Episodes Archives - Cardionerds

By CardioNerdsMedicine Health & Fitness Mental Health Education

Episodes Archives - Cardionerds episodes

June 24, 2024377. CardioOncology: Multi-modality Imaging in Cardio-Oncology with Dr. Nausheen Akhter
CardioNerds Co-Founder Dr. Daniel Ambinder, Series Co-Chair Dr. Giselle Suero Abreu (FIT at MGH), and Episode Lead Dr. Iva Minga (FIT at the University of Chicago) discuss the use of multi-modality cardiovascular imaging in cardio-oncology with expert faculty Dr. Nausheen Akhter (Northwestern University). Show notes were drafted by Dr. Sukriti Banthiya and episode audio was edited by CardioNerds Intern and student Dr. Diane Masket.
They use illustrative cases to discuss:
Recommendations on the use of multimodality imaging, including advanced echocardiographic techniques and cardiac MRI, in patients receiving cardiotoxic therapies and long-term surveillance.
Role of nuclear imaging (MUGA scan) in monitoring left ventricular ejection fraction.
Use of computed tomography to identify and/or monitor coronary disease.
Imaging diagnosis of cardiac amyloidosis.
This episode is supported by a grant from Pfizer Inc.
This CardioNerds Cardio-Oncology series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Giselle Suero Abreu, Dr. Dinu Balanescu, and Dr. Teodora Donisan.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
US Cardiology Review is now the official journal of CardioNerds! Submit your manuscript here.
CardioNerds Cardio-Oncology Page
CardioNerds Episode Page
CardioNerds Academy
Cardionerds Healy Honor Roll
CardioNerds Journal Club
Subscribe to The Heartbeat Newsletter!
Check out CardioNerds SWAG!
Become a CardioNerds Patron!
References – Multi-modality Imaging in Cardio-Oncology
Baldassarre L, Ganatra S, Lopez-Mattei J, et al. Advances in Multimodality Imaging in Cardio-Oncology. J Am Coll Cardiol. 2022 Oct, 80 (16) 1560–1578.
Meet Our Collaborators
International Cardio-Oncology Society ( IC-OS). IC-OS exits to advance cardiovascular care of cancer patients and survivors by promoting collaboration among researchers, educators and clinicians around the world. Learn more at https://ic-os.org/.
16 min
June 21, 2024376. Case Report: Tamponade or Cardiovascular Support? A case of Pericardial Decompression Syndrome – University of Michigan
CardioNerds cofounders, Dan Ambinder joins Drs. Aishwarya Pastapur, Oyinkansola Osobamiro, and Rafik Issa from the University of Michigan for drinks in Ann Arbor. They discuss the following case of pericardial decompression syndrome. Expert commentary is provided by Dr. Brett Wanamaker. Notes were drafted by Dr. Aishwarya Pastapur and Dr. Rafik Issa. The episode audio was engineered by CardioNerds Intern student Dr. Atefeh Ghorbanzadeh.
A woman in her 50s with a past medical history of stage IV lung cancer (with metastatic involvement of the liver, bone, and brain), previous saddle pulmonary emboli, pericardial effusion, and malignant pleural effusions presents with dyspnea. She was found to have a pericardial effusion with tamponade physiology relieved by pericardiocentesis. We discuss the management of cardiac tamponade, indications for pericardiocentesis, how to monitor for post-pericardiocentesis complications, and what to keep on your differential diagnosis for decompensation after pericardiocentesis. We discuss the epidemiology, pathophysiology, diagnosis, and management of pericardial decompression syndrome.
“To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.” – Sir William Osler. CardioNerds thank the patients and their loved ones whose stories teach us the Art of Medicine and support our Mission to Democratize Cardiovascular Medicine.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
US Cardiology Review is now the official journal of CardioNerds! Submit your manuscript here.
CardioNerds Case Reports Page
CardioNerds Episode Page
CardioNerds Academy
Cardionerds Healy Honor Roll
CardioNerds Journal Club
Subscribe to The Heartbeat Newsletter!
Check out CardioNerds SWAG!
Become a CardioNerds Patron!
Case Media – Pericardial Decompression Syndrome
Pearls – Pericardial Decompression Syndrome
Diminished heart sounds, a low-voltage EKG with electrical alternans, elevated jugular venous pressure/pulsations (JVP), and the presence of pulses paradoxes are important findings that could suggest tamponade.
McConnell sign is strongly concerning for right ventricular failure and pulmonary hypertension, potentially due to acute pulmonary embolism.
Mechanical thrombectomy for pulmonary embolism is not feasible if the emboli are diffusely scattered without a central lesion to target.
For patients who experience decompensation following pericardiocentesis, consider perforation, tamponade re-accumulation, or pericardial decompression syndrome (PDS).
When possible, avoid draining more than 1L of pericardial fluid at once to minimize the risk of PDS.
Notes – Pericardial Decompression Syndrome
What is Pericardial Decompression Syndrome (PDS), and how does it present?
Pericardial decompression syndrome is a rare, life-threatening syndrome occurring in about 5-10% of cases with paradoxical worsening of hemodynamics after pericardial drainage.
The clinical presentation ranges from pulmonary edema to cardiogenic shock to death, occurring a few hours to days after a successful pericardiocentesis.
What is the underlying mechanism for PDS?
The pathophysiology behind PDS is debated, but there are three proposed mechanisms:
Paradoxical Hemodynamic Derangement: After pericardiocentesis, venous return to the RV rapidly increases, resulting in RV expansion and potentially septal deviation towards the LV. Subsequently, the LV experiences decreased preload while still facing increased afterload as a compensatory response to obstructive shock, leading to decompensation.
Myocardial Ischemia: Increased intrapericardial pressure may impair coronary perfusion, leading to myocardial ischemia. Upon pericardiocentesis, there is myocardial stunning with increased demand due to increased venous return and cardiac output
Sympathetic Withdrawal: Withdrawal of sympathetic activation after drainage of pericardial fluid can trigger cardiovascular collapse
What are the risk factors for developing PDS, and how can we mitigate those risks for prevention?
Generally, patients with long-standing pericardial effusion with chronic compression of the heart, such as those with malignant pericardial effusions, are more vulnerable to developing PDS after pericardiocentesis.
Additionally, rapid fluid removal increases the risk. In terms of prevention, removing fluid to normalize CVP and MAP and letting the rest of the fluid drain slowly may mitigate the risk.
How do we manage a patient with PDS?
The management of PDS is supportive, focusing on addressing hemodynamic and respiratory derangements.
The underlying pathophysiology should resolve in 24-48 hours.
What is the prevalence and prognosis of PDS?
PDS affects 5-10% of pericardiocentesis procedures, although the exact frequency is difficult to ascertain.
It is a self-resolving process as the heart re-adapts to the new hemodynamics.
However, during the episode of PDS, mortality can be as high as 30% per some studies.
References – Pericardial Decompression Syndrome
Schnur M. Understanding Pulsus Paradoxus. Accessed February 27, 2024. https://nursingcenter.com/ncblog/august-2021/understanding-pulsus-paradoxus
Carlini’ ’Caterina Chiara De, Maggiolini’ ’Stefano. Pericardiocentesis in cardiac tamponade: indications and practical aspects. Accessed February 27, 2024. https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-15/Pericardiocentesis-in-cardiac-tamponade-indications-and-practical-aspects
Angouras DC, Dosios T. Pericardial Decompression Syndrome: A Term for a Well-Defined but Rather Underreported Complication of Pericardial Drainage. The Annals of Thoracic Surgery. 2010;89(5):1702-1703. doi:10.1016/j.athoracsur.2009.11.073
Imazio M. Pericardial decompression syndrome: A rare but potentially fatal complication of pericardial drainage to be recognized and prevented. European Heart Journal Acute Cardiovascular Care. 2015;4(2):121-123. doi:10.1177/2048872614557771
Prabhakar Y, Goyal A, Khalid N, et al. Pericardial decompression syndrome: A comprehensive review. World Journal of Cardiology. 2019;11(12):282-291. doi:10.4330/wjc.v11.i12.282
Sobieski C, Herner M, Goyal N, et al. Pericardial Decompression Syndrome After Drainage of Chronic Pericardial Effusions. JACC: Case Reports. 2022;4(22):1515-1521. doi:10.1016/j.jaccas.2022.08.023
Chhabra L. Pericardial Decompression Syndrome. American College of Cardiology. Accessed February 27, 2024. https://www.acc.org/Latest-in-Cardiology/Articles/2020/04/13/09/05/http%3a%2f%2fwww.acc.org%2fLatest-in-Cardiology%2fArticles%2f2020%2f04%2f13%2f09%2f05%2fPericardial-Decompression-Syndrome
Pradhan R, Okabe T, Yoshida K, Angouras DC, DeCaro MV, Marhefka GD. Patient characteristics and predictors of mortality associated with pericardial decompression syndrome: a comprehensive analysis of published cases. European Heart Journal Acute Cardiovascular Care. 2015;4(2):113-120. doi:10.1177/2048872614547975
Amro A, Mansoor K, Amro M, et al. A Comprehensive Systemic Literature Review of Pericardial Decompression Syndrome: Often Unrecognized and Potentially Fatal Syndrome. Current Cardiology Reviews. 17(1):101-110.
18 min
June 06, 2024375. Beyond the Boards: Foundations of Cardiovascular Prevention with Dr. Stephen Kopecky
CardioNerds (Amit Goyal and Dan Ambinder), Dr. Jaya Kanduri, and Dr. Jason Feinman discuss foundations of cardiovascular prevention with Dr. Stephen Kopecky. In this episode, the CardioNerds and topic expert Dr. Stephen Kopecky tackle cardiovascular prevention. They focus on how to identify patients at risk for cardiovascular disease by using the pooled cohort equation and discuss how to incorporate additional risk-enhancing factors in risk estimation. Later, they discuss the role of non-invasive imaging and testing for further patient risk stratification. Last, they discuss the appropriate pharmacologic interventions for patient care, how to determine what LDL-c to target for each patient, and how to modify your treatment modalities in response to side effects or the need for further lipid-lowering therapies.
Notes were drafted by Dr. Jason Feinman. Audio was engineered by CardioNerds Intern Christiana Dangas.
The CardioNerds Beyond the Boards Series was inspired by the Mayo Clinic Cardiovascular Board Review Course and designed in collaboration with the course directors Dr. Amy Pollak, Dr. Jeffrey Geske, and Dr. Michael Cullen.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
US Cardiology Review is now the official journal of CardioNerds! Submit your manuscript here.
CardioNerds Beyond the Boards Series
CardioNerds Episode Page
CardioNerds Academy
Cardionerds Healy Honor Roll
CardioNerds Journal Club
Subscribe to The Heartbeat Newsletter!
Check out CardioNerds SWAG!
Become a CardioNerds Patron!
Pearls and Quotes – Foundations of Cardiovascular Prevention
The 2018 cardiovascular prevention guidelines indicate that a single equation, like the pooled risk equation, does not fit everyone. There are additional risk enhancers that are not factored into the pooled risk equation that can impact an individual’s risk
These factors are often conditions that increase inflammation but can also include family history, ethnicity, chronic kidney disease, metabolic syndrome, premature menopause or gestational diabetes, and rheumatologic conditions
Data from Get With The Guidelines demonstrates that the average LDL at the time of the first myocardial infarction is 105 mg/dL.
Coronary artery calcium scores or a carotid ultrasound can be used to further risk stratify patients. However, CAC is likely to be negative in young women. A CAC of zero can be used to “de-risk” some patients but should not be used to guide therapy in the setting of tobacco usage, diabetes mellitus, or familial hypercholesterolemia.
Strategies to mitigate risk include healthy lifestyle habits and selectively targeting key risk factors including LDL, hypertriglyceridemia, inflammation, and the GLP1-pathway. Upcoming medications may address elevated Lp(a).
Notes – Foundations of Cardiovascular Prevention
Notes: Notes drafted by Dr. Jason Feinman.
How do you assess an individual’s risk for cardiovascular disease?
The paramount role of primary prevention is the assessment and mitigation of an individual’s risk for ASCVD event.1
The 10-year ASCVD risk calculator is a commonly used tool to assess an individual’s risk and to guide shared decision-making conversations and recommendations.2
Individuals can be characterized as having low (less than 5%), borderline (5%-7.5%), intermediate (7.5%-20%), or high (greater than 20%) risk.2
The 10-year ASCVD risk calculator has varying validation in ethnic minorities, and other risk calculators, such as the Framingham CVD risk score, may be considered in those groups.3-5
Additional risk enhancers may be used to guide recommendations for individuals at borderline or intermediate risk.1
What additional imaging testing may be beneficial in the assessment of an individual’s risk?
Individuals with intermediate or borderline risk may benefit from further non-invasive imaging to help guide therapeutic recommendations.2
Coronary artery calcification is a marker of underlying atherosclerosis, which can help to reclassify patients to be at higher risk for ASCVD events and support interventions to help lower this risk.6
Conversely, a score of zero can help to reclassify individuals into lower-risk groups
A score of zero should be used with caution in young women who are more likely to have non-calcified plaque and should not be used as a marker of low risk in individuals with other risk factors, including diabetes mellitus and tobacco usage.1
What non-pharmacological interventions may be considered to lower an individual’s ASCVD risk?
The 2019 guidelines give a class I recommendation for a diet of vegetables, fruits, nuts, whole grains, and fish to lower ASCVD risk factors.1
Increased intake of sugar has been demonstrated to correlate with increased rates of type 2 diabetes mellitus and subsequent increased risk for cardiovascular events.7
At least 150 minutes per week of moderate-intensity or 75 minutes of vigorous intensive is recommended to reduce the risk of ASCVD events.1
What pharmacological interventions can be considered for individuals with prior ASCVD events or at high risk for ASCVD?
A moderate-intensity statin is recommended for individuals at intermediate risk of ASCVD events with risk enhancers with a goal reduction in LDL-c of 30% or more.1
For individuals at a high 10-year risk for ASCVD events, a 50% reduction in LDL-C is recommended.1
A doubling of a statin dose can be predicted to lead to a 6% further reduction in LDL-C
Ezetimibe can be considered as adjunct therapy for individuals receiving statin therapy who do not reach their target LDL-C.2
How do you determine the goal LDL-c?
LDL goal is based on a history of prior ASCVD events and the risk of future ASCVD events.
For secondary prevention, especially for individuals at high risk for ASCVD events, an LDL goal of at least less than 70 mg/dL is recommended2
References – Foundations of Cardiovascular Prevention
Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Circulation. 2019 Sep 10;140(11):e649-e650] [published correction appears in Circulation. 2020 Jan 28;141(4):e60] [published correction appears in Circulation. 2020 Apr 21;141(16):e774]. Circulation. 2019;140(11):e596-e646. doi:10.1161/CIR.0000000000000678
Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Circulation. 2019 Jun 18;139(25):e1182-e1186] [published correction appears in Circulation. 2023 Aug 15;148(7):e5]. Circulation. 2019;139(25):e1082-e1143. doi:10.1161/CIR.0000000000000625
Yang X, Li J, Hu D, et al. Predicting the 10-Year Risks of Atherosclerotic Cardiovascular Disease in Chinese Population: The China-PAR Project (Prediction for ASCVD Risk in China). Circulation. 2016;134(19):1430-1440. doi:10.1161/CIRCULATIONAHA.116.022367
Jung KJ, Jang Y, Oh DJ, et al. The ACC/AHA 2013 pooled cohort equations compared to a Korean Risk Prediction Model for atherosclerotic cardiovascular disease. Atherosclerosis. 2015;242(1):367-375. doi:10.1016/j.atherosclerosis.2015.07.033
D’Agostino RB Sr, Vasan RS, Pencina MJ, et al. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation. 2008;117(6):743-753. doi:10.1161/CIRCULATIONAHA.107.699579
DeFilippis AP, Young R, Carrubba CJ, et al. An analysis of calibration and discrimination among multiple cardiovascular risk scores in a modern multiethnic cohort. Ann Intern Med. 2015;162(4):266-275. doi:10.7326/M14-1281
Löfvenborg JE, Andersson T, Carlsson PO, et al. Sweetened beverage intake and risk of latent autoimmune diabetes in adults (LADA) and type 2 diabetes. Eur J Endocrinol. 2016;175(6):605-614. doi:10.1530/EJE-16-0376
16 min
May 31, 2024374. Case Report: Unraveling the Mystery – When Childhood Chest Pain Holds the Key to a Genetic Heart Condition – Wayne State University
This case report explores the intricacies of familial hypercholesterolemia (FH), delving into its genetic basis, atherosclerotic cascade, and early-onset cardiovascular complications. It examines established diagnostic criteria and emphasizes personalized management, including statins, novel therapies, and lifestyle modifications.
CardioNerds cofounders (Drs. Amit Goyal and Danial Ambinder) join Dr. Irfan Shafi, Dr. Preeya Prakash, and Dr. Rebecca Theisen from the Wayne State University/DMC and Central Michigan University at Campus Martius in Downtown Detroit for some holiday ice-skating! They discuss an interesting pediatric case (see case synopsis below). Dr. Luis C Afonso provides the Expert CardioNerd Perspectives & Review segment for this episode. Audio editing by CardioNerds academy intern, Pace Wetstein.
“To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.” – Sir William Osler. CardioNerds thank the patients and their loved ones whose stories teach us the Art of Medicine and support our Mission to Democratize Cardiovascular Medicine.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
US Cardiology Review is now the official journal of CardioNerds! Submit your manuscript here.
CardioNerds Case Reports Page
CardioNerds Episode Page
CardioNerds Academy
Cardionerds Healy Honor Roll
CardioNerds Journal Club
Subscribe to The Heartbeat Newsletter!
Check out CardioNerds SWAG!
Become a CardioNerds Patron!
Case Synopsis
FH, a 9-year-old female with no previous medical history, recently moved back to the US from Iraq. She presented to establish care and discuss new-onset chest pain and dyspnea. A systolic ejection murmur was noted during her initial visit to the pediatrician, prompting cholesterol testing and a cardiology referral. Testing revealed, alarming cholesterol levels (Total Cholesterol: 802 mg/dL, LDL: 731 mg/dL, Triglycerides: 123 mg/dL) prompted concern for cardiac involvement.
Due to persistent symptoms, FH was transferred to Children’s Hospital of Michigan. Despite normal findings on EKG and chest x-ray, a 2/6 systolic murmur was noted. She was discharged with a cardiology clinic follow-up.
However, two days later, FH experienced severe chest pain at rest, sweating, and difficulty breathing. She was transported to Children’s Hospital again, and her troponin level measured 3000, and her total cholesterol was 695 mg/dL. An echocardiogram revealed valvar and supravalvar aortic stenosis, necessitating collaboration between Pediatric and Adult cardiology teams.
CTA thorax revealed severe supravalvular stenosis, a hypoplastic right coronary artery, and significant coronary artery obstructions. Diagnostic cardiac catheterization confirmed severe aortic stenosis and coronary artery disease, leading to the decision for surgical intervention.
FH underwent the Ross operation, left main coronary artery augmentation, and right coronary artery reimplantation. Intraoperatively, atherosclerotic plaques were observed in multiple cardiac structures.
FH’s recovery was uneventful, discharged on a regimen including Atorvastatin, Ezetimibe, evolocumab, and antiplatelet therapy. Persistent high LDL levels required regular plasmapheresis. Plans for evaluations in Genetics, Lipid Clinic, Endocrine, and Gastroenterology were made, potentially leading to a liver transplant assessment. Given the severity of her condition, a heart/liver transplant might be considered in the future.
Conclusion:
This case of FH highlights the complex presentation of severe aortic stenosis and coronary artery disease in a pediatric patient. Urgent diagnosis, interdisciplinary collaboration, and aggressive management were crucial. The case underscores the importance of comprehensive care for pediatric patients with rare cardiac conditions, emphasizing collaboration between specialties for optimal outcomes and long-term well-being.
Case Media
Pearls – Familial Hypercholesterolemia
Mutations in LDLR, ApoB, or PCSK9 genes disrupt LDL-C clearance, leading to a cascade of events culminating in accelerated atherosclerosis and early-onset cardiovascular complications (e.g., CAD, aortic stenosis, PAD, stroke).
Diagnosis of familial hypercholesterolemia relies on a combination of clinical features (xanthomas, corneal arcus, high LDL-C), family history, and genetic testing guided by established criteria like DCLN or NLA recommendations.
Supravalvular aortic stenosis, while common in many congenital cases, should raise suspicion of homozygous familial hypercholesterolemia in the setting of extensively elevated LDL and unexpected coronary artery disease.
A multidisciplinary approach, including involvement of pediatric and adult cardiology teams, lipid specialists and cardiothoracic surgeons, should be involved in the overall evaluation and management of these patients, both at initiation of diagnosis, and in an outpatient setting.
In patients with FH, it is important to delineate between homozygous and heterozygous manifestations, as this can have extensive implications on treatment, management and the overall clinical prognosis and further disease sequelae that the patient may experience.
References – Familial Hypercholesterolemia
Shah, N. (2020). Familial hypercholesterolemia: Early diagnosis and treatment is key for cardiovascular prevention.Cleveland Clinic Journal of Medicine, 87(5), 109-120. https://pubmed.ncbi.nlm.nih.gov/23469913/
Turgeon, R. D., Barry, A. R., & Pearson, G. J. (2023). Familial hypercholesterolemia: Review of diagnosis,screening, and treatment. American Journal of Health-System Pharmacy, 80(11), 917-929.https://pubmed.ncbi.nlm.nih.gov/26796832/
Collins, R. T. (2018). Cardiovascular disease in Williams syndrome. Current Opinion in Pediatrics, 30(5), 609-615. https://www.ncbi.nlm.nih.gov/books/NBK544278/
Collins, R. T., Kaplan, P., Somes, G. W., & Rome, J. J. (2010). Long-term outcomes of patients with cardiovascular abnormalities and Williams syndrome. American Journal of Cardiology, 105(6), 874-878.https://pubmed.ncbi.nlm.nih.gov/30045083/
Honjo, R. S., Monteleone, V. F., Aiello, V. D., Wagenfuhr, J., Issa, V. S., Pomerantzeff, P. M. A., Furusawa, E. A.,Zanardo, E. A., Kulikowski, L. D., Bertola, D. R., & Kim, C. A. (2022). Cardiovascular findings in Williams-Beuren Syndrome: Experience of a single center with 127 cases. American Journal of Medical Genetics. Part A,188(3), 676-682. https://www.ncbi.nlm.nih.gov/books/NBK544278/
Pham, P. P., Moller, J. H., Hills, C., Larson, V., & Pyles, L. (2009). Cardiac catheterization and operative outcomes from a multicenter consortium for children with Williams syndrome. Pediatric Cardiology, 30(1), 9-14.https://pubmed.ncbi.nlm.nih.gov/19052807/
Olsen, M., Fahy, C. J., Costi, D. A., Kelly, A. J., & Burgoyne, L. L. (2014). Anaesthesia-related haemodynamic complications in Williams syndrome patients: A review of one institution’s experience. Anaesthesia and Intensive Care, 42(6), 619-624. https://pubmed.ncbi.nlm.nih.gov/25233176/
Harada-Shiba, M., Arai, H., Ishigaki, Y., Ishibashi, S., Okamura, T., Ogura, M., Dobashi, K., Nohara, A., Bujo, H.,Miyauchi, K., Yamashita, S., & Yokote, K. (2018). Guidelines for diagnosis and treatment of familial hypercholesterolemia 2017. Journal of Atherosclerosis and Thrombosis, 25(8), 751-770.https://pubmed.ncbi.nlm.nih.gov/29877295/
Alnouri, F., & Santos, R. D. (2022). New trends and therapies for familial hypercholesterolemia. Journal of Clinical Medicine, 11(22), 6638. https://pubmed.ncbi.nlm.nih.gov/36431115/
29 min
May 30, 2024373. Narratives in Cardiology: Becoming a “Big E” Medical Educator as a Cardiologist with Dr. James Arrighi
In this episode, Dr. Katie Fell (General Cardiology Fellow at University of Michigan and CardioNerds Academy Fellow) and Dr. Gurleen Kaur (incoming General Cardiology fellow at Brigham and Women’s Hospital and Director of CardioNerds Internship) discuss with Dr. James Arrighi (General Cardiologist and CEO of ACGME-International) about developing as a clinician educator and the concept of competency-based education.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
The PA-ACC & CardioNerds Narratives in Cardiology is a multimedia educational series jointly developed by the Pennsylvania Chapter ACC, the ACC Fellows in Training Section, and the CardioNerds Platform with the goal to promote diversity, equity, and inclusion in cardiology. In this series, we host inspiring faculty and fellows from various ACC chapters to discuss their areas of expertise and their individual narratives. Join us for these captivating conversations as we celebrate our differences and share our joy for practicing cardiovascular medicine. We thank our project mentors Dr. Katie Berlacher and Dr. Nosheen Reza.
The PA-ACC & CardioNerds Narratives in Cardiology Page
CardioNerds Episode Page
CardioNerds Academy
Cardionerds Healy Honor Roll
CardioNerds Journal Club
Subscribe to The Heartbeat Newsletter!
Check out CardioNerds SWAG!
Become a CardioNerds Patron!
Video version – Becoming a “Big E” Medical Educator as a Cardiologist with Dr. James Arrighi
Quoatables – Becoming a “Big E” Medical Educator as a Cardiologist with Dr. James Arrighi
“You really have to have a passion or a love for what you do…that’s probably responsible for most of the success one has in life” (time 4:43)
“Sub-subspecialty societies in Cardiology represent [a] great opportunity for junior faculty or even trainees to get involved, even before getting involved in ACC.” (time 5:30)
“Competency-based medical education and time variable training are not synonymous.” (time 16:43)
“As Cardiology evolves into more and more subspecialties…it begs the question… ‘Is Cardiology a primary specialty?’” (time 27:30)
“We need to think about [a] more efficient ways for training.” (time 31:55)
“As a clinician educator, there’s variety, there’s innovation!” (time 41:22)
Notes – Becoming a “Big E” Medical Educator as a Cardiologist with Dr. James Arrighi
How might one develop as a clinician educator on a national level?
Junior faculty and trainees should consider taking advantage of education opportunities in various Cardiology sub-specialty societies (ex: American Society of Nuclear Cardiology, ASNC). This may include involvement in different committees. These opportunities are great ways to build connections and establish a reputation on a national level. This can help lead to other opportunities with larger national organizations (ex: ACC, AHA).
Cardiology Training Oversight
The Accreditation Council for Graduate Medical Education (ACGME) and American Board of Internal Medicine (ABIM) both have regulatory power over Cardiology training, providing the minimum clinical experience standards for Cardiology fellowship training programs.
The ACGME oversees accreditation for Cardiology fellowships.
The ABIM defines the requirements for eligibility for certification of individuals.
Over time, the ACGME has transitioned to placing an emphasis on quality improvement, with a particular focus on continuous programmatic improvement.
The American College of Cardiology (ACC) helps define more granular recommendations for Cardiology training programs and their curriculum.
Periodically the ACC releases training guidelines for Cardiology fellowship programs, called Core Cardiovascular Training Statements, or COCATS. This document provides more contemporary, detailed, and specialty-specific recommendations for Cardiology training as compared to ACGME.
While ACC has no regulatory authority over Cardiology training programs, COCATS documents provide a roadmap for program directors on how to structure training.
The most recent version of the document, COCATS 4, incorporated in the concept of competency-based education (CBME).
What is Competency-Based Education (CBME)?
Medical education has evolved to focus more on outcome-based assessments of trainees structured around competency evaluations.
In 2002, the ACGME defined competencies by which training programs should evaluate their trainees. As a result, training shifted from a time-based structure to one in which trainees must demonstrate specific competencies within a specific time frame.
ACC further defined competencies for Cardiology training in the Core Cardiovascular Training Statement 4 (COCATS 4). This is the first COCATs document introducing aspects of CBME, including defining competencies, milestones, and tools to assess a Cardiology trainee’s performance.
Each of these documents focuses on optimizing fellow time while in training, targeting education to the learner’s goals and their future career trajectory.
Moving to a competency-based, time-variable training program in the U.S. would be challenging and would require significant restructuring of our current GME training system, including Medicare funding.
What is ACGME-International (ACGME-I)?
Group within the ACGME dedicated to improving health care internationally by assessing and advancing the quality of resident physicians’ education through accreditation.
The organization is currently present in 12 countries at 23 sponsoring institutions (as of April 2024).
ACGME-I provides postgraduate medical education programs with standardized frameworks on how to improve the quality of teaching, learning, research, and clinical practice for their trainees.
References
Weissman G, Auseon AJ, Arrighi JA, et al. Perceptions and Utilization of the U.S. Core Cardiovascular Training Statement. J Am Coll Cardiol. 2019;73(22):2896-2899.
Halperin JL, Williams ES, Fuster V. COCATS 4 Introduction. J Am Coll Cardiol. 2015;65(17):1724-1733.
Arrighi JA, Kilic S, Haines PG. Perspectives on Current Training Guidelines for Cardiac Imaging and Recommendations for the Future. Curr Cardiol Rep. 2018;20(6):43. Published 2018 Apr 23.
ACGME Program Requirements for Graduate Medical Education in Cardiovascular Disease. Accessed February 2, 2024.
Mendes LA, Weissman G, Berlacher K, et al. Competency-Based Alternative Training Pathway in Cardiovascular Disease and Clinical Cardiac Electrophysiology. J Am Coll Cardiol. 2022;79(25):2540-2542.
Production Team
Dr. Gurleen Kaur
Amit Goyal, MD
Daniel Ambinder, MD
22 min
May 23, 2024372. Case Report: Chronic Chagas Cardiomyopathy with Recurrent Ventricular Tachyarrhythmia – Georgetown University
CardioNerds (Dr. Jessie Holtzman, Chair for the CardioNerds Women’s Heart Disease Committee, and Dr. Naima Maqsood, Chair for the CardioNerds Electrophysiology Committee) join Dr. Ritika Gadodia, Dr. Namratha Meda, and Dr. Tsion Aberra from the Medstar Washington Hospital Center/Georgetown University Program for the National Cherry Blossom Festival. They discuss involving a patient with Chagas cardiomyopathy. Dr. Rachel Marcus provides the Expert CardioNerd Perspectives & Review segment for this episode. Episode audio was edited by Dr. Diane Masket.
A 79-year-old male with a history of cardiomyopathy presented with recurrent ventricular tachycardia (VT) post-CRT-D placement. On arrival, the patient was in cardiogenic shock. Initial treatment with amiodarone and milrinone failed, necessitating the addition of mexiletine. Imaging was suggestive of a left ventricular ejection fraction of 20-25% with severe global hypokinesis. Prior coronary angiogram had shown nonobstructive coronary artery disease. Further non-ischemic cardiomyopathy evaluation was unrevealing. Given his El Salvadorian origins, Chagas serology results revealed Chronic Chagas Cardiomyopathy (CCM) confirmed by CDC testing. This case underscores the importance of suspecting CCM in patients with risk factors. An early diagnosis of CCM, can prevent catastrophic events (heart blocks, ventricular arrhythmias, thromboembolic events).
In summary, this case takes the learner through the journey of a patient with non-ischemic cardiomyopathy and emphasizes the importance of approaching it with a wide range of differentials.
“To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.” – Sir William Osler. CardioNerds thank the patients and their loved ones whose stories teach us the Art of Medicine and support our Mission to Democratize Cardiovascular Medicine.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
US Cardiology Review is now the official journal of CardioNerds! Submit your manuscript here.
CardioNerds Case Reports Page
CardioNerds Episode Page
CardioNerds Academy
Cardionerds Healy Honor Roll
CardioNerds Journal Club
Subscribe to The Heartbeat Newsletter!
Check out CardioNerds SWAG!
Become a CardioNerds Patron!
Case Media
Pearls – Chronic Chagas Cardiomyopathy with Recurrent Ventricular Tachyarrhythmia
Always consider Chagas cardiomyopathy when you have a patient from Latin America who presents with non-ischemic cardiomyopathy.
Chagas cardiomyopathy is associated with an unfavorable prognosis and serves as an independent predictor of mortality.
Chagas cardiomyopathy is arrhythmogenic and requires consideration for ICD and, when appropriate, catheter based ventricular tachycardia ablation.
It is crucial to treat patients with nifurtimox and benznidazole when appropriate.
Provide screening for first-degree family members or close relatives who may have lived in the same environment.
Show Notes – Chronic Chagas Cardiomyopathy with Recurrent Ventricular Tachyarrhythmia
What is the disease progression in Chagas disease5?
Acute Stage:
Initial infection occurs through contact with infected triatomine bug feces or contaminated blood products.
Symptoms may be mild or absent but can include fever, fatigue, body aches, and swelling at the injection site (chagoma).
Parasitemia is high during this stage.
Intermediate/Indeterminate Stage:
The infection becomes chronic if left untreated.
Many individuals enter this stage with no noticeable symptoms.
Parasitemia levels decrease, but the parasite remains in the body, mainly in muscle and cardiac tissue.
This stage can last for years to decades.
Chronic Stage:
Some individuals will remain asymptomatic throughout their lives.
Cardiac complications (chronic Chagas cardiomyopathy) can lead to arrhythmias, congestive heart failure, and sudden death.
Digestive complications can result in enlarged esophagus (megaesophagus) and colon (megacolon), leading to difficulties in swallowing and digestion.
When do we suspect, and who do we screen, for Chagas disease?
The seroprevalence of CCM in the USA is as high as 19%16. Among patients with LVEF<50%, the rate of positive serology was 28%. Similarly, the seropositivity among patients who reported recognizing the reduviid bug was 31%.
Individuals who have lived in endemic countries of Mexico, Central and South America, excluding the Caribbean islands.
T. cruzi seroprevalence is highest in Bolivia, Argentina, Paraguay, Ecuador, El Salvador, and Guatemala6.
Close relatives and those born to women from endemic countries7.
Persons with a history of bite/exposure to the vector responsible for transmission.
EKG abnormalities suggestive of infection even in the absence of symptoms.
TTE changes: regional wall motion abnormalities (particularly basal inferolateral, apical aneurysm)4
What diagnostic tests can confirm the diagnosis of chronic Chagas cardiomyopathy?
Serologic testing: no available assay has sufficient sensitivity and specificity to be used alone. Two serologic tests based on different antigens and/or techniques (e.g., ELISA and IFA) are used in parallel to increase the accuracy of the diagnosis8.
EKG: RBBB, LAFB, AV block, atrial fibrillation, ventricular tachycardias
TTE: dilated cardiomyopathy, reduced ejection fracture, regional wall motion abnormalities, left ventricular apical aneurysm
Cardiac MRI: myocardial fibrosis is a striking feature of CCM and LGE is used to detect and qualify the extent. Myocardial fibrosis also plays a role in risk stratification of CCM9.
What are the indications for treatment of Chagas disease?
Acute phase.
Early chronic phase, including women of childbearing age.
Reactivated infection (e.g., after immunosuppression).
Adults <50 years of age who do not have advanced cardiomyopathy (stage B1)10.
In all other cases, the potential benefit of medication in delaying the development of Chagas disease should be weighed against potential adverse reactions- benznidazole and nifurtimox should not be taken by pregnant women or people with kidney or liver failure.
What are the benefits of screening and early diagnosis?
Effective treatment, particularly in the acute phase.
The BENEFIT trial showed that Trypanocidal therapy with benznidazole in patients with CCM did not significantly reduce cardiac deterioration11.
Screening of family members/friends who grew up in the same environment.
Reduction of transmission due to blood transfusions and congenital transmission.
Early initiation of GDMT (guideline-directed medical therapy) for clinical heart failure 2/2 CCM.
Ongoing surveillance for cardiomyopathy can prevent catastrophic events (heart blocks, ventricular arrhythmias, thromboembolic events).
Cost effectiveness: Early diagnosis and treatment may reduce healthcare costs compared to the treatment of complications that arise from the chronic phase of the disease. Early diagnosis may also reduce the number of endomyocardial biopsies.
How is the management of VT unique in chronic Chagas cardiomyopathy?
In comparison to cardiomyopathies of other etiologies, CCM is associated with a higher risk of life-threatening ventricular arrhythmias and an unfavorable prognosis12,14.
Per ESC guidelines, the greatest benefit of ICD in CCM is in patients with an LVEF ≤40%15.
Per Gali et al, most patients with an ICD received appropriate ICD shocks/therapies regardless of their LV systolic function13.
Ablation of VT requires extensive mapping because multiple discrete circuits are typically present. The most common site of origin is the LV basal inferolateral wall. However, 1/3rd of the foci is located on the epicardial surface. This necessitates epicardial mapping to achieve successful ablation6.
References – Chronic Chagas Cardiomyopathy with Recurrent Ventricular Tachyarrhythmia
Ghzally Y, Mahajan K. Implantable Defibrillator. In: StatPearls. StatPearls Publishing; 2023. Accessed October 7, 2023. http://www.ncbi.nlm.nih.gov/books/NBK459196/
Vrettos A, Panoulas V. Diagnosing STEMI in the presence of paced rhythm: dispelling the myth of the ‘uninterpretable paced ECG.’ BMJ Case Rep. 2021;14(7):e242546. doi:10.1136/bcr-2021-242546
3. Bozkurt B, Colvin M, Cook J, et al. Current Diagnostic and Treatment Strategies for Specific Dilated Cardiomyopathies: A Scientific Statement From the American Heart Association. Circulation. 2016;134(23). doi:10.1161/CIR.0000000000000455
Forsyth CJ, Manne-Goehler J, Bern C, et al. Recommendations for Screening and Diagnosis of Chagas Disease in the United States. The Journal of Infectious Diseases. 2022;225(9):1601-1610. doi:10.1093/infdis/jiab513
CDC – Chagas Disease – Disease. Accessed October 7, 2023. https://www.cdc.gov/parasites/chagas/disease.html
Chagas Cardiomyopathy: An Update of Current Clinical Knowledge and Management: A Scientific Statement From the American Heart Association | Circulation. Accessed October 7, 2023. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000599
Montgomery SP, Parise ME, Dotson EM, Bialek SR. What Do We Know About Chagas Disease in the United States? The American Journal of Tropical Medicine and Hygiene. 2016;95(6):1225-1227. doi:10.4269/ajtmh.16-0213
Malone CJ. A Rapid Review on the Efficacy and Safety. Pan American Health Organization (PAHO) and the World Health Organization (WHO); 2021.
Nunes MCP, Badano LP, Marin-Neto JA, et al. Multimodality imaging evaluation of Chagas disease: an expert consensus of Brazilian Cardiovascular Imaging Department (DIC) and the European Association of Cardiovascular Imaging (EACVI). European Heart Journal – Cardiovascular Imaging. 2018;19(4):459-460n. doi:10.1093/ehjci/jex154
10. Prevention CC for DC and. CDC – Chagas Disease – Resources for Health Professionals – Antiparasitic Treatment. Published April 11, 2022. Accessed October 7, 2023. https://www.cdc.gov/parasites/chagas/health_professionals/tx.html
11. Morillo CA, Marin-Neto JA, Avezum A, et al. Randomized Trial of Benznidazole for Chronic Chagas’ Cardiomyopathy. N Engl J Med. 2015;373(14):1295-1306. doi:10.1056/NEJMoa1507574
12. Probability of Occurrence of Life‐Threatening Ventricular Arrhythmias in Chagas’ Disease versus Non‐Chagas’ Disease – FILHO – 2000 – Pacing and Clinical Electrophysiology – Wiley Online Library. Accessed October 7, 2023. https://onlinelibrary.wiley.com/doi/10.1111/j.1540-8159.2000.tb07058.x
13. Implantable cardioverter-defibrillators for treatment of sustained ventricular arrhythmias in patients with Chagas’ heart disease: comparison with a control group treated with amiodarone alone | EP Europace | Oxford Academic. Accessed October 7, 2023. https://academic.oup.com/europace/article/16/5/674/484618?login=fals
14. Barbosa MPT, Da Costa Rocha MO, De Oliveira AB, Lombardi F, Ribeiro ALP. Efficacy and safety of implantable cardioverter-defibrillators in patients with Chagas disease. EP Europace. 2013;15(7):957-962. doi:10.1093/europace/eut011
15. Requena-Méndez A, Aldasoro E, De Lazzari E, et al. Prevalence of Chagas Disease in Latin-American Migrants Living in Europe: A Systematic Review and Meta-analysis. Rodrigues MM, ed. PLoS Negl Trop Dis. 2015;9(2):e0003540. doi:10.1371/journal.pntd.0003540
16. Gadodia R, Kerai A, Aberra T, et al. SEROPREVALENCE OF CHAGAS CARDIOMYOPATHY IN LATIN AMERICAN IMMIGRANTS IN THE WASHINGTON DC METRO AREA. Journal of the American College of Cardiology. 2023;81(8):318. doi:10.1016/S0735-1097(23)00762-3
38 min
May 14, 2024371. Case Report: The Curious Case of Obstructive Cardiogenic Shock – Maine Medical Center
CardioNerds Dr. Josh Saef and Dr. Tommy Das join Dr. Omkar Betageri, Dr. Andrew Geissler, Dr. Philip Lacombe, and Dr. Cashel O’Brien from the Maine Medical Center in Portland, Maine to enjoy an afternoon by the famous Portland headlight. They discuss a case of a patient who presents with obstructive cardiogenic shock. Dr. Bram Geller and Dr. Jon Donnelly provide the Expert CardioNerd Perspectives & Review segment for this episode. Dr. Maxwell Afari, the Maine Medical Center cardiology fellowship program director highlights the fellowship program. Audio editing by CardioNerds Academy Intern, student doctor Tina Reddy.
This is the case of a 42 year-old woman born with complicated Tetralogy of Fallot repair culminating in a 29mm Edwards Sapiens (ES) S3 valve placement within a pulmonary homograft for graft failure who was admitted to the cardiac ICU for progressive cardiogenic shock requiring vasopressors and inotropic support. Initial workup showed lactic acidosis, acute kidney injury, elevated NT-proBNP, and negative blood cultures. TTE showed at least moderate biventricular systolic dysfunction. She was placed on furosemide infusion, blood cultures were drawn and empiric antibiotics initiated. Right heart catheterization demonstrated elevated right sided filling pressures, blunted PA pressures with low PCWP, low cardiac index, and low pulmonary artery pulsatility index. Intracardiac echocardiography (ICE) showed a large mass within the ES valve apparatus causing restrictive valve motion with a low gradient across the pulmonic valve in the setting of poor RV function. Angiography revealed a large filling defect and balloon valvuloplasty was performed with immediate hemodynamic improvement. Blood cultures remained negative, she was gradually weaned off of inotropic and vasopressor support, and discharged. Despite empiric treatment for culture negative endocarditis and ongoing anticoagulation, she was readmitted for recurrent shock one month later at which time the pulmonic mass was revisualized on ICE. A valve-in-valve transcatheter pulmonary valve (29mm ES S3) was placed to compress what was likely pannus, with an excellent hemodynamic result and no visible mass on ICE.
“To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.” – Sir William Osler. CardioNerds thank the patients and their loved ones whose stories teach us the Art of Medicine and support our Mission to Democratize Cardiovascular Medicine.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
US Cardiology Review is now the official journal of CardioNerds! Submit your manuscript here.
CardioNerds Case Reports Page
CardioNerds Episode Page
CardioNerds Academy
Cardionerds Healy Honor Roll
CardioNerds Journal Club
Subscribe to The Heartbeat Newsletter!
Check out CardioNerds SWAG!
Become a CardioNerds Patron!
Case Media
Pearls – Obstructive Cardiogenic ShocK
Tetralogy of Fallot is the most common cyanotic defect and can lead to long term complications after surgical repair including chronic pulmonary insufficiency, RV dysfunction, residual RVOT obstruction and branch pulmonary artery stenoses.
Chronic RV failure may be more indicative of a structural defect and therefore require interventional or surgical management.
Valve thrombosis, infective endocarditis and obstructive pannus formation should be considered in the differential of a patient with obstructive shock with a prosthetic valve.
Bioprosthetic pulmonic valve obstruction may be effectively managed with balloon valvuloplasty in patients who present in acute extremis but TCPV will likely provide a more lasting result.
While valvular gradients are typically assessed via echocardiography, invasive hemodynamics can serve as a critical adjunctive tool in its characterization.
Show Notes – Obstructive Cardiogenic ShocK
Notes were drafted by Drs. Omkar Betageri, Philip Lacombe, Cashel O’Brien, and Andrew Geissler.
What are the common therapies and management for Tetralogy of Fallot?
Tetralogy of Fallot is the most common cyanotic defect in children beyond the age of one year
Anatomic Abnormalities: Anterior and Superior deviation of the conal septum creating a SubAo VSD and encroachment on the RVOT. The Ao follows the conal septum anteriorly to override the VSD and RVH is a consequence of an RV chamber that is at systemic pressure.
The need for medical intervention is dependent on the degree of RVOT obstruction, pulmonary regurgitation, and/or peripheral pulmonary artery obstruction.
Many patients are minimally cyanotic in newborn period and clinical follow-up with elective surgical correction between 3 months and 6 months of age is a preferred approach.
Total surgical correction typically involves placing patients on cardiopulmonary bypass, relieving right sided obstruction (sometimes utilizing trans-annular patch), and connecting left ventricular blood flow with aortic, with VSD closure.
Hypercyanotic “Tet” spells can occur in the neonatal period when there is an acute muscular spasm in the RVOT, fall in SVR or increase in PVR to facilitate right to left shunting at the VSD. It is managed medically with a stepwise approach placing the patient in knee-chest position, administer oxygen, IV fluids and a dose of narcotics, IV beta blocker, IV phenylephrine, ECMO
Long term complications post-surgical repair include chronic pulmonary insufficiency, RV dysfunction, residual RVOT obstruction, peripheral PA obstruction, aortic root dilation, endocarditis, arrhythmias, and sudden cardiac death.
How should we approach the management of chronic right ventricular failure?
Briefly, RV failure can result in chamber dilatation, bowing of the interventricular septum to the LV, impairing LV stroke volume, and ultimately causing hemodynamic collapse. This is the frequently referenced “RV spiral”
The primary step in management of RV cardiogenic shock should be to identify and reverse the primary etiology
While patients in acute RV failure may respond well to therapies such as fluid resuscitation, inotropes and vasopressors, or inhaled nitric oxide, patients with chronic RV failure (such as in our case) are more likely to have structural defects driving their decompensation
Chronic RV failure can result from etiologies related to preload (ASD, tricuspid and pulmonic insufficiency), afterload (pulmonic or pulmonary artery stenosis, pulmonary vascular disease, and left heart disease) or contractility (RV myopathy or ARVC).

VSD is not volume loading to RV and Eisenmenger’s would be a pressure load b/c of increased PVR and actually volume unload the RV with R to L VSD shunting.
In acute stabilization, it is reasonable to utilize methods used to manage acute RV failure, with the understanding that interventional/surgical management will ultimately be necessary for definitive management
When should bioprosthetic valve obstruction be suspected and what is the differential for this? What is the initial workup?
Obstruction should be suspected in any patient with a history of prosthetic valve placement who presents with a new murmur, new history of exercise intolerance, syncope/presyncope, or evidence of heart failure on exam.
Differential diagnosis includes pannus ingrowth, thrombus, and vegetation. The anterior location of a surgically replaced RVOT/PV also makes it susceptible to compressive forces from the chest wall anteriorly and dilated Ao posteriorly, particularly in growing children. For bioprosthetic valves pannus is more common than acute thrombosis. Age of the valve, risk factors for infection, and anticoagulation status are clinical signs that may help differentiate.
Diagnosis is typically made by transthoracic echocardiology (TTE): Increased gradients across the PV, RV hypertrophy, dilatation or dysfunction, increasing TR volume with elevated gradients from RV to RA.
Cardiac CT or CMRI can also be helpful in characterizing the stenosis (discreet or long-segment, singular or stenoses in series).
Invasive hemodynamic assessment in the catheterization laboratory can be especially helpful to more specifically characterize the degree and location of the obstruction as well as perform intervention (balloon, stent placement, TCPV) to relieve the obstruction. It is not uncommon that distal pulmonary artery stenting is required at the time of ballooning of the valve or valve-in-valve TCPVR.
Lab testing sometimes performed includes INR, hemoglobin level, hemolysis labs, NT-BNP. If acute thrombosis of the bioprosthetic valve is diagnosed, a hypercoaguable work-up to include familial thrombophilia should be performed
FDG PET may be an adjunctive tool to help evaluate for prosthetic valve endocarditis by detection of acute inflammation.

What are the indications for management of valve obstruction? What are the primary management strategies?
As previously discussed the differential diagnosis of bioprosthetic valve obstruction includes BPVT, pannus, and vegetation. Valve intervention is indicated for symptomatic severe stenosis and treatment strategy depends on the underlying cause.
BPVT: If stable, can trial anticoagulation therapy. If unstable immediate therapy is required which requires surgery or fibrinolytics.
Pannus: Severe stenosis caused by soft tissue overgrowth with degeneration and calcium requires stenting open the obstructive valve in the catheterization laboratory followed by a valve-in-valve TCPV placement. It is increasingly rare that an obstructed bioprosthetic PV cannot be managed in this fashion and surgical PVR is needed. Medical therapy is ineffective in treating the underlying cause although can treat consequences from heart failure.
Vegetation: Endocarditis with vegetation causing severe stenosis is usually treated with surgical intervention. Decisions regarding surgical indications for endocarditis are complex and a trial of medical therapy is reasonable in less severe disease.
For native pulmonic valve obstruction many patients are amenable to balloon valvuloplasty and recurrent stenosis is rare. Patients are usually left with some degree of pulmonic insufficiency. Balloon valvuloplasty alone is rarely an effective long-term solution for bioprosthetic valve stenosis.
What is the role of right heart catheterization in valvular obstructive shock?
Typically valve gradients are obtained by TTE in a parasternal short axis view but hemodynamic gradients measured in the cath lab can provide supportive information
Additionally right heart catheterization can assist in the characterization of the degree of shock (through calculation of cardiac indices, pulmonary artery pulmonary index, and cardiac power output).
In pulmonary stenosis, the narrowed valve creates a pressure differential between the RV and PA such that a peak pressure difference RVSP-PASP >64 mmHg is considered severe or mean difference of >35 mmHg
As in this case, catheterization also allows for therapeutic intervention either through balloon valvuloplasty or TCPVP.
References – Obstructive Cardiogenic ShocK
Egbe AC, Pislaru SV, Pellikka PA, et al. Bioprosthetic Valve Thrombosis Versus Structural Failure: Clinical and Echocardiographic Predictors. J Am Coll Cardiol. 2015;66(21):2285-2294. doi:10.1016/j.jacc.2015.09.022
McElhinney DB, Zhang Y, Levi DS, et al. Reintervention and Survival After Transcatheter Pulmonary Valve Replacement. J Am Coll Cardiol. 2022;79(1):18-32. doi:10.1016/j.jacc.2021.10.031
Nishimura RA, Carabello BA. Hemodynamics in the cardiac catheterization laboratory of the 21st century. Circulation. 2012;125(17):2138-2150. doi:10.1161/CIRCULATIONAHA.111.060319
Otto, Catherine M et al. “2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.” Circulation vol. 143,5 (2021): e35-e71. doi:10.1161/CIR.0000000000000932
Rao PS. Management of Congenital Heart Disease: State of the Art-Part II-Cyanotic Heart Defects. Children (Basel). 2019;6(4):54. Published 2019 Apr 4. doi:10.3390/children6040054
Stout, Karen K et al. “2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.” Journal of the American College of Cardiology vol. 73,12 (2019): 1494-1563. doi:10.1016/j.jacc.2018.08.1028
VARC-3 WRITING COMMITTEE et al. “Valve Academic Research Consortium 3: updated endpoint definitions for aortic valve clinical research.” European heart journal vol. 42,19 (2021): 1825-1857. doi:10.1093/eurheartj/ehaa799
Arrigo, M., Huber, L. C., Winnik, S., Mikulicic, F., Guidetti, F., Frank, M., Flammer, A. J., & Ruschitzka, F. (2019). Right ventricular failure: Pathophysiology, diagnosis and treatment. Cardiac Failure Review, 5(3), 140–146. https://doi.org/10.15420/cfr.2019.15.2
Kanwar, M. K., Everett, K. D., Gulati, G., Brener, M. I., & Kapur, N. K. (2022). Epidemiology and management of right ventricular-predominant heart failure and shock in the cardiac intensive care unit. European Heart Journal. Acute Cardiovascular Care, 11(7), 584–594. https://doi.org/10.1093/ehjacc/zuac063
51 min
May 13, 2024370. CardioOncology: Advanced Heart Failure in CardioOncology with Dr. Richard Cheng
CardioNerds Co-Founder Dr. Daniel Ambinder, Episode Chair Dr. Dinu Balanescu, and FIT Lead Dr. Natalie Tapaskar discuss advanced heart failure in CardioOncology with expert Dr. Richard Cheng. Audio editing by CardioNerds Academy Intern, Dr. Akiva Rosenzveig.
In this episode, we discuss the spectrum of advanced heart failure in patients with a history of cancer. We dissect cancer therapy-related cardiac dysfunction (CTRCD) cases and the imaging and biomarker tools available for risk stratification and disease monitoring. We delve into the data on the use of guideline-directed medical therapy (GDMT) and cardiac resynchronization therapy (CRT) in these patients. We discuss the risk of prior radiation and chemotherapy during cardiac surgery. Finally, we learn about the post-transplant risk of rejection, recurrent malignancy, and de-novo malignancies, as well as treatment strategies we can employ for these patients.
This episode is supported by a grant from Pfizer Inc.
This CardioNerds Cardio-Oncology series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Giselle Suero Abreu, Dr. Dinu Balanescu, and Dr. Teodora Donisan.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
US Cardiology Review is now the official journal of CardioNerds! Submit your manuscript here.
CardioNerds Cardio-Oncology Page
CardioNerds Episode Page
CardioNerds Academy
Cardionerds Healy Honor Roll
CardioNerds Journal Club
Subscribe to The Heartbeat Newsletter!
Check out CardioNerds SWAG!
Become a CardioNerds Patron!
Pearls and Quotes – Advanced Heart Failure in CardioOncology
Use the HFA-ICOS risk tool to understand the baseline risk of developing cancer therapy-related cardiac dysfunction (CTRCD). Key factors are type of cancer therapy, baseline CV risk factors, and age.
A relative change in global longitudinal strain of more than 15% from baseline is a marker of early cardiac dysfunction and predicts the subsequent risk for systolic dysfunction in patients undergoing cardiotoxic chemotherapy.
Statins may be useful in prevention of cardiovascular dysfunction in patients receiving anthracycline chemotherapy. There is limited data on the 4 pillars of GDMT in prevention of CTRCD, but should be started early once CRTCD is suspected or diagnosed!
Mediastinal radiation causes adhesions and scarring which increase the risk of bleeding during cardiac surgery, lead to longer operative times, and can lead to RV failure and poor wound healing.
Patients with a pre-transplant history of malignancy have a higher risk of mortality due to post-transplant malignancy. And patients with active cancer should not be considered for heart transplant. Post-transplant malignancy risk can be mitigated by utilizing an mTOR based, CNI free immunosuppression regimen.
Show notes – Advanced Heart Failure in CardioOncology
How do cardio-oncology and advanced heart failure intersect?
There are 3 basic populations of patients to consider:
Patients with advanced heart failure who develop cancer.
Patients with pre-existing chemotherapy and radiation exposure for cancer treatment who later develop advanced heart failure
Heart transplant recipients who, in the long term are at very high risk of developing cancer
Cardio-oncologists must consider risk assessment and mitigation, long-term prognosis, and treatment strategies for each of these unique populations.
How can we assess the risk of developing cardiovascular disease during cancer treatment (CTRCD)?
There are many proposed risk tools. However, the majority are not well-validated.
One of the most used tools is the HFA-ICOS risk tool.1
You can select the planned cancer therapy for the patient (anthracyclines, HER-2, VEGF, RAF/MEK inhibitors, Kinase inhibitors, multiple myeloma therapies) and then calculate their risk of developing CV disease during cancer treatment based on baseline variables:
1) previous history of CV disease,
2) biomarkers – troponin and NT-proBNP
3)age,
4) CV risk factors -HTN, DM, CKD,
5) previous cardio-toxic treatments,
6) lifestyle risk factors- smoking, obesity
The risk tool will then give you a ranking of very high, high, medium, or low risks.
How should we use imaging to evaluate cardiac dysfunction in patients undergoing cancer treatments?
Echo with global longitudinal strainA relative change in global longitudinal strain of more than 15% from baseline is a marker of early cardiac dysfunction and predicts the subsequent risk for systolic dysfunction.Data are mixed on the benefit of intervening on drops in GLS without a concomitant drop in LVEF. Current vendor software has improved the consistency in GLS measurements across vendors, which used to be quite problematic.
Echo LVEF
Some centers prefer to use 3D LVEF to track patients over time.
For asymptomatic high-risk patients, we should obtain echocardiograms at 1, 3, and 5 years post-cancer therapies and then every 5 years thereafter.
But surveillance should occur on a case-by-case basis.
CPET
Can be used to risk stratify patients with lung or colon cancer before starting cancer treatment.
You can trend peak VO2 over time after cancer treatments.
However, this is generally a data-sparse zone!
Can we use serum biomarkers such as troponin or NT-proBNP in monitoring for the development of CTRCD?
Elevations in BNP during cancer treatment are associated with subsequent cardiovascular disease.
Elevations in troponin and myeloperoxidase in breast cancer patients receiving anthracyclines can predict the risk of cardiotoxicity.
Novel biomarkers – data-free zone
CRP is a marker of inflammation and may be helpful in patients undergoing radiation therapy.
Immunoglobulins- baseline elevated IgE levels have a lower risk for cardiotoxicity.
Cell-free DNA – may be the future?
What is the role of cardiovascular medications and devices in preventing and treating CTRCD?
Prevention:
Statins – The STOP-CA trial showed that use of atorvastatin 40 mg/day in patients with lymphoma receiving anthracycline chemotherapy reduced the incidence of cardiac systolic dysfunction compared to placebo.2
SGLT2i – limited retrospective data in patients with diabetes and anthracycline chemotherapy. May have lower rates of cardiac events on SGLT2i.
Currently there is not enough data to recommend routine use of SGLT2i, ARNI, and BB for cardioprotection before cancer therapies.
Treatment:
Treat these patients similarly to other heart failure patients. The four pillars of GDMT work! Early recognition is critical to confer better long-term outcomes.
CRT-D: MADIT-CHIC3 showed that CRT therapy improved LVEF at 6 months in patients with chemotherapy-induced cardiomyopathy.
Only consider ICD if life expectancy is >1 year.
There is a risk of device reset for radiation directly over the device. ICDs are more sensitive to ionizing radiation, leading to inappropriate shocks.
Can consider moving the device to a non-radiation field.
What do we need to consider when patients with a history of cancer are being evaluated for heart transplant and left ventricular assist device (LVAD)?
Heart transplant
Patients with chemo-induced cardiomyopathy have no differences in post-transplant outcomes compared to patients with other causes of cardiomyopathy.
Patients with a pre-transplant history of malignancy have a higher risk of mortality due to post-transplant malignancy, particularly in those with a history of hematologic malignancy.
Patients with active cancer should not be considered for heart transplant.
The duration and interval of waiting after active cancer before a heart transplant depends on the type and stage of cancer.
LVAD
Patients with chemotherapy-induced cardiomyopathy have similar outcomes and rates of post-LVAD RV dysfunction as patients with other etiologies of cardiomyopathy.
Limited data on performing LVAD in patients with active cancer.
What risk does prior mediastinal radiation pose to cardiac surgery?
Mediastinal radiation
Increases adhesions and scarring, increasing the risk of bleeding during cardiac surgery. Longer operative times may also increase the risk of RV failure.
There can also be atrophy of sternal muscles, which can lead to poor wound healing
What do the post-heart transplant rejection and malignancy profiles look like for patients with a history of chemotherapy-induced cardiomyopathy?
Patients with prior chemotherapy have depressed immunosurveillance from their innate immune system and, thus, may have a lower risk of rejection. But there is limited data here.
Patients with a history of pre-transplant malignancy are at increased risk of recurrence and PTLD. You can consider decreasing immunosuppression or switching to mTOR inhibitor-based regimen to reduce the risk.
What must we know about de-novo malignancy post-heart transplant?
Risk factors: history of prior malignancy, heavier immunosuppression, older recipient age, smoking history, radiation exposure, genetic variants.
Treatment: reduce immunosuppression as much as possible and switch to an mTOR-based regimen.
What about immune checkpoint inhibitors post-transplant?
These work by upregulating T cell activity, which counteracts our transplant immunosuppression. High risk of rejection, but some successful case reports of use.
References – Advanced Heart Failure in CardioOncology
Lyon AR, Dent S, Stanway S, et al. Baseline cardiovascular risk assessment in cancer patients scheduled to receive cardiotoxic cancer therapies: a position statement and new risk assessment tools from the C ardio‐ O ncology S tudy G roup of the H eart F ailure A ssociation of the E uropean S ociety of C ardiology in collaboration with the I nternational C ardio‐ O ncology S ociety. Eur J Heart Fail. 2020;22(11):1945-1960. doi:10.1002/ejhf.1920
Neilan TG, Quinaglia T, Onoue T, et al. Atorvastatin for Anthracycline-Associated Cardiac Dysfunction: The STOP-CA Randomized Clinical Trial. JAMA. 2023;330(6):528. doi:10.1001/jama.2023.11887
Singh JP, Solomon SD, Fradley MG, et al. Association of Cardiac Resynchronization Therapy With Change in Left Ventricular Ejection Fraction in Patients With Chemotherapy-Induced Cardiomyopathy. JAMA. 2019;322(18):1799. doi:10.1001/jama.2019.16658
Meet Our Collaborators
International Cardio-Oncology Society ( IC-OS). IC-OS exits to advance cardiovascular care of cancer patients and survivors by promoting collaboration among researchers, educators and clinicians around the world. Learn more at https://ic-os.org/.
45 min
May 07, 2024369. Case Report: Apical Obliteration with Biventricular Thrombus – West Virginia University
CardioNerds, Dr. Richard Ferraro and Dr. Dan ambinder join Dr. Li Pang, Dr. Emily Hendricks, and Dr. Bei Jiang from West Virginia University to discuss the following case that features apical obliteration with biventricular thrombus. Dr. Christopher Bianco provides the Expert CardioNerd Perspectives & Review (E-CPR) for this episode. Audio editing by CardioNerds Academy Intern, student doctor Tina Reddy.
A 37-year-old Caucasian man with a history of tobacco smoking and hypertension who presented with chest pain and elevated troponin was admitted for non-ST elevation myocardial infarction (NSTEMI). Ischemic evaluation with an invasive coronary angiogram was negative. He was treated as NSTEMI and scheduled for outpatient cardiac MRI (CMR). The patient came back 2 months later with right arm weakness and confusion and was found to have an embolic stroke. Labs showed positive troponin with a flat trend and hypereosinophilia. Transthoracic echocardiogram (TTE) showed obliteration of LV and RV apex with thrombus and reduced LV systolic function. CMR was consistent with myocarditis with biventricular thrombus. The patient was started on corticosteroids and warfarin. Hypereosinophilia workup was positive for PDGFRA alpha rearrangement. He was diagnosed with primary hypereosinophila syndrome. Imatinib was initiated. The patient was followed up with the hematology clinic, achieved a complete hematologic response with normalized cell count, and remained free from any cardiovascular event at the 8-month follow-up.
“To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.” – Sir William Osler. CardioNerds thank the patients and their loved ones whose stories teach us the Art of Medicine and support our Mission to Democratize Cardiovascular Medicine.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
US Cardiology Review is now the official journal of CardioNerds! Submit your manuscript here.
CardioNerds Case Reports Page
CardioNerds Episode Page
CardioNerds Academy
Cardionerds Healy Honor Roll
CardioNerds Journal Club
Subscribe to The Heartbeat Newsletter!
Check out CardioNerds SWAG!
Become a CardioNerds Patron!
Case Media
Pearls – Apical Obliteration with Biventricular Thrombus
Cardiac MRI is a valuable test for patients presenting with myocardial infarction with non-obstructive coronary arteries (MINOCA).
Obliterated apex with apical thrombus on TTE with hypereosinophilia should raise high suspicion for eosinophilic myocarditis.
Initiation of corticosteroids is the first-line treatment for eosinophilic myocarditis, which is associated with lower mortality in patients with myocarditis. For other potential complications, such as heart failure, intracardiac thrombus, arrhythmia, and pericardial effusion, the standard of care for each disorder is recommended.
Hypereosinophilia can be seen in parasitic infections, vasculitis, asthma, allergy, hematological malignancies, and as a primary disorder.
Show Notes – Apical Obliteration with Biventricular Thrombus
What is the differential diagnosis for patients with elevated troponin and nonobstructive CAD?
The occurrence of acute myocardial infarction (AMI) without significant CAD was reported 80 years ago. However, the term MINOCA (myocardial infarction with non-obstructive coronary arteries) has only been used recently to describe these patients. It involves ischemic and nonischemic etiologies. First, overlooked ischemic etiologies need to be ruled out by reconciling the angiogram images such as spontaneous coronary artery dissection (SCAD) and plaque disruption. Intracoronary imaging, such as intravascular ultrasound (IVUS) or optical coherence tomography (OCT), may be applied to evaluate for SCAD and subtypes of plaque disruption when indicated.
The investigation continues with nonischemic causes such as stress cardiomyopathy, myocarditis, pulmonary embolism, demand ischemia from sepsis, anemia, chest trauma, heart failure exacerbation, arrhythmia, and stroke.
The diagnosis of MINOCA is established when it fulfills the following criteria: First, it is AMI by the Fourth Universal Definition; Second, less than 50% of stenotic lesion on angiogram; Third, there is no alternate diagnosis. MINOCA etiologies include coronary artery spasms and microvascular dysfunction.
It is recommended to perform CMR in all MINOCA patients without an obvious underlying cause.
What are the common causes of LV thrombus?
The incidence of LV thrombus has been reported between 4-39% after anterior MI. The temporal incidence has been decreasing. It is also commonly seen in dilated cardiomyopathy with an incidence of 2-36%.
The pathophysiology of intracardiac thrombus formation obeys Virchow’s triad rule, which states that endocardial injury, hypercoagulability/inflammation, and stasis lead to thrombogenesis.
Other etiologies of LV thrombus include eosinophilic myocarditis and LV noncompaction.
What are the characteristic echocardiographic and CMR findings of eosinophilic myocarditis (EM)?
During the acute necrotic stage, there is increased subendocardial echogenicity, wall thickening, impaired regional wall motion, and pericardial effusion; there is edema without fibrosis on CMR.
During the thrombotic stage, intracardiac thrombus is often detected in the ventricles on TTE; on CMR, there is endomyocardial involvement and intracardiac thrombus.
During the fibrotic stage, in addition to the cumulative findings from previous stages, restrictive physiology, valvular thickening, and restricted motion can occur on TTE; on CMR, endomyocardial fibrosis with LGE is present.
What is the management for eosinophilic myocarditis (EM)?
Two aspects must be considered in the treatment of eosinophilic myocarditis: the management of acute cardiac conditions and the treatment of underlying causes.
Corticosteroids are the first-line treatment for EM. A meta-analysis of 179 cases showed that steroid use is associated with a lower mortality rate. No clinical trial data are available for the treatment of eosinophilic myocarditis. The dose and duration of corticosteroids in each individual case can be different.
For intracardiac thrombus, vitamin K antagonists (VKAs) are the drugs of choice. Complete gradual resolution of intracardiac thrombus with VKA in eosinophilic myocarditis was reported at the 18-month follow-up. The INR target was 2-3. Emerging data showed the noninferiority of using DOAC for LV thrombus compared to warfarin as an alternative for stroke prevention. There is an increased risk of stroke in patients on VKA but with subtherapeutic INR levels. The guidelines recommend DOAC as a reasonable alternative to VKA to treat LV thrombus.
For other potential complications such as heart failure, intracardiac thrombus, arrhythmia, and pericardial effusion, the standard of care for each complication is recommended. There is no large data to suggest a specific approach in eosinophilic myocarditis. It has been reported to achieve full recovery with GDMT in addition to treating the underlying cause in a case report of eosinophilic myocarditis with severely reduced LV systolic function.
What is hypereosinophilic syndrome (HES)?
HES is pleomorphic in clinical presentation and can be idiopathic or associated with a variety of underlying conditions, including allergic, rheumatologic, infectious, and neoplastic disorders.
There are 4 groups. In primary HES, the hypereosinophilia is driven by a clonal process in stem cell or myeloid lineage. Patients usually present with a myeloid neoplasm and myeloid proliferative disorder. Besides eosinophilia, they may have other cytopenias, blasts, or dysplastic cells in peripheral blood. They can present with constitutional symptoms or hepatosplenomegaly. Some of these patients have disease-defining mutations or chromosome translocation. They require treatment for their underlying hematologic condition. Secondary HES usually have polyclonal eosinophilia secondary to some stimulus. The stimulus may be infections, rheumatology conditions, solid tumors, and lymphoid neoplasm. The underlying condition increases eosinophilic cytokines leading to an increase in eosinophil production. The third group is familial HES results from certain genetic factors. If no cause of HES can be identified, they fall into the category of idiopathic HES.
Patients with HES secondary to myeloid and lymphoid disorders need to follow up with a hematology specialist.
References – Apical Obliteration with Biventricular Thrombus
Bondue A, Carpentier C, Roufosse F. Hypereosinophilic syndrome: considerations for the cardiologist. Heart 2022;108:164-171.
Merlo M, Gagno G, Baritussio A et al. Clinical application of CMR in cardiomyopathies: evolving concepts and techniques : A position paper of myocardial and pericardial diseases and cardiac magnetic resonance working groups of Italian society of cardiology. Heart Fail Rev 2023;28:77-95.
Murthy SB. Troponin Elevation After Ischemic Stroke and Future Cardiovascular Risk: Is the Heart in the Right Place? Journal of the American Heart Association 2021;10:e021474.
Dhaliwal JSS, Ansari SA, Ghosh S, Chitkara A, Khizer U. Duet of Death: Biventricular Thrombus in a Methamphetamine User. Cureus 2023;15:e39917.
Levine GN, McEvoy JW, Fang JC et al. Management of Patients at Risk for and With Left Ventricular Thrombus: A Scientific Statement From the American Heart Association. Circulation 2022;146:e205-e223.
Parrillo JE. Heart Disease and the Eosinophil. New England Journal of Medicine 1990;323:1560-1561.
Wright BL, Leiferman KM, Gleich GJ. Eosinophil Granule Protein Localization in Eosinophilic Endomyocardial Disease. New England Journal of Medicine 2011;365:187-188.
Polte CL, Bobbio E, Bollano E et al. Cardiovascular Magnetic Resonance in Myocarditis. Diagnostics 2022;12:399.
Ammirati E, Frigerio M, Adler ED et al. Management of Acute Myocarditis and Chronic Inflammatory Cardiomyopathy: An Expert Consensus Document. Circ Heart Fail 2020;13:e007405.
Ito S, Isotani A, Yamaji K, Ando K. Follow-up magnetic resonance imaging of Löffler endocarditis: a case report. Eur Heart J Case Rep 2020;4:1-4.
Miller T, Gabriel A, Bianco C, Hamirani Yasmin S. ACUTE EOSINOPHILIC MYOCARDITIS: AN ATYPICAL PRESENTATION DIAGNOSED BY COMBINED CARDIAC MAGNETIC RESONANCE IMAGING AND ENDOMYOCARDIAL BIOPSY WITH FULL RECOVERY. Journal of the American College of Cardiology 2022;79:2298-2298.
48 min
May 05, 2024368. Obesity: Procedural Management of Obesity with Dr. Steve Nissen
CardioNerds (Drs. Richard Ferraro, Gurleen Kaur, and Rupan Bose) discuss the growing epidemic of obesity and dive into the role of its procedural management with Dr. Steve Nissen, Chief Academic Officer at the Cleveland Clinic HVTI and past president of the American College of Cardiology. This is an exciting topic that reflects a major inflection point in cardiovascular care. In this episode, we discuss the importance of addressing obesity in cardiovascular care, as it is a major driver of cardiovascular disease and the progression of associated cardiovascular comorbidities. We look at the role of bariatric surgery and its ability to produce sustained weight loss. Finally, we look into the emerging role of new medical therapies such as GLP1 and GIP agonist medications. Notes were drafted by Dr. Rupan Bose and episode audio was edited by CardioNerds Intern Dr. Atefeh Ghorbanzadeh.
This episode was produced in collaboration with the American Society of Preventive Cardiology (ASPC) with independent medical education grant support from Novo Nordisk. See below for continuing medical education credit.
Claim CME for this episode HERE.
Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.
US Cardiology Review is now the official journal of CardioNerds! Submit your manuscript here.
CardioNerds Prevention Page
CardioNerds Episode Page
CardioNerds Academy
Cardionerds Healy Honor Roll
CardioNerds Journal Club
Subscribe to The Heartbeat Newsletter!
Check out CardioNerds SWAG!
Become a CardioNerds Patron!
Pearls and Quotes – Procedural Management of Obesity with Dr. Steve Nissen
Obesity is associated with adverse cardiovascular outcomes. Returning to a healthy weight can largely prevent the downstream consequences of obesity.
Regarding lifestyle modifications, diet alone is insufficient in sustaining prolonged weight loss. It is associated with short-term weight loss, but it is generally necessary to supplement with exercise and activity to ensure sustained weight loss.
Bariatric surgery should be considered for patients with BMI ≥40 kg/m2 or BMI ≥35 kg/m2 with obesity-related comorbid conditions who are motivated to lose weight and who have not responded to behavioral treatment with or without pharmacotherapy.
New emerging medications, including GLP1 receptor agonists, GIP receptor agonists, and glucagon receptor agonists, are beginning to approach weight loss levels that were previously only seen with bariatric surgery. Further research in this dynamic area is ongoing.
Show notes – Procedural Management of Obesity with Dr. Steve Nissen
Notes drafted by Dr. Rupan Bose.
What is the role of obesity in the burden of cardiovascular disease, and why is it so important for CardioNerds to address it?
According to the AHA, approximately 2.8 to 3.5 billion people worldwide are either overweight or obese. It is estimated that by 2030, 30% of people in the US will have a BMI greater than 30.
Adipose tissue is associated with cytokine release. Cytokines, in turn, can activate and increase levels of IL-1 beta, IL-6, and CRP, leading to an increased inflammatory state. This pro-inflammatory state then accelerates the rate of cardiovascular disease.
Obesity is also associated with significant joint and orthopedic diseases, which further impact patients’ quality of life and morbidity.
Additionally, obesity is associated with NASH cirrhosis. These adverse liver outcomes hold additional significant systemic implications and morbidity.
How do you determine one’s goal weight and goal BMI? Is BMI a good standard for measuring obesity?
BMI is a variable of both weight and height. However, it cannot differentiate those whose weight is from adipose tissue versus from muscle mass. Therefore, BMI measurements can sometimes be misleading. Waist circumference may be a better measurement standard for obesity and risk assessment.
The “apple shape” body type, with more abdominal fat, is associated with higher inflammation and cardiovascular risk than the “pear-shaped” body type, which is where there is more fat deposition in the buttocks and thighs. A fat distribution that is more centralized corresponds with greater cardiovascular risk.
“Normal” BMI and “normal” waist circumference can differ based on ethnicity. For example, a BMI of 22.6 in South Asians carries a similar risk to a BMI of 30 in White European patients. Therefore, providers must remain cognizant of these differences when making individual patient recommendations.
Does childhood obesity correlate with obesity at later ages? At what age should we start screening for and addressing obesity?
Childhood obesity, or obesity at a young age, often correlates with continued obesity later in life. But it is interesting that if one can return to a healthy body weight at some point in their life, one can largely prevent the downstream consequences of obesity
The USPSTF recommends clinicians screen for obesity in children and adolescents age 6 and older and offer behavioral interventions to promote improvements in weight status (grade B recommendation)
What procedures or surgeries are available to patients with obesity?
Bariatric surgery is an excellent option with great outcomes if done for the right patient.
The 2013 AHA/ACC/TOS guidelines for the management of overweight and obesity in adults recommend bariatric surgery for patients with BMI ≥40 kg/m2 or BMI ≥35 kg/m2 with obesity-related comorbid conditions who are motivated to lose weight and who have not responded to behavioral treatment with or without pharmacotherapy.
Several studies have shown that patients with bariatric surgery had a huge reduction in myocardial infarction, stroke, kidney disease, and death.
Bariatric surgery can help address other cardiovascular comorbidities. For example, the STAMPEDE trial (Schauer, R et al.) demonstrated that bariatric surgery plus intensive medical therapy was more effective than intensive medical therapy alone in decreasing or, in some cases, resolving hyperglycemia.
Additionally, the magnitude of weight loss from bariatric surgery is often greater than the absolute magnitude of weight loss through medical therapy alone. Therefore, for patients with a very high BMI, bariatric surgery may be better suited to achieve the necessary weight loss.
What emerging medications are available to patients with obesity? And what medications are just around the corner?
GLP1 agonists, or dual GIP-GLP1 receptor agonists, drugs are associated with approximately 20% reduction in body weight.
In the SELECT trial, semaglutide was associated with a 9.3% reduction in body weight (Please see GLP1 series for additional details!).
In the SURMOUNT-1 trial, tirzepatide was associated with a 22% reduction in body weight.
Future trials will look at triple agonists that combine GLP1, GIP, and glucagon agonist properties. One such drug is retatrutide, which previously demonstrated a 24% (and approximately 28.5% in females) reduction in body weight. These medications are approaching similar weight loss magnitudes to bariatric surgery (a Roux en Y procedure achieves approximately 25% weight loss on average), though additional studies are ongoing.
What other strategies can one use to lower body weight and maintain that weight loss?
Diet alone is not sustainable in reducing weight and keeping weight off. Unfortunately, the body subconsciously activates adaptive responses that down-regulate metabolism, which in turn burns fewer calories.
Therefore, exercise and activity play a key role in continuing to burn calories, allowing for sustained weight loss.
All patients should, therefore, be counseled on both diet and exercise strategies to address obesity and weight loss.
Discussing weight and body image is often a sensitive subject and can carry a stigma for some patients. What are some recommendations on how we can address these topics in a safe and supportive manner?
It is important to create a safe, supportive, and non-judgmental space when discussing weight with patients.
We should also make an effort to understand the specific drivers of each individual patient’s weight gain. Some drivers include emotional stress, socio-economic factors, lifestyle barriers, etc. By understanding each specific driver, we can be more targeted in our approach and build more individualized plans with our patients.
We can also recruit other clinical team members to assist the patient in their weight loss journey. Some such teammembers include dieticians, psychiatrists, social workers, etc.
References – Procedural Management of Obesity with Dr. Steve Nissen
Jastreboff, A. M., Aronne, L. J., Ahmad, N. N., Wharton, S., Connery, L., Alves, B., … & Stefanski, A. (2022). Tirzepatide once weekly for the treatment of obesity. New England Journal of Medicine, 387(3), 205-216.
https://www.nejm.org/doi/full/10.1056/NEJMoa2206038
Lincoff, A. M., Brown-Frandsen, K., Colhoun, H. M., Deanfield, J., Emerson, S. S., Esbjerg, S., … & Ryan, D. H. (2023). Semaglutide and cardiovascular outcomes in obesity without diabetes. New England Journal of Medicine.
https://www.nejm.org/doi/full/10.1056/NEJMoa2307563
Schauer, P. R., Bhatt, D. L., Kirwan, J. P., Wolski, K., Aminian, A., Brethauer, S. A., … & Kashyap, S. R. (2017). Bariatric surgery versus intensive medical therapy for diabetes—5-year outcomes. New England Journal of Medicine, 376(7), 641-651.
https://www.nejm.org/doi/full/10.1056/nejmoa1600869
Jensen, M. D., Ryan, D. H., Apovian, C. M., Ard, J. D., Comuzzie, A. G., Donato, K. A., … & Yanovski, S. Z. (2014). 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Journal of the American college of cardiology, 63(25 Part B), 2985-3023.
Powell-Wiley, T. M., Poirier, P., Burke, L. E., Després, J. P., Gordon-Larsen, P., Lavie, C. J., … & American Heart Association Council on Lifestyle and Cardiometabolic Health; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Epidemiology and Prevention; and Stroke Council. (2021). Obesity and cardiovascular disease: a scientific statement from the American Heart Association. Circulation, 143(21), e984-e1010.
Lopez-Jimenez, F., Almahmeed, W., Bays, H., Cuevas, A., Di Angelantonio, E., le Roux, C. W., … & Wilding, J. P. (2022). Obesity and cardiovascular disease: mechanistic insights and management strategies. A joint position paper by the World Heart Federation and World Obesity Federation. European Journal of Preventive Cardiology, 29(17), 2218-2237.
Sjöström, L., Peltonen, M., Jacobson, P., Sjöström, C. D., Karason, K., Wedel, H., … & Carlsson, L. M. (2012). Bariatric surgery and long-term cardiovascular events. Jama, 307(1), 56-65.
Liakopoulos, V., Franzén, S., Svensson, A. M., Sattar, N., Miftaraj, M., Björck, S., … & Eliasson, B. (2020). Renal and cardiovascular outcomes after weight loss from gastric bypass surgery in type 2 diabetes: cardiorenal risk reductions exceed atherosclerotic benefits. Diabetes Care, 43(6), 1276-1284.
Eisenberg, Dan, et al. 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) indications for metabolic and bariatric surgery. (2023): 3-14. doi: https://doi.org/10.1016/j.soard.2022.08.013
38 min

About Episodes Archives - Cardionerds

From the publisher's feed

A cardiology platform that aims to democratized cardiovascular education

Share Episodes Archives - Cardionerds

Sign up to save your podcasts

Episodes Archives - Cardionerds

Episodes Archives - Cardionerds episodes

About Episodes Archives - Cardionerds