left atrial and left ventricular volumes and also had signal average EKG's for filtered P-wave durations and atrial light potentials. He made assessments at baseline, so before everyone started, and 10 and 24 months. Dr Carolyn Lam:                Hold on, hold on. Let's really understand here how much exercise were these sedentary middle-aged adults subjected to. Dr Greg Hundley:             So, let's talk about that because that was very interesting because a lot of us are out there exercising. So briefly the way he started this, there was an initial phase that was comprised of six months of regressive training during which an increase in the frequency, the duration, and the intensity of exercise, including two high-intensity aerobic interval sessions per week that were prescribed to peak training load. The peak training load included five to six hours of exercise per week that included two interval sessions, at least one being an hour-long session, and then two 30-minute sessions.                                                 Once you got that peak training load, that was sustained for four months and then he made these 10-month measurements as part of his study design. Now following that phase, a 14-month sort of a continuation, all of the 24 months, a 14-month period of maintenance exercise was completed where the frequency of high-intensity intervals was reduced to once per week plus continuous training all the way to that 24-month time point. And during the maintenance phase, participants performed a total of about three hours a week of aerobic exercise. Dr Carolyn Lam:                Well, don't keep us in suspense now. What did the study show? Dr Greg Hundley:             So at the 24 month time point of high-intensity exercise, it led to a disproportionate dilation of the left atrium compared to the left ventricle. So, mechanical changes, but no electrical remodeling was seen. And interesting, and remember he had that comparison cohort with master's athletes. Those participants randomized exercise training demonstrated lower absolute left atrial and left ventricular volumes, but a similar left atrial to left ventricular ratio after 24 months of exercise training.                                                 So, what's going on here, if you're middle-aged or young, some of us like to think, and you start one of these aggressive training sessions, you do have some changes mechanically in the shaping of your left atrium and left ventricle, but they're concordant, but no electrical remodeling that was observed in this situation. So, how do those elite athletes develop atrial fibrillation in the electrical remodeling? Don't know. It may be they need a longer duration of exercise. Maybe they start at a different time point because these are relatively sedentary individuals, and maybe their training regimen is very different.                                                 So, more research is needed, but it was interesting that these middle-aged folks that start with this little bit more aggressive regimen really didn't develop the electrical remodeling. So, Carolyn, you've got a couple of papers that are sort of tied together. Dr Carolyn Lam:                Indeed. A couple of papers centered on lipoprotein little A. Now, we know that lipoprotein little A levels predict the risk of myocardial infarction and this has been shown in populations of European ancestry, however there's very little data available in other ethnic groups. And so, this was addressed by Dr Paré from McMaster University and the Interheart Investigators who looked at more than 6000 cases of first myocardial infarction and more than 6800 controls, all from the Interheart study, and were stratified by ethnicity and included African, American, Chinese, European, Latin American, South Asian, and Southeast Asian ancestries.                                                 Lipoprotein little A concentration was measured in each participant, first using an SA that was insensitive to iso-form size and then iso-form size itself was also assessed by Western Blot in a subset of more than 4200 participants. So, what they found was that lipoprotein little A concentration and iso-form size varied markedly among the ethnic groups. Africans had the highest concentrations with the smallest iso-form size whereas Chinese had the lowest concentrations with the largest iso-form size.                                                 Furthermore, higher lipoprotein little A concentrations were associated with an increased risk of myocardial infarction and carried an especially high population burden in South Asians and Latin Americans. And a high concentration above 15 milligrams per deciliter was associated with significantly increased risk of myocardial infarction in all populations except Arabs and Africans. The iso-form size, on the other hand, was inversely associated with lipoprotein little A concentrations and did not significantly contribute to the risk. Dr Greg Hundley:             So, Carolyn, how do we use this clinically? I mean, do we measure this in folks? Dr Carolyn Lam:                Yeah. So, there are two take-home messages. I think one is about the monitoring or measuring and it supports a clinical use of the actual lipoprotein A concentration rather than iso-form size as a marker of myocardial infarction in this ethnically diverse population. But this is, other than Africans and Arabs where, remember that cut off did not seem to associate with a risk of MI's in these two ethnicities. The second take-home is that the effects of clinical interventions that reduce lipoprotein A should be investigated especially in South Asians and Latin Americans where the population attributable risk is really high. And that actually brings me to the second study.                                                 So, we've always been looking for intervention that can reduce lipoprotein A and this current paper is really interesting 'cause it talks about insights from the Fourier trial. So, we may finally have a therapy that can reduce it. Dr O'Donoghue from the TIMI study group and Brigham and Women's Hospital in Boston, Massachusetts and colleagues looked at the relationship between lipoprotein A levels, PCSK9 inhibition, and cardiovascular risk in the Fourier trial, which you remember is a randomized trial of Evolocumab versus placebo in patients with established atherosclerotic cardiovascular disease.                                                 So, they found that patients with a higher concentration of lipoprotein little A were at increased risk of coronary events independent of the LDL concentration. And individuals with a higher baseline LP little A concentration tended to have a greater relative and absolute coronary risk reduction with Evolocumab and therefore a lower number needed to treat. It was as low as four T for individuals with a lipoprotein A above the median versus 105 number needed to treat for those at or below a lipoprotein A level below the median. Dr Greg Hundley:             So should we start checking this in all our patients now, these lipoprotein little A levels? Dr Carolyn Lam:                Yeah. So, this issue was discussed beautifully in a company editorial by Dr Thanassoulis from McGill University Health Center. And here he mentions that there remains tremendous clinical inertia honestly for the measurement of lipoprotein A in North America and in fact, worldwide. For this to be successful, we really need to be proactively screening our patients with myocardial infarction and stroke and especially those with premature events or a family history. And particular attention will need to be made on screening individuals with recurrent events despite adequate lipid or LDL lowering who frequently may still have high lipoprotein little A. It's encouraging to know that the most recent version of the US Lipid Guidelines has newly recommended LP little A measurements in select individuals as a risk enhancer and so this should further raise awareness of lipoprotein little A as a risk marker.                                                 Finally, the editorialist mentioned that common misconception that we have a lack of therapeutic options to lower high LP little A. Still, we need to remember that these individuals may obtain significant benefit from more aggressive lifestyle modifications. And now we have these results of this trial that suggest that PCSK9 may be one of the few drugs that can lower lipoprotein little A. And so, the editorialist actually ended with targeting therapy for lipoprotein A is around the corner and a test of this hypothesis is really imminent, so we should watch this space. Dr Greg Hundley:             Yeah, so it sounds like another wonderment of PCSK9 inhibitors. Dr Carolyn Lam:                Yeah. Dr Greg Hundley:             Well Carolyn, let me jump in and finish our chat here talking about iron. This particular paper is from Dr Jean-Sébastien Silvestre from Paris, France, and he's looking at the iron regulator Hepcidin. So, we know that iron deficiency is frequent in patients with coronary artery disease and increases morbidity in those with high risk profiles such as those with diabetes and anemia and then conversely, excess iron is also detrimental to cardiac function. We see this with iron overload cardiomyopathies and as a major co-morbidity in patients with genetic hemochromatosis.                                                 So, among the multiple regulators of iron homeostasis is Hepcidin. It plays an instrumental role in fine-tuning systemic iron trafficking by modulating the transfer of dietary, recycled, and stored iron from intracellular compartments to extracellular fluids. Hepcidin is a catatonic peptide hormone. It's produced primarily by hepatocytes, but also, it's produced in macrophages. So, given the role of Hepcidin to locally regulate cardiac function and that inflammation guides cardiac remodeling after acute MI, the investigators hypothesized that inflammatory macrophages may control cardiac repair through a Hepcidin-dependent mechanism. And until now, the role of Hepcidin in some other cardiac diseases challenged by inflammation hasn't really been explored. Dr Carolyn Lam:                Huh, interesting. So, what did they find? Dr Greg Hundley:             Great question and let's lead to the main results of this study. The hormone Hepcidin, they found, was produced by a distinct sub-population of inflammatory cardiac macrophages residing in infarcted heart tissue and the deletion of Hepcidin in macrophages improved tissue remodeling and stimulated cardiomyocyte renewal in both, just as our wonderful basic science studies have, in both adult mice with myocardial infarction, neonatal animals with apical resection and also in human subjects. And so, this study provided novel insights into the complex roles of the immune response during cardiac repair following MI and suggests and deleterious role for the macrophage-derived Hepcidin in cardiac repair.                                                 Interesting, Carolyn. Another role for iron in acute MI and more research to come. Dr Carolyn Lam:                Indeed. Well, thanks Greg. Let's move on to our feature discussion, shall we?                                                 For our feature discussion today, we are talking about the first results from the Get With the Guidelines atrial fibrillation. That is huge, and I have none other than the first author, Dr Jonathan Piccini from Duke Clinical Research Institute, as well as Dr William Lewis from Case Western Reserve University here to discuss these really important results, so listen up. I think to start with it is such an honor to have you with us, Bill. I mean, as Chair of the Get With the Guidelines atrial fibrillation work group, could you give us a background on how did this start? How far has it come? Dr William Lewis:             The Get With the Guidelines program started in 2000. Greg Fonarow figured out that if we put in place mechanisms to improve adherence, that we could get people on appropriate therapies. In 2012, there was some focus on atrial fibrillation and I had been participating in the program since 2004 and I kept telling them that A-fib was a big, big problem. And in 2012, they said, "Let's do this," so we built this program to try to improve adherence in atrial fibrillation. Get With the Guidelines is a national, hospital-based, quality improvement program that improves adherence to guidelines over time and it has been very successful at doing that.                                                 So, by 2013 we were ready to start enrolling patients and we started getting patients in the database and we're now up to about 162 hospitals nationwide, in the United States, and we've enrolled about 75000 patients in the program. So, it's been very successful from that standpoint. Dr Carolyn Lam:                Congratulation. And today we're actually going to be talking about that very question you asked. Adherence. How well are we adhering to guideline-directed stroke prevention therapy for atrial fibrillation? Jonathan, wanna share the key results? Dr Jonathan Piccini:         I think you're getting exactly to the point of what was the rationale for this study and I think most individuals that are familiar with the field and atrial fibrillation and also clinicians across the world who are treating patients with atrial fibrillation know that most large reports, most nationwide studies have shown that adherence for oral anticoagulation to prevent stroke in patients with atrial fibrillation usually ranges in the 50, 60, 70 percent range at best. And there's been some notable publications in the past several years from nationwide registries that have shown rates as low as 50 percent or lower in high-risk patients. So, one of the main goals of the program, as Bill articulated, was to try and improve the use of oral anticoagulation in patients who had a guideline recommendation. So, patients who had a CHA2DS2-VASc score of two and higher with atrial fibrillation.                                                 And so, looking at over 30000 admissions between 2013 and 2017 and the guidelines A-fib program, we saw that just under 60 percent of patients who had known AF at the time of admission were on oral anticoagulation. And not surprisingly, the patients who were on oral anticoagulation had lower rates of stroke during their hospitalization. But the major finding from the program was that in this quality improvement program, the program was able to improve adherence to oral anticoagulation at discharge from 60 percent to admission all the way up to 93.5 percent in the overall cohort. And if you looked at results over time, adherence improved from 80 percent at discharge all the way to 96 percent and those improvements were sustained in follow up as well. Dr Carolyn Lam:                Could you tell us, what do you think are the key elements that help this improvement? Is it just because there's a program and people know they're being watched? Is it that there was a change? I mean, when you say oral anticoagulants I bet you mean both Warfarin and the newer oral anticoagulants, so how much did that help? What do you think is the key ingredient here? Dr Jonathan Piccini:         It was several things. Having visited several of these hospitals and spoken with them about the impact of the program, I think you can't emphasize enough that if you don't measure something, you can't really expect to improve it. So, just the fact that hospitals were having systematic data on their atrial fibrillation patients at discharge illustrating who was and who was not getting oral anticoagulation makes a big difference. Between the program itself and the conferences affiliated with the program and teaching sessions affiliated with the program, there's a heavy emphasis on education of the importance of guideline recommended treatments for atrial fibrillation, so that's a second component.                                                 And then there's an iterative relationship between the sites and the American Heart Association where improvements in the rates of oral anticoagulation are recognized and celebrated. And I think it's not any one thing, in my opinion. I think it's all of those things taken together. And again, Bill, who's been with the program since its inception probably has additional thoughts on that as well. Dr Carolyn Lam:                Bill, did you expect such remarkable results? Dr William Lewis:             No. I actually didn't expect 96, but in a previous study where we were looking at patients who had had a stroke in the stroke database, we were able to achieve 93 percent adherence. And so, 96 is remarkable and it's the highest number that's ever been seen in any A-fib program. I was going to mention about the idea of what makes the special sauce, if you will, and I think John put forth a number of items. I think, again, celebrating success, those kinds of things, but I think that docs, by their very nature, are very competitive and when you get a data report that says you're doing x percent and somebody else is doing y percent and their percentage is higher, you tend to get motivated to actually do better. And so, we provide these reports in the program to hospitals so that they can measure their success against other institutions. Dr Carolyn Lam:                That's such a good idea. And, you know, I practice here in Asia and there aren't these very massive programs that are accepted in many places. So, what do you think is the generalizability of something like this? Dr Jonathan Piccini:         That's such a critical question because a limitation is that these are hospitals that are saying voluntarily, "We want to commit to the program because we think quality care for atrial fibrillation patients is important." And so, you could argue that, well, these results really don't generalize to your run of the mill hospital in different parts of the world. And I think while that's a limitation, it's also a call for what the next steps are. So, having visited many of these hospitals, these are real hospitals of brick and mortar that face many of the same challenges other health systems and hospitals across the world do and I think the key message is that a hospital that implements these types of interventions is very likely to see the same improvement with their patients. And so, I think that's a very important message and a very positive message for patients all over the US and all over the world. Dr William Lewis:             I agree. I think it's, not turn-key, it's much more generalizable than we had ever expected. So, community hospitals do this. The American Heart Association is using other Get With the Guidelines programs in China. I think that there is a lot that has to do with the support that's provided by the program and the tools that are made available to them to be able to make it so that you can recreate it in a hospital. I agree, it is more difficult in some hospitals than others. Dr Carolyn Lam:                John, before we end, what are the take-home messages for clinicians listening out there? Dr Jonathan Piccini:         I'd have two messages. The first message is that this study shows that with some assistance any healthcare system or hospital can achieve optimal adherence to these medications for their patients and thus in so doing achieve a significant benefit for the public health. And the second message I would have, which isn't necessarily specifically related to the paper, but I think it's equally important, that this is just the beginning for the American Heart Association and the Heart Rhythm Society Get With the Guidelines A-fib registry. Though stroke prevention is obviously just one of many different aspects of quality care for atrial fibrillation and so keep an eye out 'cause you'll be seeing a lot of studies coming out about how Get With the Guidelines A-fib is better informing care and treatment for atrial fibrillation across many different therapy domains, including catheter ablation and rate control and other interventions for rhythm control. And again, on behalf of all the co-authors and the American Heart Association, the Heart Rhythm Society sponsors, we really appreciate to have the opportunity to talk about the program. Dr Carolyn Lam:                Thank you so much for sharing that with us.                                                 Audience, you heard it right here on Circulation on the Run. Don't forget to tune in again next week.                                                 This program is copyright American Heart Association 2019.  

Oussama Wazni, MD, Section Head, Cardiac Electrophysiology and Pacing and Bruce Lindsay MD, past Section Head and past president of Heart Rhythm Society discusses the challenges and findings from the CABANA trial and its implications on future clinical practice, when to offer ablation vs. medical management.

Author:  Pete Bakes, MD Educational Pearls:   AICD: Automated Implantable Cardioverter-Defibrillator. Can be placed for secondary prevention of cardiac arrest (i.e. history of cardiac arrest not from reversible cause). Also indications for primary prevention: EF 35% or less; ventricular tachycardia with underlying structural heart disease; Brugada; genetic-induced prolonged QT-syndromes.   References: Al-Khatib SM et. al. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm. 2017 Oct 30. pii: S1547-5271(17)31249-3. doi: 10.1016/j.hrthm.2017.10.035.

ReMag Pico-Ionic Liquid Magnesium Supplement by Dr. Dean: http://amzn.to/2H9f1ub BOOK: Magnesium Miracle - Second Edition http://amzn.to/2H6IrsQ www.drcarolyndean.com www.drcarolyndeanlive.com   Magnesium http://learntruehealth.com/magnesium/ Magnesium is an essential mineral that can cure various health conditions. However, most people take magnesium for granted when along with other minerals, so many illnesses can be reversed. So, we’re fortunate to have Dr. Carolyn Dean elaborate on why magnesium is vital to our health.   Early Challenges   Dr. Carolyn Dean went into practice in 1979. Before that, she went through quite a challenge since around that time; women weren’t given high ranks in the workforce even if they were bright.    Getting her medical degree first, Dr. Carolyn Dean recalls that back then, there were no Naturopathic schools in Canada. But she already thought back then that thirty to forty years down the road, becoming a Naturopath would be popular, and everyone would get on board taking care of health. Dr. Carolyn Dean even thought a three-day work week was possible.   “But we know what happened. The commercialization of medicine and disease happened, and medicine just turned into the dark side,” said Dr. Carolyn Dean.   Roadblocks   Dr. Carolyn Dean also remembers the obstacles she went through especially for doctors like her who were promoting their dietary supplements.  Their voices were suppressed if it was about supporting natural products.   “Medical authorities won’t allow us to say something like magnesium might be a health cure. They won’t let you see that because it will mean that you’ll stop taking drugs,” reveals Dr. Carolyn Dean.   Legal Challenges   Dr. Carolyn Dean was practicing as a Naturopath and was into natural treatments like Acupuncture and Homeopathy. She also did occasional medical surgeries to help save organs.   Things started to get out of hand when Dr. Carolyn Dean said some bad things about sugar on a Canadian national TV show in 1991 or 1992. After the episode aired, Dr. Carolyn Dean found herself attacked by the Sugar Institute of Canada. They went to Dr. Carolyn Dean’s licensing board which resulted in the board admonishing her. They even sent spies into her practice.   “They got this young man to complain to my licensing board that I refused to give him a homeopathic remedy for his allergies on his first appointment. If I gave it to him, he still would have complained. It was a planned thing,” said Dr. Carolyn Dean.  Years later, Dr. Carolyn Dean had no more license to practice in Canada, since she already acquired her California license. The medical board took the opportunity to hold a mock court in Toronto. They took away Dr. Carolyn Dean’s non-existent license to send a message to medical practitioners that they couldn’t do alternatives.   “So if people wonder why doctors don’t get involved with nutrition, alternatives, and dietary supplements, it is because they are likely to be attacked,” said Dr. Carolyn Dean.    I understand Dr. Carolyn Dean’s ordeal.  My hero, Dr. Joe Wallach has been attacked eleven or twelve times by the FDA. He’s very outspoken and has always stood his ground on his research and findings.    The Magnesium Miracle Book   There are 65 health conditions that Dr. Carolyn Dean has listed in her Magnesium Miracle book. According to her, those conditions can be triggered or caused by a magnesium deficiency and misdiagnosed as diseases.    I suggest everyone get a copy of the book as well as Dr. Carolyn Dean’s other published works. It is a wonderful resource to educate you on why minerals are so essential.   Magnesium And Sugar   Dr. Carolyn Dean says there is apparently a vindication about magnesium and sugar. Sugar-lobbied groups changed the whole dialogue about sugar and made it about fats. They saw the research thirty to forty years ago, showing that sugar was bad for the heart.    “Groups buried that research and blamed it on fats. We know that olive oil, coconut oil, and butter are good for the body, but those groups instead lobbied for trans fat which is even worse for health than sugar,” said Dr. Carolyn Dean.    Burning Fats   Dr. Carolyn Dean explains that now with all this sugar and excess carbohydrates that the body cannot sustain, our body keeps making insulin. The insulin will push some of the sugars into our cells for energy, the rest in liver storage. Hence, increasing the risk of having a fatty liver.    “As long as you are eating carbohydrates constantly, you will never burn fat. So the beauty of a ketogenic diet and fasting is that you stop eating carbohydrates to a great extent. After sugar gets used up, that’s when you start fat burning and lose weight,” Dr. Carolyn Dean explains.   Ongoing Debate   There has never been a death due to dietary supplements. Despite that, Dr. Carolyn Dean says many medical authorities are still saying supplements are dangerous. And lucky for us, things are different now than it was before. Today, our voices can be heard especially since more people are seeking treatments the natural way.   One major issue at hand is the fact that the FDA made an announcement recently, planning to pass a guideline wherein people can no longer buy homeopathic remedies. The verdict is still pending. Because currently, there is a write-in and call in period wherein the public is allowed to comment on these proposed FDA guidelines making homeopathic remedies into drugs.    Codex Alimentarius   I recall Dr. Rima Laibow, who is a successful doctor of Natural Medicine. She graduated from Albert Einstein College of Medicine in 1970 and had studied more than 16,000 pages of Codex Alimentarius documentation.    Codex Alimentarius is a compilation of medical standards, codes of practice and guidelines on food, food production, and food safety. But Dr. Rima Laibow believes it is a severe threat to health freedom. She spoke lengthily about it in her speech at the 2005 National Association of Nutrition Professionals conference.    On the other hand, Dr. Carolyn Dean encourages people to support the causes of the National Health Alliance. Among the organization’s current focus is spearheading activities to fight against the suppression of Natural Medicine. This is because medicine companies look at Natural Medicine as competition.   Importance of Dietary Supplements   Dr. Carolyn Dean says we need dietary supplements to make up for the loss of vitamins and minerals in our body. She reveals that a hundred years ago, we could get approximately 500mg of magnesium in our diet. But now we’re considering ourselves lucky even to get at least 200mg of magnesium in our diet. The alarming thing is, not any of this information is brought out to the public.   “For all the processing the body goes through to burn fat for energy, we need other co-factors for those metabolic processes. And magnesium is necessary for 700 to 800 different enzymatic processes in the body,” Dr. Carolyn Dean said.   Dr. Carolyn Dean also says that patients are usually clueless on how to maximize taking supplements. It was also a learning process for Dr. Carolyn Dean. Years ago, she initially was anti-supplements after trying to work with her heart palpitations, leg cramps, and neck pain.   “In my efforts to get healthy, I realized I was the poster child for magnesium deficiency. But I found out I couldn’t take one pill of magnesium without getting the laxative effect,” said Dr. Carolyn Dean. “Years after I wrote my book, I even was trying to interest minerals manufacturers in researching, and making non-laxative magnesium.”   ReMag Supplements She adds, “Finally, I made my own. When people started to take my ReMag supplements, they didn’t need anything else. They started feeling better,” said Dr. Carolyn Dean.   In further studies, Dr. Carolyn Dean also found out that the body absorbs only 4% of magnesium oxide. The rest becomes a laxative. She also explained in her first book that 500mg of magnesium oxide has 300g of elemental magnesium. Taking Dr. Carolyn Dean’s line of supplements in effect regulates so many factors that our body needs to function well, especially our heart.   “The heart is one big muscle. Magnesium controls muscles and nerves. If you don’t have enough magnesium, your muscle goes into spasm because it has too much calcium,” said Dr. Carolyn Dean.   She adds, “Magnesium doesn’t act like blood thinner. But it prevents the excess calcium from building up, and calcium triggers blood clots. The enzyme that balances cholesterol is controlled by magnesium.”   Suggested Diet   First of all, Dr. Carolyn Dean recommends taking Epson salt and magnesium citrate in powder form, mix with water and sip through the day. Mostly, it is essential to stay hydrated.   Dr. Carolyn Dean recommends drinking half your body weight (in pounds) in ounces of water. Then add ¼ tsp of Sea salt or Himalayan salt to every quart of drinking water.   For solid foods, Dr. Carolyn Dean’s favorite is making a huge salad mixed with salmon for protein and macadamia nuts pate. Macadamia nuts are high in fat, but they’re fantastic!   To make the pate, mix 8 ounces of lemon juice concentrate, 4 ounces of water, one teaspoon of unrefined sea salt, a handful of garlic and blend with 2 to 3 cups of nuts.    Dr. Carolyn Dean’s favorite treats, on the other hand, is eating frozen organic strawberry with a quarter cup of heavy whipping cream. She sometimes mixes it with kefir and eats it with ice cream.  Her simple banana treat sounds just as delicious! She suggests taking a frozen banana, roll it with a tablespoon of cacao powder, a tablespoon of coconut oil and sugar substitute.   She also affirms that there are a lot of fun things you can do with a ketogenic diet. Out of all the diets, the ketogenic diet is an excellent detox from sugar, it gives the pancreas a nice rest, and it is an anti-inflammatory diet.   Diet Tips For more diet tips, Dr. Carolyn Dean personally recommends linking to the website of Dr. Jason Fung, also known as The Diet Doctor. Dr. Jason Fung is a Canadian nephrologist and the leading expert on how to fast the right way.   People have to take responsibility for their health on so many levels. A Naturopath or a Holistic doctor each has their way of running things. They have their line of supplements, so do your research.    “When you take charge of your body and provide it with the best absorbable basic nutrient building blocks, you can overcome most health problems,” said Dr. Carolyn Dean.    Additional Resources  Aside from Dr. Carolyn Dean’s impressive list of published books, you can also tune in to her 2-hour call-in radio show at www.achieveradio.com, Mondays at 4 pm PST. She also has an amazing blog filled with informative articles that will help you find your way to better health so check it out!   Dr. Carolyn Dean also has a free online newsletter, a valuable online 2-year wellness program called Completement Now! You can also learn about Total Body ReSet program using her unique Completement Formulas: RnA Drops, ReMag, ReMyte, ReCalcia, ReAline, ReStructure, and ReNew at www.RnAReSet.com.  Dr. Carolyn Dean is a Medical Doctor and Naturopathic Doctor. She is the author of 110 Kindle books and 35 health books. She is on the Medical Advisory Board of the non-profit educational site – Nutritional Magnesium Association. Her magnesium outreach has won her an award from the Heart Rhythm Society in the UK for “Outstanding Medical Contribution to Cardiac Rhythm Management-2012.”   Get Connected With Dr. Carolyn Dean!  Official Website Dr. Carolyn Dean Live Completement Formulas Facebook – Dr. Carolyn Dean Facebook – The Magnesium Miracle Facebook – RnA ReSet Completement Now Wellness Program   Twitter  Book by Dr. Carolyn Dean The Magnesium Miracle   Recommended Links:  Dr. Rima Laibow – 2005 NANP speech National Health Alliance Dr. Jason Fung – The Diet Doctor     The Links You Are Looking For: Support Us on Patreon & Join the Learn True Health Book Club!!! 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Atrial Fibrillation affects your heart, but it can also affect your mind. The risk of stroke is five times higher in those with AFib. Learn more and take an online AFib risk assessment at MyAFib.org (1)

Munster Lowers Apple Target Thanks to Anticipated Lower-Margins for (Unconfirmed) Low-Cost iPhone  AT&T Starts iPhone Sales Through New Pre-Paid Subsidiary “Aio” Samsung-Infringed Apple Patent Gets Tentative Rejection from USPTO Apple Wins Case Over Use of Term “iBooks” Apple Insider: Unnamed Source Says Big Changes Coming to AppleCare and AppleCare+ Apple Insider: Apple Rolls Out Two-Step Verification to at Least 13 More Countries Amazon Launches Photo Stream Competitor Cloud Drive Photos for Mac and iOS WSJ: Microsoft Working on Set-Top Streamer (It May Never Release) 14-Year Old Presents on Hazards Related to iPad 2 and Implanted Defibrillators at Heart Rhythm Society

I will be talking with Dr. Carolyn Dean, author of The Magnesium Miracle. Dr. Dean will be sharing why magnesium is called the “miracle nutrient” and why she argues that it is the most important supplement we can take. You will learn how you can test if you are Magnesium deficient, and what forms of Magneisum you can take beyond your food intake. Dr. Carolyn Dean is a medical doctor and naturopathic doctor on the cutting edge the natural medicine revolution since 1979. She has two patents pending on novel health products including the iCell, the basic ingredient of RnA Drops. Dr. Dean  is the author/coauthor of over 30 health books (print and eBooks) including The Magnesium Miracle, Death by Modern Medicine, IBS for Dummies, IBS Cookbook for Dummies, The Yeast Connection and Women's Health, Future Health Now Encyclopedia, Everything Alzheimers, and Hormone Balance. Dr. Dean is on the Medical Advisory Board of the non-profit educational site - Nutritional Magnesium Association. Her magnesium outreach has recently won her an award from the Heart Rhythm Society in the UK for “Outstanding Medical Contribution to Cardiac Rhythm Management-2012.” For more information please visit: www.rnadrops22.com

Host: Jack Lewin, MD Guest: Robert Hauser, MD Because new cardiac technologies are often rapidly integrated into clinical practice, we must be mindful that these innovations can contain a level of risk. Regrettably, we've seen examples of this before with previous generations of implantable cardioverter-defibrillators (ICD), and some experts say the latest advances in ICD technology could pose similar problems. Host Dr. Jack Lewin explores this issue with Dr. Robert Hauser, senior consulting cardiologist at the Minneapolis Heart Institute and a founder and past president of the Heart Rhythm Society.

Host: Jack Lewin, MD Guest: Robert Hauser, MD Because new cardiac technologies are often rapidly integrated into clinical practice, we must be mindful that these innovations can contain a level of risk. Regrettably, we've seen examples of this before with previous generations of implantable cardioverter-defibrillators (ICD), and some experts say the latest advances in ICD technology could pose similar problems. Host Dr. Jack Lewin explores this issue with Dr. Robert Hauser, senior consulting cardiologist at the Minneapolis Heart Institute and a founder and past president of the Heart Rhythm Society.