Episodes Archives - Cardionerds

CardioNerds (Amit Goyal, Daniel Ambinder) and Dr. Mark Belkin, (CardioNerds Correspondent) and Dr. Shirlene Obuobi (CardioNerds Ambassador) from University of Chicago are honored to bring to you the Dr. Milton Packer perspective on the evolution of the neurohormonal hypothesis as part of The CardioNerds Heart Success Series. In part 2 Dr. Packer shares his journey as the trailing spouse and tells the story of how the neurohormonal hypothesis was developed.

Check out the CardioNerds Heart Failure Success Series Page for more heart success episodes and content!

This is a non CME episode. Disclosures: Milton Packer reports receiving consulting fees from Abbvie, Actavis, Amgen, Amarin, AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Casana, CSL Behring, Cytokinetics, Johnson & Johnson Health Care Systems Inc., Eli Lilly and Company, Moderna, Novartis, ParatusRx, Pfizer, Relypsa, Salamandra, Synthetic Biologics, Teva Pharmaceuticals USA Inc. and Theravance Biopharma Inc.

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This CardioNerds Heart Failure Success Series was created in memory of Dr. David Taylor. We thank our partners at the Heart Failure Society of America which is a multidisciplinary organization working to improve and expand heart failure care through collaboration, education, research, innovation, and advocacy. Its members include physicians, scientists, nurses, nurse practitioners, and pharmacists. Learn more at hfsa.org.

CardioNerds (Amit Goyal, Daniel Ambinder) and Dr. Mark Belkin, (CardioNerds Correspondent) and Dr. Shirlene Obuobi (CardioNerds Ambassador) from University of Chicago are honored to bring to you the Dr. Milton Packer perspective on the evolution of the neurohormonal hypothesis as part of The CardioNerds Heart Success Series.

In part 1 Dr. Packer discusses taking risks, upsetting people and the ridiculousness of humanity and how stand-up comedy helped contribute and shape his career in cardiovascular medicine. Dr. Packer also discusses how the study of afterload agents in heart failure and the discovery of tachyphylaxis with prazosin helped inspire a long and prosperous career in academic cardiology by changing the status quo.

Check out the CardioNerds Heart Failure Success Series Page for more heart success episodes and content!

This is a non CME episode. Disclosures: Milton Packer reports receiving consulting fees from Abbvie, Actavis, Amgen, Amarin, AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Casana, CSL Behring, Cytokinetics, Johnson & Johnson Health Care Systems Inc., Eli Lilly and Company, Moderna, Novartis, ParatusRx, Pfizer, Relypsa, Salamandra, Synthetic Biologics, Teva Pharmaceuticals USA Inc. and Theravance Biopharma Inc.

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This CardioNerds Heart Failure Success Series was created in memory of Dr. David Taylor. We thank our partners at the Heart Failure Society of America which is a multidisciplinary organization working to improve and expand heart failure care through collaboration, education, research, innovation, and advocacy. Its members include physicians, scientists, nurses, nurse practitioners, and pharmacists. Learn more at hfsa.org.

CardioNerds (Amit Goyal and Daniel Ambinder), ACHD series co-chair Dr. Agnes Koczo (UPMC), and ACHD FIT lead Dr. Katia Bravo (UCLA) join ACHD expert Dr. Carole Warnes (Professor of Medicine and founder of the Adult Congenital Heart Disease Clinic at Mayo Clinic), to discuss adult congenial heart disease and pregnancy. They cover preconception counseling in women with congenital heart disease, appropriate risk stratification to estimate maternal and neonatal morbidity using existing tools and an individualized care approach and preparation for a multidisciplinary delivery plan. Audio editing by CardioNerds Academy Intern, Dr. Leticia Helms.

The CardioNerds Adult Congenital Heart Disease (ACHD) series provides a comprehensive curriculum to dive deep into the labyrinthine world of congenital heart disease with the aim of empowering every CardioNerd to help improve the lives of people living with congenital heart disease. This series is multi-institutional collaborative project made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Josh Saef, Dr. Agnes Koczo, and Dr. Dan Clark.

The CardioNerds Adult Congenital Heart Disease Series is developed in collaboration with the Adult Congenital Heart Association, The CHiP Network, and Heart University. See more

Claim free CME for enjoying this episode! Disclosures: None

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1. Women with congenital heart disease can safely carry a pregnancy if appropriate risk stratification and management is performed by an expert multidisciplinary cardio-obstetrics team.
2. There are a myriad of hemodynamic and vascular changes which impact congenital cardiac physiology and evolve throughout the different stages of pregnancy. Therefore, planning is key. An evaluation of heart rate response to exercise and optimization of potential factors that could worsen during pregnancy, such as arrhythmias, are recommended.
3. Maternal morbidity & mortality risk-stratification systems such as the modified WHO, CARPREG or ZAHARA criteria are helpful starting points. Ultimately, each patient requires individualization given the heterogeneity that exists among congenital heart defects.
4. Vaginal delivery is generally preferred over C-section from a cardiac standpoint. An assisted second stage of labor during the period of greatest hemodynamics changes should also be considered if vaginal delivery is pursued.

1. Why is preconception counseling important in women with congenital heart disease and what does it entail?

• Ensuring women with congenital heart disease are optimized prior to conception decreases maternal and neonatal complications. For this reason, preconception counseling is paramount for these patients.
• In addition, counseling leads to patients making more informed decisions about family planning.
• The integral parts of preconception counseling include: (1) discussing the current anatomical and physiological status, (2) discussing possible complications during pregnancy specific to the patient’s congenital heart defect (with genetic counseling referral if appropriate), (3) evaluating cardiac medications, taking into account benefits vs teratogenic potential, (4) discussing and planning for necessary pre-pregnancy tests or interventions (exercise stress testing is an important tool in evaluating how the patient will tolerate the stressors of pregnancy), (5) organizing antepartum care with high-risk obstetrics teams, (6) discussing location, timing and mode of delivery, (7) discussing alternative options to carrying a pregnancy in women who are at extreme risk (ie Fontan physiology, Eisenmenger syndrome) and (8) discussing postpartum contraception. 

2. How do we risk stratify women with congenital heart disease who are contemplating pregnancy?

An expert evaluation by an ACHD specialist is recommended using a thorough clinical and hemodynamic assessment centered around the individual patient and her values. Several risk prediction tools are available and should be used as a starting point. These include the modified World Health Organization (mWHO) classification, risk factors derived from CARPREG II (CARdiac disease in PREGnancy II), and ZAHARA (acronym based on Dutch translation for Pregnancy in congenital heart defects – Zwangerschap bij Aangeboren HARtAfwijkingen I) studies. 

• The mWHO classification groups congenital hearts conditions into class I to IV, with higher classes indicating higher predicted risk of cardiovascular maternal morbidity and mortality.
• The CARPREG II risk prediction index assigns points based on a number of different predictors including prior cardiac events or arrhythmias, baseline New York Heart Association Class III-IV or cyanosis, presence of a mechanical valve, ventricular dysfunction, high risk left-sided valve disease or left ventricular outflow tract obstruction, pulmonary hypertension, and coronary artery disease or high-risk aortopathies.
• The ZAHARA risk score also considers sub-pulmonary atrioventricular valve regurgitation and cardiac medications before pregnancy as additional risk factors as well.

3. What are the potential fetal/neonatal risks associated with pregnancy in congenital heart conditions?

Some of the risks include spontaneous abortion, premature birth, small for gestational age neonate, and congenital heart disease in the baby (which may be different than maternal CHD (see Table 1). Most of these are related to maternal heart failure; however other complications such as arrhythmias, endocarditis, thromboembolic events, and medication adverse effects predispose to neonatal complications. Specifically, women with uncorrected cyanotic heart disease and pulmonary hypertension with saturation levels ≤ 85% reach a live birth rate of only 12%.

Table 1. Recurrence rate for congenital heart lesions in affected mothers.

What should a multidisciplinary delivery plan include?

Detailed delivery planning should be undertaken prior to expected delivery date to plan for obstetric anesthesia and analgesia, inpatient peripartum management (level of acuity, need for bubble filters in cases of shunts, avoidance of excessive volume load, infective endocarditis prophylaxis, mode of delivery), as well as postpartum care and discharge planning  including post-partum contraception.

Maternal and Neonatal Risk by Congenital Lesion

1. Stout KK, Daniels CJ, Aboulhosn JA, et al. 2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. Apr 2 2019;139(14):e698-e800. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000603
2. European Society of G, Association for European Paediatric C, German Society for Gender M, et al. ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). European heart journal. Dec 2011;32(24):3147-3197. https://academic.oup.com/eurheartj/article/39/34/3165/5078465
3. Pierpont ME, Brueckner M, Chung WK, et al. Genetic Basis for Congenital Heart Disease: Revisited: A Scientific Statement From the American Heart Association. Circulation. Nov 20 2018;138(21):e653-e711. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000606
4. Elkayam U, Goland S, Pieper PG, Silversides CK. High-Risk Cardiac Disease in Pregnancy: Part II. Journal of the American College of Cardiology. Aug 2 2016;68(5):502-516. https://www.jacc.org/doi/full/10.1016/j.jacc.2016.05.048

Adult Congenital Heart Association
Founded in 1998, the Adult Congenital Heart Association is an organization begun by and dedicated to supporting individuals and families living with congenital heart disease and advancing the care and treatment available to our community. Our mission is to empower the congenital heart disease community by advancing access to resources and specialized care that improve patient-centered outcomes. Visit their website (https://www.achaheart.org/) for information on their patient advocacy efforts, educational material, and membership for patients and providers

CHiP Network

The CHiP network is a non-profit organization aiming to connect congenital heart professionals around the world. Visit their website (thechipnetwork.org) and become a member to access free high-quality educational material, upcoming news and events, and the fantastic monthly Journal Watch, keeping you up to date with congenital scientific releases. Visit their website (https://thechipnetwork.org/) for more information.

Heart University
Heart University aims to be “the go-to online resource” for e-learning in CHD and paediatric-acquired heart disease. It is a carefully curated open access library of educational material for all providers of care to children and adults with CHD or children with acquired heart disease, whether a trainee or a practicing provider. The site provides free content to a global audience in two broad domains: 1. A comprehensive curriculum of training modules and associated testing for trainees. 2. A curated library of conference and grand rounds recordings for continuing medical education. Learn more at www.heartuniversity.org/

Carole A. Warnes, M.D., is a cardiologist in the Division of Structural Heart Disease, Department of Cardiovascular Medicine with a joint appointment in the Division of Pediatric Cardiology at Mayo Clinic. Dr. Warnes joined the staff of Mayo Clinic in 1987 and founded the Adult Congenital Heart Disease Clinic, which she directed for 27 years. She holds the academic rank of professor of medicine. She is recognized with the distinction of the Penske Foundation Professorship in Clinical Medicine in Honor of Ian D. Hay, M.D., Ph.D., and J. Eileen Hay, M.B., Ch.B.

Dr. Warnes completed her M.B., B.S. at Newcastle Upon Tyne Medical School in the United Kingdom and did her general medicine training in Newcastle. She was registrar in cardiology at both the London Chest Hospital and the National Heart Hospital in London. Dr. Warnes was visiting staff associate in cardiology at the National Institutes of Health and a British Heart Foundation research fellow at the National Heart Hospital. She received her postgraduate M.D. degree with commendation at Newcastle Upon Tyne Medical School. In 2005 she was made a fellow of the Royal College of Physicians (FRCP).

As a cardiologist, Dr. Warnes focuses on adult congenital heart disease, and she oversees the treatment of many patients with difficult cases, including those related to heart disease and pregnancy. She speaks internationally and nationally on these topics and has published three books and more than 200 papers in prominent peer-reviewed journals. She has served as an editorial board member for American Journal of Cardiology, Circulation and Heart. In 2008 she chaired the American College of Cardiology/American Heart Association (ACC/AHA) Guidelines for the Management of Adults with Congenital Heart Disease. She has held multiple leadership roles in addition to serving on many committees of the ACC and served on their Board of Trustees for seven years. In 2016 she received the Distinguished Fellowship Award from ACC.

Dr. Warnes is the recipient of the Heart Heroes Leadership Award from the Adult Congenital Heart Association and received the Henry S. Plummer Distinguished Physician Award from Mayo Clinic. She has been honored consistently as Outstanding Teacher of the Year in the Cardiovascular Division at Mayo Clinic, where she was also recognized with the Distinguished Educator Award in 2010 and the Lifetime Achievement for Outstanding Contributions to Medical Education in 2014. In 2015 she received the Laennec Master Clinician Award from the AHA.

Dr. Warnes provides mentorship to numerous fellows and for 10 years served as dean of Mayo Clinic School of Continuing Medical Education. She holds teaching/examining privileges in Clinical and Translational Science at Mayo Clinic Graduate School of Biomedical Sciences.

Dr. Katia Bravo-Jaimes (@Bravo__MD) is an Adult Congenital Heart Disease Fellow at the University of California, Los Angeles. She is interested in reducing disparities in congenital heart disease care at local, national and global levels. She plans to continue her academic career combining clinical care, education and collaborative research to help patients with congenital heart disease reach their full potential.

• Amit Goyal, MD
• Daniel Ambinder, MD

CardioNerds (Amit Goyal and Daniel Ambinder) join Dr. Kushani Gajjar and Dr. Mitha Naik from the Allegheny Health Network for a walk along the Three Rivers Trail in Pittsburgh. They discuss a case of young woman in her third trimester of pregnancy with a known history of pulmonary arterial hypertension. The management of pulmonary hypertension in pregnancy and RV failure in the context of pregnancy is described. The E-CPR segment is provided by Dr. Nandita Scott, Co-Director Corrigan Women’s Heart Health Program and Cardiovascular Disease and Pregnancy Service at Massachusetts General Hospital. Special cameo appearance by Dr. Dani Crousillat.

If you’re a current internal medicine resident, interested in the intersection between medical education, cardiovascular disease and digital media, consider applying to the CardioNerds Academy using this link. The deadline for this application is October 15th 2021. Learn more by visiting the CardioNerds Academy page.

Claim free CME just for enjoying this episode! Disclosures: None

Jump to: Patient summary – Case media – Case teaching – References

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A 33-year-old woman in the third trimester of pregnancy, with a known history of untreated PAH in the setting of TKI therapy, presents with shortness of breath. She is found to have PA pressure greater than systemic pressure with PASP >130. We describe the management of PH and RV failure in the context of a pregnancy. The patient was admitted to the ICU where a multidisciplinary team was mobilized, involving high risk ob-gyn, maternal fetal medicine, critical care, anesthesiology, and advanced heart failure. They began pulmonary vasodilators including treprostinil, tadalafil and inhaled nitric oxide. They also added inotropic and vasopressor support for right ventricular dysfunction with her severe PAH. Fetal heart monitoring was performed. PAH also led to worsening of known chronic thrombocytopenia in the setting of CML. HELLP syndrome was ruled out. The patient had preterm rupture of membranes at 32 weeks of gestation and the team pursued assisted vaginal delivery to prevent vagal response. Following successful delivery, the patient elected to undergo intra-uterine device placement. Post-delivery, vasopressors and inotropes were weaned, and she was discharged on treprostinil, ambrisentan and tadalafil. Thankfully both the mother and baby returned healthy and well at 1 month follow up.

• CMR
• CXR
• TTE
• TTE

1. Pulmonary Hypertension is defined as a mean pulmonary arterial pressure (mPAP) of >20mmHg. There are 5 major types of pulmonary hypertension. Risk modifiers include symptom burden, exercise capacity, presence of pericardial effusion, RV function and hemodynamics.
2. Multidisciplinary care teams are the key to achieving optimal pregnancy outcomes in patients with PH. It is critical to create a team of experts with experience in pulmonary hypertension and plan for constant communication before, during, and after pregnancy.
3. Pregnant women who are already on PAH therapy outpatient should continue them during pregnancy (under the direction of PH experts) except for endothelin receptor blockers which fall in pregnancy category X.
4. PH during pregnancy is associated with up to 38% maternal mortality rate as the right ventricle (RV) is often unable to handle the volume shifts and hemodynamic changes that occur during pregnancy, labor, and delivery.
5. Patients with RV failure leading to low cardiac output and hypotension, like in this case, may benefit from vasopressors with the goal to maintain systemic blood pressure above pulmonary arterial pressures, preserving right coronary blood flow and preventing intracardiac shunting. Swan-guided management may be useful – to titrate inotropes and vasopressors, optimize pulmonary vasodilators and ensure that the patient is being adequately fluid-optimized to maintain a CVP of around 8-10.

1. What are the different types of pulmonary hypertension (PH)?
The WHO separates PH into 5 groups:

2. What is the role of TTE and RHC in the workup of PH?

• Tyrosine kinase inhibitors are known to cause PAH and there should be a low threshold to do screening TTEs in these patients when there is concern for the development of PAH.
• Echocardiogram is essential in the evaluation of PH –for positing the presence of PH, evaluating the left heart and congenital defects for clues to PH etiology, and assessing the structural consequences of PH on the right heart. In addition to estimating the pulmonary artery systolic pressure (PASP) by measuring the tricuspid regurgitant jet, we can characterize RV and RA size, RV function, and RV wall thickness, which may help both support the diagnosis and gauge prognosis for PH. Further, we can evaluate for left-sided heart disease contributing to PH. The presence of a pericardial effusion is a poor prognostic sign in those with pulmonary hypertension. Notably, the PASP is not of prognostic value due both to inaccuracies in measurement and falling values in the context of severe PH with failing RV function; a such PASP should not be used to surveil patients with PH or monitor response to PH therapies.

McLaughlin et al suggest using a checklist in the echocardiographic assessment of PH which includes the following1:

• Right heart catheterization is necessary to confirm the diagnosis of PH. The updated hemodynamic definition of PH hinges on accurate hemodynamic assessment. In a PH crisis, such as our patient, it is also important to delineate the impact of PH on the RV. Invasive hemodynamic testing is the gold standard for differentiating isolated precapillary, isolated postcapillary and combined pre and post capillary PH (see table below).

When we consider the hemodynamic profiles of pulmonary hypertension, we break down PH into isolated pre-capillary, isolated post-capillary, or combined pre-and post-capillary pulmonary hypertension as shows in the table below.

Furthermore, we can determine if a patient is “vasodilator responsive.” In the catheterization lab, a positive vasodilator response is defined as a decrease in mPAP ≥ 10 mmHg to an absolute value of ≤ 40 mmHg (without a decrease in cardiac output) with the use of inhaled nitric oxide or IV epoprostenol. If a patient has positive vasodilator test, calcium channel blockers can be initiated, however not all patients will be long term responders. We tend to do vasoreactivity testing in patients with PAH and not for other forms of PH (e.g., Pulmonary Veno-Occlusive Disease or Groups 2, 3, 4, or 5).

3. What are PAH-specific pharmacologic treatments?

• Remember that PAH is fundamentally a disease of increased pulmonary vascular resistance (PVR) causing elevated pulmonary pressures. The consequence of increased PVR includes increased RV afterload and hypoxemia and the subsequent clinical manifestations of PAH. Normally, the pulmonary vascular bed has a balance between vasodilators and vasoconstrictors that maintain a low-resistance, high-compliance state. This balance is disturbed in PAH and the goal of therapy is to “restore” balance between vasodilation and vasoconstriction.
• The management of PAH relies on 3 primary medication groups1:

Also remember calcium channel blockers in vasodilator responsive patients with PAH!

Other aspects of pharmacologic PAH treatment not discussed here include diuretics, digoxin, and oral anticoagulation, especially for patients with more advanced disease and on continuous parenteral prostacyclin therapy due to microthrombi in pulmonary arterioles.

4. What is the impact of pregnancy in PH?

• Prevalence of pulmonary hypertension has been rising due to the number of patient with congenital heart disease living to childbearing age, as well as the emergence of effective pulmonary vascular therapy.2,3
• According to one widely quoted systemic analysis, although a publication bias cannot be excluded, overall maternal mortality was significantly lower compared with previous era (25 vs. 38%, P = 0.047). Seventy-eight per cent of deaths occurred within the first month after delivery. Primigravidae and parturients who received general anesthesia were at higher risk of death. Maternal mortality in parturients with PAH remains prohibitively high, despite lower death rates than in previous decades. Early counseling regarding pregnancy risks, including contraception, remains paramount. Women with PAH who become pregnant warrant a multidisciplinary approach with consideration of advanced therapies and discussion of pregnancy termination.3-5
• Morbidity and mortality were highest in women with idiopathic PH, and lowest in women with PH due to left sided heart disease. Complications were also higher in patient with severe PH (RVSP >70mmHg).7
• A comprehensive study looking at approximately 1500 pregnant women with PH from the national inpatient sample (spanning from 2003-2012) found that the rate of major adverse cardiovascular events was around 24.8%.6
• Overall mortality for PH patients during pregnancy is quite high, up to 50%. The majority of patients died within the first month after delivery and major causes of death were heart failure, sudden cardiac death and pulmonary embolism4,5,8
• Complications of PH during pregnancy:
  • The normal physiologic changes of pregnancy (increased plasma volume, increased stroke volume, increased cardiac output, decreased systemic vascular resistance), are poorly tolerated in PH due to an inability to decrease pulmonary vascular resistance and accommodate the increased pulmonary flow. This can lead to increased right ventricular overload.
  • Decrease in systemic vascular resistance and associated drop in blood pressure can also lead to decreased RV perfusion leading to RV failure.
  • Pregnancy is both a prothrombotic and a pro-arrhythmic state, and maternal morbidity and mortality may also be related to complications from veous thromboembolism and arrhythmias.
  • Abnormal maternal hemodynamics in PH also contribute to increased fetal and neonatal complications including preterm birth as well as fetal and neonatal death.

5. What are some of the most important delivery considerations to keep in mind for these patients?

• Delivery timing and location: Consider delivering most patients by 37 weeks of gestation, if not earlier, depending on the stability of the patient. While some women may be followed in obstetric hospitals, delivery should take place in a location with backup of a cardiology, critical care, and advanced heart failure teams. 8
• Mode of delivery: If women are stable, assisted vaginal delivery is preferred as it is associated with fewer complications. 8
• Monitoring: In conjunction with OB consider the use of an arterial line for invasive blood pressure monitoring, central access for IV medication administration etc. A PA catheter may be necessary to optimize PAH therapy and RV support.8 Be wary of increased vascular fragility and the increased risk of complications of invasive vascular procedures during pregnancy.
• Anesthesia: Epidural anesthesia with good pain management is preferred (to avoid sympathetic surge from pain), with avoidance of general anesthesia if possible (as GA is associated with greater complications in patients with PH)8
• VA-ECMO: If concerns for patient destabilization arise, VA-ECMO should be initiated. 8

Post-partum: The majority of complications occur after delivery, with the first week posing the highest risk period. Close monitoring must be initiated, preferably in a CCU/ICU for several days post-delivery. Early diuresis is paramount, as fluid mobilization after delivery can lead to fluid overload and right heart failure.  8

1. McLaughlin, V.V., Shah, S.J., Souza, R. and Humbert, M., 2015. Management of pulmonary arterial hypertension. Journal of the American College of Cardiology, 65(18), pp.1976-1997.

2. Meng, M.L., Landau, R., Viktorsdottir, O., Banayan, J., Grant, T., Bateman, B., Smiley, R. and Reitman, E., 2017. Pulmonary hypertension in pregnancy. Obstetrics & Gynecology, 129(3), pp.511-520.

3. Lima, F.V., Yang, J., Xu, J. and Stergiopoulos, K., 2017. National trends and in-hospital outcomes in pregnant women with heart disease in the United States. The American journal of cardiology, 119(10), pp.1694-1700.

4. Bedard, E., Dimopoulos, K. and Gatzoulis, M.A., 2009. Has there been any progress made on pregnancy outcomes among women with pulmonary arterial hypertension?. European heart journal, 30(3), pp.256-265.

5. Weiss BM, Zemp L, Seifert B, Hess OM. Outcome of pulmonary vascular disease in pregnancy: A systematic overview from 1978 through 1996. J Am Coll Cardiol. Published online 1998. doi:10.1016/S0735-1097(98)00162-4

6. Thomas E, Yang J, Xu J, Lima F V., Stergiopoulos K. Pulmonary hypertension and pregnancy outcomes: Insights from the national inpatient sample. J Am Heart Assoc. Published online 2017. doi:10.1161/JAHA.117.006144

7. Sliwa K, van Hagen IM, Budts W, et al. Pulmonary hypertension and pregnancy outcomes: data from the Registry Of Pregnancy and Cardiac Disease (ROPAC) of the European Society of Cardiology. Eur J Heart Fail. Published online 2016. doi:10.1002/ejhf.594

8. Martin, S.R. and Edwards, A., 2019. Pulmonary hypertension and pregnancy. Obstetrics & Gynecology, 134(5), pp.974-987.

• Karan Desai, MD
• Amit Goyal, MD
• Daniel Ambinder, MD

CardioNerds Dr. Rick Ferraro, Director of the #CardsJC Journal Club and cardiology fellow at Johns Hopkins, and Dr. Tommy Das, Program Director of the CardioNerds Academy and cardiology fellow at Cleveland Clinic, learn all about the clinical application of the ASCVD primary and secondary prevention guidelines in terms of lifestyle modifications and lipid lowering strategies from Dr. Allison Bailey, Editor-in-Chief of the ACCEL Audio Journal and Advanced Heart Failure and Transplant Cardiologist at Centennial Heart. Dr. Baily was a co-author on the 2018 ACC/AHA Guideline on the Management of Blood Cholesterol.

In this episode we will learn about the current guidelines for primary prevention of ASCVD, the evidence for specific dietary changes in improving cardiovascular outcomes, the current guidelines for secondary prevention of ASCVD, how successful are clinicians and patients in meeting LDL-C recommendations, and what the recent SAMSON trial teaches us about statin intolerance.

If you’re a current internal medicine resident, interested in the intersection between medical education, cardiovascular disease and digital media, consider applying to the CardioNerds Academy using this link. The deadline for this application is October 15th 2021. Learn more by visiting the CardioNerds Academy page.

Relevant disclosure: None

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“Lifestyle should be the first step and the last step of everything we do.”

1. In patients without established clinical ASCVD, the percent reduction in LDL-C is the strongest predictor of cardiovascular benefit. In patients with high LDL-C levels, a 50% reduction in LDL-C levels should be targeted.
2. In high-risk patients with established clinical ASCVD, we should target a 50% reduction in LDL-C levels and an LDL-C level less of than <70mg/dL. Lower LDL-C levels are associated with better ASCVD outcomes, and European guidelines recommend targeting an LDL-C level of <55mg/dL.
3. LDL-C lowering starts with promoting a health-lifestyle with emphasis on regular exercise and heart-healthy diet. Randomized trials support the efficacy of the Mediterranean diet in reducing cardiovascular events.

1. What are the current guidelines for primary prevention of ASCVD?

• The 2019 ACC/AHA Guidelines on the primary prevention of Cardiovascular Disease provides the following guidance for clinicians (applicable to those without established clinical ASCVD):
  • For all patients, a heart-healthy lifestyle focused on diet and exercise is the most important way to prevent atherosclerotic disease.
  • For any patient with an LDL-C ≥ 190 mg/dL, a high intensity statin is recommended.
  • Patients aged 40-75 years old who have diabetes mellitus warrant at least a moderate intensity statin, and may benefit from a high-intensity statin based on additional risk factors
  • For patients aged 40-75 years old and with an LDL-C between 70-189 mg/dL without diabetes, the pooled cohort equation can determine 10-year ASCVD risk and guide a patient-centric risk discussion.
  • Percent reduction in LDL-C is the strongest predictor of cardiovascular benefit; a 50% reduction in LDL-C should be targeted for most patients.

2. What evidence exists for specific dietary changes in improving cardiovascular outcomes?

• A diet emphasizing intake of vegetables, fruits, legumes, nuts, whole grains, and fish is recommended to decrease ASCVD risk factors. Additionally, minimizing intake of processed meats, refined carbohydrates, and sweetened beverages can reduce ASCVD risk.
• The PREDIMED trial showed that among patients with high cardiovascular risk, a Mediterranean diet supplemented with extra-virgin olive oil or nuts reduced the incidence of major cardiovascular events when compared to a control diet (with advice to reduce dietary fat).
  • In a sub-study analysis of PREDIMED, a Mediterranean diet supplemented with nuts was associated with delayed progression of internal carotid intima-media thickness and plaque height by ultrasound, suggesting a mechanistic cause of the Mediterranean diet’s cardio-protective effect.
• The Adventist Health Study-2 cohort demonstrated a significant association between vegetarian diets and decreased all-cause mortality and cardiovascular mortality. 

3. What are the current guidelines for secondary prevention of ASCVD?

• Secondary prevention of ASCVD is important for all patients with history of clinical ASCVD (e.g. prior history of ACS, MI, stable or unstable angina, stroke, TIA, or PAD including aortic aneurysm of atherosclerotic origin).
• In these patients, a healthy lifestyle should be emphasized as the first intervention.
• In addition, patients should be started on a high intensity statin. For all patients we should target a percent LDL-C reduction of at least 50%. In high-risk patients (those with a history of multiple major ASCVD events or one major ASCVD event and multiple high-risk conditions), we should target a LDL-C level of ≤70 as well.
  • While American guidelines recommend targeting a goal of ≤70 mg/dL, European guidelines recommend a target of ≤55 mg/dL. Most data suggests that lower is better for LDL-C; to learn why, enjoy Episode #132 – LDL Physiology & Function with Dr. Peter Toth)!
• If LDL-C remains above goal (of 70 mg/dL), ezetimibe should be started for an anticipated extra 20% lipid lowering.
• If LDL-C remains above goal, a PCSK-9 inhibitor should be considered. Notably, the ACC’s prior authorization tool is designed to collect data on the approval of these medications. 

4. How successful are clinicians and patients in meeting LDL-C recommendations?

• In a recent analysis of the PINNACLE registry (made up of over 2.5 million patients with known ASCVD), 52.7% had no history of being prescribed lipid lowering therapy, and 71.9% did not meet an LDL-C goal of ≤70.
• In the ISCHEMIA trial, only 41% patient patients were on optimal medical therapy by the end of the trial.
• Dr. Bailey suggests an approach to patient counseling wherein patients are aware of which medications actively improve their symptoms, and which medications improve longevity. Additionally, polypharmacy should be avoided through careful medication reconciliation.

5. What does the recent SAMSON trial teach us about statin intolerance?

• In this recent trial, 60 patients with a prior history of statin intolerance were randomized to either atorvastatin 20mg, a placebo, or no treatment. Each patient cycled through all three treatment options.
• When patients were taking either the statin or placebo, they reported significantly more side effects compared to when they were taking no treatment.
• Notably, after learning whether they were taking placebo or statin while experiencing symptoms at the completion of the trial, roughly 50% of patients were able to tolerate a statin.

1. 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
2. Estruch R, Ros E, Salas-Salvadó J, et al. Primary Prevention of Cardiovascular Disease with a Mediterranean Diet Supplemented with Extra-Virgin Olive Oil or Nuts. N Engl J Med. 2018;378(25):e34. doi:10.1056/NEJMoa1800389
3. Sala-Vila A, Romero-Mamani ES, Gilabert R, et al. Changes in ultrasound-assessed carotid intima-media thickness and plaque with a Mediterranean diet: a substudy of the PREDIMED trial. Arterioscler Thromb Vasc Biol. 2014;34(2):439-445. doi:10.1161/ATVBAHA.113.302327
4. Orlich MJ, Singh PN, Sabaté J, et al. Vegetarian dietary patterns and mortality in Adventist Health Study 2. JAMA Intern Med. 2013;173(13):1230-1238. doi:10.1001/jamainternmed.2013.6473
5. 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]. Circulation. 2019;139(25):e1082-e1143. doi:10.1161/CIR.0000000000000625
6. Authors/Task Force Members; ESC Committee for Practice Guidelines (CPG); ESC National Cardiac Societies. 2019 ESC/EAS guidelines for the management of dyslipidaemias: Lipid modification to reduce cardiovascular risk [published correction appears in Atherosclerosis. 2020 Jan;292:160-162] [published correction appears in Atherosclerosis. 2020 Feb;294:80-82]. Atherosclerosis. 2019;290:140-205. doi:10.1016/j.atherosclerosis.2019.08.014
7. Wood FA, Howard JP, Finegold JA, et al. N-of-1 Trial of a Statin, Placebo, or No Treatment to Assess Side Effects. N Engl J Med. 2020;383(22):2182-2184. doi:10.1056/NEJMc2031173
8. O’Keefe JH Jr, Cordain L, Harris WH, Moe RM, Vogel R. Optimal low-density lipoprotein is 50 to 70 mg/dl: lower is better and physiologically normal. J Am Coll Cardiol. 2004;43(11):2142-2146. doi:10.1016/j.jacc.2004.03.046

Alison L. Bailey @a_l_bailey is a General Cardiologist in Chattanooga, TN. She completed her medical training (all of it!) at the University of Kentucky and has been using what she learned there for the last 20 years. She loves ALL of cardiology, but spends most of her clinical time in prevention and heart failure. She believes that Food is Medicine and is passionate about helping her community find healthier ways to live. She has been involved in medical education throughout her career as a chief resident, chief fellow and Cardiology Fellowship program director. She currently serves as the Editor-in-Chief of ACCEL and thinks the most important contribution any of us can make is to elevate medical education. She believes in the mission of CardioNerds wholeheartedly. She enjoys cooking, reality TV and hanging out with Max, her favorite son.

• Tommy Das, MD
• Dr. Rick Ferraro
• Amit Goyal, MD
• Daniel Ambinder, MD

CardioNerds Amit Goal, Daniel Ambinder, & Dr. Alex Pipilas (FIT, Boston University) discuss the clinical examination in patients with heart failure with Dr. Mark Drazner, professor of medicine, clinical chief of cardiology, and medical director of the LVAD and Cardiac Transplantation Program at UT Southwestern. In this pearl laden episode, they discuss how the exam can be used to non-invasively assess a patient’s hemodynamic status, risk stratify and inform prognosis, and guide management. They also discuss ways to master the evaluation of the JVP and categorize patients based on their RA:PCWP ratio.

Check out the CardioNerds Failure Heart Success Series Page for more heart success episodes and content!

Relevant disclosures: None

The CardioNerds Heart Success Series is developed in collaboration with the Heart Failure Society of America. The Heart Failure Society of America is a multidisciplinary organization working to improve and expand heart failure care through collaboration, education, research, innovation, and advocacy. Its members include physicians, scientists, nurses, nurse practitioners, and pharmacists. Learn more at hfsa.org.

This episode is made possible with support from Panacea Financial. Panacea Financial is a national digital bank built for doctors by doctors. Visit panaceafinancial.com today to open your free account and join the growing community of physicians nationwide who expect more from their bank. Panacea Financial is a division of Primis, member FDIC.

Pearls • Notes • References • Guest Profiles • Production Team

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• Begin hemodynamic assessment with the evaluation of congestion (“wet” vs “dry”) and perfusion (“cold” vs “warm”). In a 2×2 table, this breaks patients into 4 broad hemodynamic profiles
• The most sensitive markers of congestion (PCWP > 30) are JVP >12 with an OR of 4.6 and the presence of orthopnea with an OR of 3.6
• “If you are cold, you are cold, if you are warm, you can still be cold”. Sensitivity for clinical markers of low cardiac index is very poor. Consider a low output state in patients with poor response to what are thought to be appropriate therapies
• Most patients with acute on chronic heart failure have an RA:PCWP ratio of 1:2. These patients are the so called “concordant” phenotype. There are two other sub-phenotypes:
  • The “RV equalizer group” have an elevated RA:PCWP ratio
  • The “RV compensated” group have a lower RA:PCWP ratio
• Clinical congestion at the time of hospital admission as well as discharge portends a poor prognosis for patients with heart failure

1. What is the physical exam important in patients with heart failure?

• Important to view the physical exam as a diagnostic test with strengths and limitations
• It is a noninvasive way to assess hemodynamics and risk stratify patients
• Can provide information on prognosis
• May enhance the provider-patient relationship

2. How might we classify hemodynamics noninvasively?

• Framework begins with the “Stevenson” Classification, developed by Dr. Lynne Stevenson
• Classifies patients along two axes: congestion and perfusion
• Congestion is the assessment of overall volume status and estimation of right and left sided filling pressures, broadly broken up into “wet” or “dry”:
  • “Wet”, PCWP >15mmHg
  • “Dry”, PCWP <15mmHg
• Perfusion is the assessment of the adequacy of cardiac output to provide oxygen to peripheral tissues, broken up into “warm” (i.e adequate perfusion) or “cold” (i.e poor perfusion):
  • “Warm”, Cardiac index >2.2
  • “Cold”, Cardiac index <2.2
• You then develop a 2×2 table to begin hemodynamic assessment (Figure 1 – above)

3. What is the role of the clinical exam in the assessment of congestion: “Wet” or “Dry”

• Signs:
  • Elevated jugular venous pressure. The JVP is one of the two most sensitive markers for congestion such that a JVP > 12 predicts PCWP > 30 with an OR of 4.6 (Drazner, 2008).
  • Rapidly developing ascites or edema
  • Square wave test. The square wave test takes advantage of an abnormal response to Valsalva in patients with low systolic function and elevated filling pressures. In those with congestion, the MAP fails to fall with decrease in RV and LV preload from the Valsalva maneuver due to preexisting high filling pressures. This is likely the best evidence that the patient has elevated filling pressures and may help to identify patients with the discordant hemodynamic phenotypes.
• Symptoms:
  • Orthopnea: one of the two most sensitive markers for congestion such that the presence of orthopnea predicts PCWP > 30 with an OR of 3.6 (Drazner, 2008).
  • Bendopnea: the sensation of feeling breathless within 30 seconds of bending over. Bendopnea is associated with higher filling pressures and low cardiac index (Thibodeau JT T. A.-M., 2014), with increased risk of short term heart failure admission ( (Thibodeau JT J. B., 2017), and with elevated VE/VCO2 (more advanced HF marker from CPET) (Dominguez-Rodriguez A, 2016). Relief of bendopnea during hospitalization is associated with greater fall in median NT-proBNP.
• The following are less helpful for identifying patients with acute on chronic  HF
  • Rales have a low sensitivity and specificity for acute on chronic decompensated heart failure. If rales are present in chronic HF patients, consider looking for pulmonary pathology. This doesn’t apply for patients with acute MI or flash pulmonary edema.
  • Weight may be misleading as heart failure is a cachexia promoting illness such that variation in weight may not be referred to fluid status alone. Volume overload often leads to appetite changes and weight loss as well as fluid retention which together can lead to net negligible weight change. Additionally once patients are euvolemic and clinically improved, they might gain true caloric weight which makes tracking “dry weights” difficult. Weight may be helpful over the short term i.e with a report of 10lbs of weight gain within the past week + significant stigmata of overload. With these considerations, we must be cautious regarding targeting a fixed “dry” weight over long periods of time given true changes in body weight.
• Adjunctive data may help adjudicate the bedside assessment of congestion:
  • Prognosis is better with down trending natriuretic peptides but no data clearly suggests benefit from tailoring therapy based on these levels.
  • Echo parameters such as the PASP, mitral inflow pattern, and IVC size may be helpful in the right context.
  • Implantable PA sensors (i.e. CardioMems) may be helpful. A large RCT looking at this, Guide-HF, trial is still enrolling. 

4. What are some tips & tricks for measuring the JVP?

• We are not looking for venous structure, but rather referred pulsating waves, which are usually better seen than felt.
• Look on both sides of the neck!
• Carotid vs Jugular vein – if you compress BELOW the pulsation and it goes away then it is a VENOUS pulsation. If not, then it is likely carotid. Venous pulsation (not carotid pulsation) will change in height as you adjust the degree of patient’
• If unable to see the pulsation, sit the patient upright and assess. It may be too high to see when recumbent
• Can use the EJ if it is respirophasic. If it isn’t then the high level could be due to a valve in the vein in which case we need to be cautious with interpretation.

5. What is the connection of the JVP (i.e estimated RA pressure) to left sided filling pressures (i.e PCWP/LVEDP) (Drazner 2008)?

• The RAP:PCWP ratio is ~1:2 (“concordant”) in 70-75% of patients in acute on chronic heart failure from ESCAPE trial data.  Importantly, this relationship does not hold in all groups of patients including those with acute MI or other conditions which may cause discordance between right- and left-sided filling pressures like primary pulmonary hypertension, significant valvular disease, etc.
• This relationship does not hold ~25-30% of the time, where the RAP and PCWP are “discordant.” The two sub-phenotypes to think about are:       
  • Right/left equalizers: high RAP:PCWP ratio (ratio ~≥ 2:3). Clinically, a high JVP may overestimate the overall fluid status. They may run into hypotension and worsening renal function because left sided pressures are lower than you would estimate by the JVP. These tend to be sicker patients with a generally worse prognosis (Grodin JL, 2015).
  • Compensated RV group: low RAP:PCWP ratio (ratio ~≤ 1:3). In contrast to the right/left equalizers, those with a “compensated RV” may have a JVP which underestimates the overall fluid status since the RAP is lower for a given PCWP. Consider this phenotype in those with classic left sided HF symptoms despite a relatively low or normal JVP.
• There are no clear clinical makers to identify patients who are in the discordant phenotypes but if the clinical course is not what you expect, consider exploring if a patient’s hemodynamics fall within these discordant phenotypes.
• If a patient has had a RHC in the past, you can use their previous RA:PCWP ratio to estimate left sided filling pressures with JVP during subsequent encounters
  • There is some data to suggest that a given patient us unlikely to move from one extreme to another, at least over a short period of time (i.e move from right/left equalizers to compensated RV ect)
  • More likely, a patient may move from extremes to the middle with either progression of disease or improvement

6. What is the role of the clinical exam in the assessment of perfusion: “Warm” or “Cold”?

• “If they are cold, they are cold. If they are warm, they still may be cold.” In other words, the sensitivity of the clinical evaluation is poor for the diagnosis of poor perfusion, but the specificity is high.
• Signs:
  • Narrow pulse pressure
    • Sensitivity is 10%, specificity is 96%
  • SBP <90 mmHg
    • Sensitivity 12%, specificity 86%
  • Cool lower extremities
    • Sensitivity of 20%, specificity of 88%
  • Consider low output if there is poor response to appropriate diuretic administration (Drazner, 2008) (Thibodeau JT D. M., 2018)
• Symptoms:
  • Lethargy – likely signifies a more advanced low output state, though not specific to heart failure

7. How does the hemodynamic profile guide initial management strategies?

• Profile A, “warm and dry”: compensated heart failure, if symptomatic, then consider heart failure mimics such as pulmonary or hematologic disease.
• Profile B, “warm and wet”: IV diuretics. If they do not respond as expected, then consider discordant RAP:PCWP groups or low output state.
• Profile C, “Cold and wet”, sick patients: IV diuretics, Inotropes, vasodilators, mechanical support.
• Profile L, “Cold and dry”, often very sick, tailored to situation.

8. What is the connection between the hemodynamic status and prognosis?

• Congestion portends a poor prognosis.
  • The occurrence of a heart failure hospitalization marks a steep inflection point in a patient’s prognosis (Drazner MH R. J., 2001).
  • The occurrence of clinical congestion and decompensation is a marker for increased mortality in the patient with heart failure.
  • The reason for the poor prognosis of heart failure decompensation is not clear. Is decompensation indicative of poor cardiorespiratory reserve or is it causal in some way? Reasons for the poor prognosis may include: neurohormal activation, ischemia, etc. More research is needed.
• Admission Congestion = increased risk of adverse event (Guillem Caldentey, 2014).
  • Unclear what the pathway is from clinical congestion to adverse outcomes.
    • Part could be renal congestion, cardiac cachexia and liver dysfunction.
• Discharge congestion = increased risk of adverse events when compared to patients who are discharged without congestion (Ambrosy, 2013).
• If you are UNABLE to congest someone or if re-congestion occurs within 1 year (i.e 2 hospitalizations in one year) this suggests a sick patient that may need to be considered for advanced therapies.

1. Ambrosy, A. P., Pang, P. S., Khan, S., Konstam, M. A., Fonarow, G. C., Traver, B., Maggioni, A. P., Cook, T., Swedberg, K., Burnett, J. C., Grinfeld, L., Udelson, J. E., Zannad, F., & Gheorghiade, M. “Clinical course and predictive value of congestion during hospitalization in patients admitted for worsening signs and symptoms of heart failure with reduced ejection fraction: Findings from the EVEREST trial.” European Heart Journal (2013): 835-43.
2. Dominguez-Rodriguez A, Thibodeau JT, Abreu-Gonzalez P, Ayers CR, Jimenez-Sosa A, Aranda JM Jr, Drazner MH. “Association Between Bendopnea and Key Parameters of Cardiopulmonary Exercise Testing in Patients With Advanced Heart Failure.” Journal of Cardiac Failure (2016): 163-165.
3. Drazner MH, Rame JE, Stevenson LW, Dries DL. “Prognostic importance of elevated jugular venous pressure and a third heart sound in patients with heart failure.” New England Journal of Medicine (2001): 574-81.
4. Drazner MH, Velez-Martinez M, Ayers CR, Reimold SC, Thibodeau JT, Mishkin JD, Mammen PP, Markham DW, Patel CB. “Relationship of right- to left-sided ventricular filling pressures in advanced heart failure: insights from the ESCAPE trial.” Circulation Heart Failure (2013): 264-70.
5. Drazner, M. H., Hellkamp, A. S., Leier, C. V., Shah, M. R., Miller, L. W., Russell, S. D., Young, J. B., Califf, R. M., & Nohria, A. “Value of clinician assessment of hemodynamics in advanced heart failure: the ESCAPE trial. .” Circulation. Heart failure (2008): 170-177.
6. Grodin JL, Drazner MH, Dupont M, Mullens W, Taylor DO, Starling RC, Tang WH. “A disproportionate elevation in right ventricular filling pressure, in relation to left ventricular filling pressure, is associated with renal impairment and increased mortality in advanced decompensated heart failure.” American Heart Journal (2015): 806-812.
7. Guillem Caldentey, Paul Khairy, Denis Roy, Hugues Leduc, Mario Talajic, Normand Racine, Michel White, Eileen O’Meara, Marie-Claude Guert. “Prognostic Value of the Physical Examination in Patients With Heart Failure and Atrial Fibrillation: Insights From the AF-CHF Trial.” JACC Heart Failure (2014): 15-23.
8. Thibodeau JT, Drazner MH. “The Role of the Clinical Examination in Patients With Heart Failure.” JACC Heart Failure (2018): 543-551.
9. Thibodeau JT, Jenny BE, Maduka JO, Divanji PH, Ayers CR, Araj F, Amin AA, Morlend RM, Mammen PP, Drazner MH. “Bendopnea and risk of adverse clinical outcomes in ambulatory patients with systolic heart failure.” American Heart Journal (2017): 102-107.
10. Thibodeau JT, Turer AT, Gualano SK, Ayers CR, Velez-Martinez M, Mishkin JD, Patel PC, Mammen PP, Markham DW, Levine BD, Drazner MH. “Characterization of a novel symptom of advanced heart failure: bendopnea. .” JACC Heart Failure (2014): 24-31.

Mark Drazner, M.D., is a Professor in the Department of Internal Medicine at UT Southwestern Medical Center. He specializes in treating patients with cardiomyopathy and advanced heart failure, including those who undergo a heart transplant or implantation of a ventricular assist device to help the heart pump blood. He is the Clinical Chief of Cardiology at UT Southwestern and the Medical Director of the Left Ventricular Assist Device (LVAD) and Cardiac Transplant Program. He holds the James M. Wooten Chair in Cardiology.

Dr. Drazner earned his medical degree at Washington University in St. Louis. He completed a residency in internal medicine at UT Southwestern Medical School, where he was Chief Resident. He received advanced training in cardiology through a fellowship at Duke University and then further specialized training in heart failure/cardiac transplantation through a fellowship at Brigham and Women’s Hospital. He also earned a Master of Science in epidemiology at Harvard University School of Public Health.

Dr. Drazner was one of the first physicians in North Texas to be certified by the American Board of Internal Medicine in the new subspecialty of advanced heart failure and transplant cardiology.

He has been at the forefront of research in heart failure and cardiac transplantation and has published numerous academic articles in top medical journals.

Dr. Drazner is a member of several professional organizations, including the American Heart Association, the American College of Cardiology, the Heart Failure Society of America, and the International Society for Heart and Lung Transplantation.

He has been selected as a Best Doctor by D Magazine, a Super Doctor by Texas Monthly, a Best Doctor in America by Best Doctors Inc., and a Top Doctor by Castle Connolly on numerous occasions.

Alexandra Pipilas (@apipilasMD) is a cardiology fellow at Boston Medical Center. She completed her undergraduate training at Boston University before leaving for a short stint in Chicago for medical school. She then returned to Boston for internal medicine residency and chief residency at Boston Medical Center. Outside of the hospital, she is enjoys attempting to climb the peloton leaderboard and spending time with friends and family.

• Amit Goyal, MD
• Daniel Ambinder, MD

In the PA.ACC – CardioNerds Narratives in Cardiology episode, CardioNerd Amit Goyal joins Dr. Miranda Merrill (FIT, Oregon Health & Science University), Dr. Stephanie Fuentes Rojas (FIT, Houston Methodist Hospital), and Dr. Natasha Cuk (FIT, Cedars-Sinai Medical Center) for a discussion with Dr. Kamala Tamirisa (Clinical Cardiac Electrophysiologist, Texas Cardiac Arrhythmia, National ACC Women in Cardiology Leadership Council Member and Co-Chair for ACC Women in Cardiology Advocacy Work Group, and current co-chair of the Texas Chapter ACC EP section) about gender equity and women in cardiology and electrophysiology. This episode focuses on the experiences of women in cardiology across the spectrum of training, from medical school, fellowship, through the procedural field of electrophysiology, to local and national leadership and beyond. Listen to the episode to learn about the factors which have led to Dr. Tamirisa’s success as a private practice electrophysiologist incorporating leadership roles in medical education and national organizations. Closing remarks by Texas ACC chapter governor, Dr. Kenneth Shaffer. Episode script was developed by Dr. Miranda Merrill and episode notes were developed by Dr. Natasha Cuk.

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.

Video Version • Notes • References • Production Team

Claim free CME just for enjoying this episode! There are no relevant disclosures for this episode.

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“The exciting part today is to see three women who are interested in EP… like RBG said, when all EP physicians are women, that’s the day we’re going to celebrate” 07:15

“There’s nothing (more) exciting… than EP, just that technology, the marriage between analytical thinking, tactile, touch, with a deductive logic.” 09:18

“Multiple studies have documented sex disparities in cardiovascular care… (Historically) women and minorities did not receive implantable cardioverter defibrillators or even BiV (biventricular) pacers… a potential driver for these disparities in cardiovascular disease is lack of diversity in the workforce. Very simple.” 19:28

“I still want to wear my lipstick. I still want to wear my heels. I want to do my hair. I still want to be a proceduralist and that’s okay. Make room.” 28:00

While this episode and the following notes are specific to women in electrophysiology, these same basic principles apply to fostering a more inclusive and welcoming environment in other subspecialties for all persons regardless of sex, gender, race, ethnicity, IMG status, and the other factors which make us different from one another and which enrich our workforce.

1. Why choose electrophysiology?

• An EP career is unique – it combines the biology, physiology, and procedural skills learned in residency and fellowship training with engineering, mathematic, and imaging principles learned and refined in advanced EP fellowship.1
• EPs work in a spectrum of settings and with a spectrum of modalities: inpatient, outpatient clinic, EP lab and with fluoroscopy, echocardiography (including intracardiac echo), 3D mapping systems, intracardiac EGMs, surface EKGs. Bedside medicine is still key to this field.
• Curative procedures performed in EP have a meaningful impact on patients’ quality and quantity of life1 and life saving devices such as implantable cardioverter defibrillators have profound impacts on mortality with a number needed to treat to save one life between 3-27 for both primary and secondary prevention indications from multiple randomized controlled trials.2
• If you LOVE EKGs, find yourself dissecting telemetry strips, and bonding with your mentors over EKG analysis, then EP is the field for you!
• 40% of the 130 clinical cardiac electrophysiology fellowship positions in the U.S. remain unfilled and there is a decline in the number of fellows choosing EP for advanced training over the last 5 years. Early exposure to internal medicine residents and first year cardiology fellows to the field will allow time for exploration and may help direct more trainees with an interest to this career.1

2. What are some opportunities for an electrophysiologist in private practice?

• Private practice can facilitate a certain level of independence and flexibility including directing choices both large and small such as which devices and tools are used, how the lab is set up, or even the ability to build an entirely new ablation program.
• Leadership is inherent to private practice, especially in EP – there are opportunities everywhere!
• Private practice facilitates close, longitudinal relationships with patients.
• Understanding the finances is important – take time to learn about this from mentors not just in EP but in other fields of medicine or even outside of medicine.
• Community initiatives can be a fulfilling aspect in addition to procedures, patient care, and leadership opportunities. Dr. Tamirisa earned a Healthcare Heroes Award for Northwest Ohio in 2017 for making an impact on community wellbeing, domestic violence/impact on cardiovascular disease, and health of minority women and was nominated for the Thomas Jefferson Award for the Northwest Ohio region in 2016 for her contribution to women’s empowerment in the community.

3. Why and how should we promote diversity within electrophysiology?

• Women physicians across subspecialties are more likely to provide patient centered communication and may provide improved outcomes for certain patient populations.3,4
• Diversity drives innovation, which is why drawing more women and underrepresented minorities to EP will advance the field.5
• Women are “unicorns” in the procedural subspecialties of cardiology.6 Their representation is not growing at the same rate as in other parts of medicine; only 7-10% of EPs currently in practice are women and there remains limited visibility in leadership roles for women at the national level.1,7,8
• How can we address barriers to entry into the field? Dr. Tamirisa makes several suggestions in her EP lab digest article and in the podcast.1
  • Adjust work and training environments so that they are more inclusive to women and URiM.
  • Address sexual harassment and discrimination on the basis of sex, gender, race, ethnicity, and other factors which make us different and enrich our field.9
  • Advocate for work-life integration for all, including flexible (full- and part-time) work schedules such as 4 day-a-week schedules.
  • Acknowledge and respond to family planning concerns given that childbearing age may overlap with the training period: limit radiation exposure, protect research and family leave time, provide access to lactation areas, and consider reduced or flexible training schedules (such as 2.5 years/30 months of cardiology fellowship and 18 months of EP training).

4. Mentorship in Electrophysiology and Empowering Women to Succeed

• Mentorship in EP for women can and should be from both women and men! Initiatives such as social media hashtags #HeforShe and #TakeAWomanToTheCathLab and official speaking opportunities eliminating “manels” at national conferences are creating a more inclusive field.10
• Tips for mentors:
  • Be kind always.
  • Listen to your mentees – even without offering advice, just listening can lead to profound insights.
  • Show your flaws – shattering the illusion of a perfect career or trajectory can help your foster confidence and the ability to tackle obstacles.
  • Be open, vulnerable, and honest (both as a mentor and mentee!)
  • Be inclusive with your projects.
  • Understand the microaggressions that women and underrepresented minorities face in training and their careers. Help them with tools to address those issues including microresistance response strategies.11,12
  • Engage and share your creative endeavors! Dr. Tamirisa writes poetry and journals as her outlet.13

Tamirisa KP. The Importance of Choosing Cardiac Electrophysiology as a Career: Thoughts on the EP Fellow Shortage. EP Lab Digest. 2020;20(2). https://www.hmpgloballearningnetwork.com/site/eplab/importance-choosing-cardiac-electrophysiology-career-thoughts-ep-fellow-shortage

2.   Al-Jefairi N, Burri H. Relevance of guideline-based ICD indications to clinical practice. Indian Heart J. 2014;66 Suppl 1:S82-87. https://www.ncbi.nlm.nih.gov/pubmed/24568834

3.   Roter DL, Hall JA. Physician gender and patient-centered communication: a critical review of empirical research. Annu Rev Public Health. 2004;25:497-519. https://www.ncbi.nlm.nih.gov/pubmed/15015932

4.   Tsugawa Y, Jena AB, Figueroa JF, Orav EJ, Blumenthal DM, Jha AK. Comparison of Hospital Mortality and Readmission Rates for Medicare Patients Treated by Male vs Female Physicians. JAMA Intern Med. 2017;177(2):206-213. https://www.ncbi.nlm.nih.gov/pubmed/27992617

5.   Welson-Rossman T. Healthcare Needs More Diverse Experts To Guide Innovation. ForbesWomen. 2021. https://www.forbes.com/sites/traceywelsonrossman/2021/02/09/healthcare-needs-more-diverse-experts-to-guide-innovation/?sh=358d5b2769e6

6.   The Unicorns: Women in Cardiac Electrophysiology and Interventional Cardiology [Webinar]2020. https://www.acc.org/education-and-meetings/meetings/meeting-items/2020/04/01/12/41/the-unicorns

7.   Burgess S, Shaw E, Ellenberger K, Thomas L, Grines C, Zaman S. Women in Medicine: Addressing the Gender Gap in Interventional Cardiology. J Am Coll Cardiol. 2018;72(21):2663-2667. https://www.ncbi.nlm.nih.gov/pubmed/30466523

8.   Yong CM, Balasubramanian S, Douglas PS, et al. Temporal Trends in the Proportion of Women Physician Speakers at Major Cardiovascular Conferences. Circulation. 2021;143(7):755-757. https://www.ncbi.nlm.nih.gov/pubmed/33587663

9.   Tamirisa KP, Volgman AS, Parwani P, Lundberg GP. Advocacy to End Sexual Harassment: Voices From Women in Cardiology. JACC Case Rep. 2021;3(6):975-977. https://www.ncbi.nlm.nih.gov/pubmed/34319306

10. Harrington RA. 5 Questions: Robert Harrington on research, health equity and the gender gap in cardiology. 2020. https://med.stanford.edu/news/all-news/2020/02/harrington-on-research-health-equity-and-more.html. Accessed August 5, 2020. Accessed February 19, 2020.

11. POD Diversity Committee White Paper. 2016 POD Network Conference; November 9-13, 2016, 2016; Louisville, Kentucky. https://podnetwork.org/content/uploads/DC-white-paper-2016_Final2.pdf

12. Wheeler DJ, Zapata J, Davis D, Chou C. Twelve tips for responding to microaggressions and overt discrimination: When the patient offends the learner. Medical Teacher. 2019;41(10):1112-1117. https://doi.org/10.1080/0142159X.2018.1506097

13. Tamirisa KP. Poem | Metaphors For a Woman. ACC WIC Section Online. 2020. https://www.acc.org/membership/sections-and-councils/women-in-cardiology-section/section-updates/2020/02/27/12/42/a-poem-metaphors-for-a-woman

• Dr. Gurleen Kaur
• Amit Goyal, MD
• Daniel Ambinder, MD

CardioNerds Dr. Rick Ferraro, Director of the #CardsJC Journal Club and cardiology fellow at Johns Hopkins and Dr. Tommy Das, Program Director of the CardioNerds Academy and cardiology fellow at Cleveland Clinic join Academy fellow and episode lead Dr. Julie Power, chief fellow at the University of Minnesota to learn all about the link between LDL-C and cardiovascular events and disparities in care from Dr. Keith Ferdinand, Professor of Medicine and Chair in Preventative Cardiology at Tulane University School of Medicine.

As we’ve learned in prior episodes, LDL-C plays a key role in lipid pathophysiology.  But how does it lead to cardiovascular events?  LDL-C directly leads to plaque expansion and deposition in the arterial intima. Increasing levels of LDL-C are directly related to worsening plaque burden, a principle exhibited powerfully by the dose-dependent nature of coronary atherosclerosis in patients with underlying mutations leading to LDL-C elevation, such as familial hypercholesterolemia.

Importantly, the treatment of atherosclerosis and implementation of lipid-lowering therapies are not uniform, with significant disparities throughout the community. The message is clear: Reducing LDL-C is of paramount significance in the prevention and treatment of coronary atherosclerosis and ensuring equitable access to care is critical to addressing the societal burden of cardiovascular disease and improving the health of our communities.

There is no CME associated with this episode. To get free CME from other CardioNerds episodes, please visit VCU Health here.

Relevant disclosure: Dr. Ferdinand reported severing as a consultant for Medtronic, Amgen, and Novartis.

Pearls • Quotables • Notes • References • Guest Profiles • Production Team

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1. LDL-C is a major stimulant for the initiation and progression of atherosclerosis.
2. The lower the LDL-C level, the greater the clinical benefit in both primary and secondary ASCVD prevention.
3. Our healthcare systems continue to have major disparities in access to quality care and it is essential to reduce barriers to cardiovascular wellness for all communities.
4. Lowering LDL-C in individuals at high cardiovascular risk, especially in those with familial hypercholesterolemia, prevents ASCVD events.

“Empower patients to be partners in their care”

1. What is the link between LDL-C and cardiovascular events?

• LDL-C is a major stimulant for the initiation and progression of atherosclerosis. The key events in the initiation of ASCVD are the retention and accumulation of cholesterol-rich lipoproteins within the arterial intima at sites with a predilection for plaque formation. As serum levels of LDL-C increase, the probability of intimal retention of LDL leading to the development of atherosclerotic plaque increases in a dose-dependent manner [4].
• The WOSCOPS trial demonstrated genes associated with lower LDL-C levels are also associated with a three-fold reduction in the risk of cardiovascular disease per unit reduction in LDL-C [4].
• The Emerging Risk Factors Collaboration (ERFC) and Prospective Studies Collaboration reported plasma LDL-C was associated with increased risk of non-fatal MI or CHD death [4].
• Statins uniformly reduce atherosclerotic risk across varying levels of baseline LDL-C and are first line therapy for primary and secondary prevention of ASCVD.
• In high-risk individuals and secondary prevention populations, AHA/ACC guidelines recommend 50% reductions in LDL-C, regardless of baseline, to < 70 mg/dL, using a combination of statins, ezetimibe, and PCSK9 inhibition [6].
• Intravascular ultrasound studies of coronary atherosclerosis involving statin-treated patients demonstrated that progression of coronary atherosclerotic plaque volume can be arrested once an LDL-C of 70 mg/dL is reached [4, 10, 11].
• The effect of LDL-C on the risk of ASCVD is both causal and cumulative over time; therefore, lowering the LDL-C level early will lead to greater reductions in the lifetime risk of ASCVD. Each millimole per liter reduction in LDL-C reduces the relative risk of ASCVD events by ∼10% in the first year of treatment and ∼20–25% after 5 years [4].

2. What is Familial Hypercholesterolemia?

• Familial hypercholesterolemia (FH) is an autosomal co-dominant disorder that results from a mutation in an LDL receptor gene, ApoB gene, or PCSK9 gene. FH is characterized by markedly elevated levels of LDL-C and premature atherosclerosis.
• Siblings who inherit an FH mutation have markedly elevated plasma LDL-C levels and a corresponding markedly elevated lifetime risk of ASCVD as compared to their unaffected siblings, providing powerful evidence that LDL causes ASCVD.
• Heterozygous FH affects between 1:200 and 1:300 people worldwide and when untreated is characterized by LDL-C levels >190. FH should be considered in adults with LDL-C levels > 190 mg/dL or total cholesterol levels > 310 mg/dL [5].
• Homozygous FH is a much rarer condition, with an extreme phenotype characterized by untreated plasma LDL-C levels above >400 from birth and almost universal development of ASCVD and xanthomas in childhood or early adolescence. Statins can be started as early as 8-10 years of age. PCSK-9 inhibitors may also be used. LDL apheresis is also a common treatment option [5].
• To learn more about personalized ASCVD risk assessment and FH, enjoy CardioNerds Episode #98: Personalized Risk Assessment for Cardiovascular Prevention with Dr. Amit Khera.

3. What is the interaction of LDL-C with other ASCVD risk factors?

• There are numerous risk factors for ASCVD: hypertension, diabetes mellitus, tobacco smoking, and more. Patients with more risk factors have a higher absolute rate of ASCVD in comparison with persons with fewer risk factors [4].
• However, reduction in LDL-C is associated with the same proportional risk reduction of ASCVD, regardless of the presence or absence of these other risk factors [4].
• Statin therapy reduces vascular event rates, including major coronary events, stroke, and coronary revascularization by 15-25% for each 1 mmol/L reduction in LDL-C [8].

4. How do we best support the cholesterol management and cardiovascular health needs of underserved and low-resource communities?

• We must recognize and work together to address CV health disparities from both the individual and population levels.
• Reduced adherence to statin therapy among eligible patients is associated with increased mortality. Minority patients, those with low income, and those with barriers to health literacy have been found to be less likely to adhere to statins, signaling important disparities that must be addressed further. The reasons are likely multifactorial and require a multipronged approach to address.
• Team care delivered in nontraditional locations shows promise, but the cost-effectiveness and sustainability of these approaches need to be studied further [13].
• Barriers to treatment in low-resource communities exist at multiple levels:  educational opportunities, environment, limited access to healthy food options, access to healthcare providers, transport to healthcare facility organization and practice settings where care occurs, and governmental health policy. Focus is needed on developing cross-sectional partnerships to target multiple barriers [13, 16]
• Programs need early-stage investigators committed to disparities research to bridge these findings to clinical practice and formulation of health policy.
• To learn about the use of community based participatory research to meaningfully engage and empower the community in addressing these barriers, enjoy CardioNerds Episode #131 with Dr. LaPrincess Brewer and Dr. Norrisa Haynes.
• To learn about strategies to engage minority patients in clinical trials, enjoy CardioNerds Episode #135 with Dr. Clyde Yancy.

5. What are some other benefits and consequences of lowering LDL-C?

1. Intensive LDL-C lowering is associated with a greater reduction of all-cause mortality in addition to CV mortality [9].
2. LDL-C lowering has exhibited protective effects against cerebrovascular events.
3. The ODYSSEY trial in 2019 demonstrated that PCSK-9 therapy decreased the risk of stroke in patients with recent ACS and dyslipidemia; however, this was regardless of LDL-C levels achieved.
4. There is no evidence for an increased risk of cognitive impairment (PROSPER trial) or hemorrhagic stroke with lower LDL-C levels.

1. Baigent C, Blackwell L, Emberson J, et al. Efficacy and Safety of More Intensive Lowering of LDL Cholesterol: A Meta-Analysis of Data from 170,000 Participants in 26 Randomised Trials. Lancet. 2010; 376: 1670–81.
2. Damask A, Steg PG, Schwartz GG et al. Patients With High Genome-Wide Polygenic Risk Scores for Coronary Artery Disease May Receive Greater Clinical Benefit From Alirocumab Treatment in the ODYSSEY OUTCOMES Trial. Circulation. 2020 Feb 25;141(8):624-636.
3. Duran EK, Aday AW, Cook NR, et al. Triglyceride-Rich Lipoprotein Cholesterol, Small Dense LDL Cholesterol, and Incident Cardiovascular Disease. J Am Coll Cardiol. 2020 May 5; 75(17):2122-2135.
4. Ference BA, Yoo W, Alesh I, et al. Effect of Long-Term Exposure to Lower Low-Density Lipoprotein Cholesterol Beginning Early in Life on the Risk of Coronary Heart Disease: a Mendelian Randomization Analysis. Journal of the American College of Cardiology. 2012; 60: 2631-9.
5. Goldberg AC, Hopkins PN, Toth PP, et al. Familial Hypercholesterolemia: Screening, Diagnosis and Management of Pediatric and Adult Patients: Clinical Guidance from the National Lipid Association Expert Panel on Familial Hypercholesterolemia. J Clin Lipidol. 2011; 5:133–40.
6. 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. J Am Coll Cardiol. 2019;73: e285–350.
7. Mach F, Baigent C, Catapano AL, et al. 2019 ESC/EAS guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J. 2020; 41: 111–88.
8. Mihaylova B, Emberson J, Blackwell L, et al. The Effects of Lowering LDL Cholesterol with Statin Therapy in People at Low Risk of Vascular Disease: Meta-analysis of Individual Data from 27 Randomised Trials. Lancet. 2012; 380: 581-90.
9. Navarese EP, Robinson JG, Kowalewski M, et al. Association Between Baseline LDL-C Level and Total and Cardiovascular Mortality after LDL-C Lowering: A Systematic Review and Meta-analysis. JAMA. 2018; 319 (15): 1566-1579.
10. Nicholls SJ, Ballantyne CM, Barter PJ, et al. Effect of Two Intensive Statin Regimens on Progression of Coronary Disease. N Engl J Med. 2011; 365: 2078–2087.
11. Nissen SE, Nicholls SJ, Sipahi I, et al. ASTEROID Investigators. Effect of Very High-intensity Statin Therapy on Regression of Coronary Atherosclerosis: the ASTEROID Trial. JAMA. 2006; 295: 1556–1565.
12. Ridker, PM. LDL Cholesterol: Controversies and Future Therapeutic Directions. Lancet. 2014; 384: 607-617.
13. Schultz WM, Kelli HM, Lisko JC, et al. Socioeconomic Status and Cardiovascular Outcomes: Challenges and Interventions. Circulation. 2018. 137 (20): 2166–2178
14. Shepherd J, et al. Prevention of Coronary Heart Disease with Pravastatin in Men with Hypercholesterolemia”. The New England Journal of Medicine. 1995. 333 (20): 1301-1308.
15. Valdes-Marquez E, Parish S, Clarke R, et al. Relative Effects of LDL-C on Ischemic Stroke and Coronary Disease: a Mendelian Randomization Study. Neurology. 2019; 92: e1176–87.
16. Whelton PK, Einhorn PT, Muntner P, et al. Research Needs to Improve Hypertension Treatment and Control in African Americans. Hypertension. 2016.

Keith C Ferdinand, MD, is Professor of Medicine at the Tulane University School of Medicine and the Tulane Heart and Vascular Institute in New Orleans, Louisiana. He was previously Professor of Clinical Pharmacology at Xavier University, New Orleans and Clinical Professor of Medicine at Emory University, Atlanta, Georgia. Dr. Ferdinand received his medical degree from the Howard University College of Medicine in Washington, DC. He is board-certified in internal medicine and cardiovascular disease, certified in the subspecialty of nuclear cardiology, and a specialist in clinical hypertension certified by the American Society of Hypertension.

Dr. Julie Power @JuliettePower44 is a cheif cardiology fellow at the University of Minnesota. She completed medical school at Drexel University in Philadelphia followed by residency training at Allegheny General Hospital in Pittsburgh where she also served a Chief Resident. In addition to a continued involvement in medical education, Julie plans to pursue additional training in interventional cardiology after her general cardiology fellowship. In her free time, she enjoys spending time with family and friends, including exploring Minnesota with her boyfriend, Steve.

• Tommy Das, MD
• Dr. Rick Ferraro
• Amit Goyal, MD
• Daniel Ambinder, MD

CardioNerds (Amit Goyal and Daniel Ambinder) join fellow lead, Dr. Giselle A. Suero-Abreu (FIT, Massachusets General Hospital), Dr. Isadora Sande Mathias (FIT, Houston Methodist and CardioNerds Academy Fellow), and Dr. Victor Nauffal (FIT, Brigham and Women’s Hospital) for a discussion with Dr. William Zoghbi (Chair, Department of Cardiology, Houston Methodist Hospital, Methodist DeBakey Heart & Vascular Center, Past President, the American College of Cardiology) about international medical graduates in the cardiology workforce. This episode focuses on the narratives of international medical graduates (IMGs) who make important contributions to the US medical workforce and scientific innovation. Listen to the episode to learn the state of IMGs in the US physician workforce and the field of Cardiology, an overview of factors that influence IMG selection when applying to residency and fellowship training programs in the US, the impact of recent changes in licensing exams and immigration restrictions, and how to address challenges and support IMGs throughout their medical careers. Audio editing by CardioNerds Academy Intern, Dr. Leticia Helms.

Claim free CME just for enjoying this episode! Disclosures: None

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1. What is the definition of an international medical graduate (IMGs)?

• International medical graduates (IMGs) are physicians who who graduated from a medical school outside the United States, regardless of nationality.

• This group of foreign-trained physicians include US-IMGs (US citizens) and non-US IMGs (non-US citizens). Nearly 80% of IMGs are born abroad [1].

• In a paper senior authored by Dr. Zoghbi, IMGs in the US physician workforce are described as “the multicultural, multiethnic, open-minded, and plural fabric that has defined American medicine and contributed to its success over the years” [2].

2. Why are IMGs important?

• IMGs are an integral part of the U.S. healthcare system. They constitute about 25% of the physician workforce and, since 2010, the number of IMGs in practice has grown by nearly 18% [1, 3].

• IMGs play a critical role in addressing healthcare inequities across the US, comprising a significant proportion of physicians in high-need rural and underserved urban areas [1, 3, 4].

• IMGs contribute to the diversity and cultural competence in the US physician workforce with 98% of them speaking two or more languages fluently. They help patients overcome linguistic and cultural barriers that can interfere with their care [5]. Learn more about Diversity and inclusion (Episode 95) and Latinx representation in cardiology  (Episode 129).

• Racial and ethnic concordance between physicians and their patients results in improved healthcare outcomes, and IMGs are essential in matching the needs of the increasingly diverse US population [6].

• Many IMGs pursue the opportunity to train in the best academic programs in the US and return as leaders to serve their country. This becomes an avenue for international collaboration to help patients and contribute to research, innovation, and education.

3. What is the state of the IMG workforce in Cardiology?

• IMGs in cardiology serve as an important source of cardiac care in the United States.

• Data from the 2020 Physician Specialty Data Report from the Association of American Medical Colleges (AAMC) [7] showed that:

• Among active US physicians, IMGs comprise 31% of general cardiologists, 46% of interventional cardiologists, and 26% of pediatric cardiologists.
  • Among ACGME trainees, IMGs constitute 38% of fellows in cardiovascular disease, 53% in interventional cardiology, and 20% in pediatric cardiology.
  • Many IMGs have non-immigrant visas, including the J-1 Visitor Exchange visa, and pursue visa waivers at the end of their training. This provides an important source of care to patients in rural and underserved urban areas but can also pose restrictions that affect the career choices and post-training employment opportunities of these physicians [4, 8].
  • For example, only a third of visa waiver positions can go to specialists, creating difficulty for highly trained cardiovascular subspecialists who are IMGs (such as interventionalists and electrophysiologists) who sometimes have limited options to find a job that matches their training when integrating into the US cardiology workforce [4].

4. What are some challenges IMGs face?

• IMGs face a series of barriers when entering US residency programs, during their training experiences, and upon the transition into practice [2, 4, 8-11].

• There are disparities and biases concerning IMGs during the residency and fellowship match process. For instance, data from the 2020 NRMP Program Director survey showed that 36% of program directors would “seldom” interview a non-US IMG and 18% would “never” do so. When ranking non-US IMGs, 37% of program directors would “seldom” and 21% would “never” do so [12]. These numbers have remained similar over recent years.

• Over the past few years, changes related to licensing exams, immigration policies, and the COVID-19 pandemic have impacted the recruitment and integration of IMGs into the US physician workforce [2, 8, 11]

• Nearly 15,000 IMGs in active clinical practice in the US are awaiting permanent residency status. This limits their ability to work to the fullest capacity and capability, especially during public health emergencies [13].

• Understanding the challenges faced by IMGs can inform efforts to strengthen support and guidance for this resilient and hard-working group of physicians.

5. How can we support IMGs throughout their medical careers?

• There are many opportunities for addressing the professional and personal challenges faced by IMGs and supporting their integration throughout their medical careers (Table 1)  [4, 5, 10, 11].

• Discussion among program leadership at different institutions can help administrators learn from each other’s experiences regarding the recruitment and retention of IMGs and may help reduce barriers.

• Major medical organizations and the cardiology community can help address immigration and licensure policies affecting IMGs during training and when transitioning to the cardiology workforce in the US [2, 4, 13].

• Incorporating diversity and inclusion efforts into the mission of organizations is paramount to ensuring professional satisfaction and success for IMGs as academic faculty.

• Advocacy, mentorship, and sponsorship enable IMGs to contribute to their highest potential in their medical careers in the US and internationally.

• Figure 1. Arjun et al [10]
• Table 1. (Zaidi, Z. et al) [5]

The CardioNerds Narratives in Cardiology series features cardiovascular faculty representing diverse backgrounds, subspecialties, career stages, and career paths. Discussing why these faculty chose careers in cardiology and their passion for their work are essential components to inspiring interest in the field.

Each talk will feature a cardiology faculty from an underrepresented group, within at least one of several domains: gender, race, ethnicity, religion, national origin, international graduate status, disadvantaged backgrounds, etc.

Featured faculty will also represent a variety of practice settings, academic ranks, subspecialties (e.g. clinical cardiology, interventional cardiology, electrophysiology, etc), and career paths (e.g. division chief, journal editor, society leadership, industry consultant, etc).

Faculty will be interviewed by fellows-in-training for a two-part discussion that will focus on:

1) Faculty’s content area of expertise
2) Faculty’s personal and professional narrative

As part of their narrative, faculty  will discuss their unique path to cardiology and their current professional role with particular attention to challenges, successes, and advice for junior trainees. Specific topics will be guided by values relevant to trainees, including issues related to mentorship, work-life integration, and family planning.

To help guide this important initiative, the CardioNerds Narratives Council was founded to provide mentorship and guidance in producing the Narratives series with regards to guests and content. The CardioNerds Narratives Council members include: Dr. Pamela Douglas, Dr. Nosheen Reza, Dr. Martha Gulati, Dr. Quinn Capers, IV, Dr. Ann Marie Navar, Dr. Ki Park, Dr. Bob Harrington, Dr. Sharonne Hayes, and Dr. Michelle Albert.

The Narratives Council includes three FIT advisors who will lead the CardioNerds’ diversity and inclusion efforts, including the current project: Dr. Zarina Sharalaya, Dr. Norrisa Haynes, and Dr. Pablo Sanchez.

Dr. William A. Zoghbi, a renowned cardiology, echocardiography and cardiac imaging expert, has developed noninvasive heart function and valve disorder evaluation techniques. As a result, Dr. Zoghbi has overseen national and international heart valve evaluation guideline development.He built his reputation on his ischemic heart disease, myocardial function and hibernation research, as well as his development of echocardiographic techniques to evaluate valvular dynamics and measure valvular regurgitation. Dr. Zoghbi has authored more than 300 publications and lectured at every major cardiology conference worldwide.

Dr. Giselle Alexandra Suero Abreu is a cardiology fellow at Massachusetts General Hospital. She was born and raised in Dominican Republic where she received her M.D. from the Instituto Tecnológico de Santo Domingo (INTEC). During medical school, she discovered a passion for research and then attended New York University School of Medicine where she pursued a MSc in biology, physiology and neuroscience and then a PhD in biomedical imaging. During her PhD, she studied angiogenesis and tumor development in cancer models using multimodality molecular imaging. She went on to complete an internal medicine residency at Rutgers University New Jersey Medical School and is currently completing a chief resident year. She plans to pursue a career as a physician-scientist in the fields of cardio-oncology and cardiac imaging, and is interested in furthering diversity in academic medicine.

Dr. Victor Nauffal is a Clinical Fellow in the Division of Cardiovascular Medicine at the Brigham and Women’s Hospital. He was born in Sydney, Australia and earned his medical school degree from the American University of Beirut. He completed his internal medicine training at the Osler Housestaff Training Program at the Johns Hopkins Hospital. He will be pursuing subspecialty training in cardiac electrophysiology. His research efforts in cardiovascular epidemiology are focused on the intersection of  genetics and cardiac arrhythmias. In his free time he enjoys skiing and playing basketball.

Dr. Isadora “Isa” Sande Mathias is a cardiology fellow at Houston Methodist Hospital and completed internal medicine residency at the Cleveland Clinic. She was born and raised in the diverse city of Salvador de Bahia, Brazil, where she completed her medical school in 2017. Isa has always been upbeat, outgoing, making friends everywhere, and thus interested in connecting with people from different backgrounds and cultures, and that combined with a strong passion for cardiology and education attracted her to CardioNerds. In her free time, she likes to cook and try new restaurants, run, hike and practice yoga outdoors, and spend time with her cat Caju.

1.   Ahmed, A.A., et al., International Medical Graduates in the US Physician Workforce and Graduate Medical Education: Current and Historical Trends. J Grad Med Educ, 2018. 10(2): p. 214-218.

2.   Kalra, A., P.K. Shah, and W.A. Zoghbi, Travel Bans and Threats to US Health Care-Our Hearts Are at Stake. JAMA Cardiol, 2017. 2(4): p. 351-352.

3.   Murphy, B. How IMGs have changed the face of American medicine. 2020.

4.   Zoghbi, W.A., et al., Working group 4: International medical graduates and the cardiology workforce. Journal of the American College of Cardiology, 2004. 44(2): p. 245-251.

5.   Zaidi, Z., M. Dewan, and J. Norcini, International Medical Graduates: Promoting Equity and Belonging. Acad Med, 2020. 95(12S Addressing Harmful Bias and Eliminating Discrimination in Health Professions Learning Environments): p. S82-s87.

6.   Institute of Medicine Committee on, U., R. Eliminating, and C. Ethnic Disparities in Health, in Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, B.D. Smedley, A.Y. Stith, and A.R. Nelson, Editors. 2003, National Academies Press (US)

Copyright 2002 by the National Academy of Sciences. All rights reserved.: Washington (DC).

7.   2020 Physician Specialty Data Report. Active physicians who are international medical graduates (IMGs) by specialty. .  [cited 2021 June 22, 2021]; Available from: https://www.aamc.org/data-reports/workforce/interactive-data/active-physicians-who-are-international-medical-graduates-imgs-specialty-2019.

8.   Fanari, Z., Effect of Changes in Visa Policies and Procedures on Fellows-in-Training and Early Career Cardiologists. J Am Coll Cardiol, 2017. 69(25): p. 3115-3117.

9.   Chen, P.G.-C., et al., Professional Challenges of Non-U.S.-Born International Medical Graduates and Recommendations for Support During Residency Training. Academic Medicine, 2011. 86(11): p. 1383-1388.

10. Kanwal, A., G. Sharma, and E. Surkova, The Assimilation of International Medical Graduates Into the Cardiovascular Workforce. JACC: Case Reports, 2020. 2(3): p. 508-512.

11. Khan, M. and V. Madaan, New Ways to Support the Recruitment of International Medical Graduates During the Pandemic. Academic Medicine, 2021. 96(5): p. 616.

12. Results of the 2020 NRMP Program Director Survey.  June 2021]; Available from: https://www.nrmp.org/main-residency-match-data/.

13. Nagarajan, K.K., et al., Prevalence of US-trained International Medical Graduates (IMG) physicians awaiting permanent residency: a quantitative analysis. J Community Hosp Intern Med Perspect, 2020. 10(6): p. 537-541.

• Amit Goyal, MD
• Daniel Ambinder, MD

CardioNerds Cardio-OB series co-chairs University of Texas Southwestern Cardiology Fellow, Dr. Sonia Shah (FIT, University of Texas Southwestern) and Dr. Natalie Stokes, (FIT, University of Pittsburgh) join  Dr. Nanette Wenger, Professor of Medicine in the Division of Cardiology at the Emory University School of Medicine and a consultant to the Emory Heart and Vascular Center and Dr. Sharonne Hayes, Professor of Internal Medicine and Cardiovascular Diseases and founder of the Women’s Heart Clinic at Mayo Clinic for an in depth discussion about lifelong advocacy for women’s cardiovascular health.

Audio editing by CardioNerds Academy Intern, Dr. Leticia Helms.

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Dr. Nanette Wenger is Professor of Medicine in the Division of Cardiology at the Emory University School of Medicine. Dr. Wenger received her medical degree from Harvard Medical School in 1954 as one of their first female graduates followed by training at Mount Sinai Hospital where she was the first female to be chief resident in the cardiology department. She is among the first physicians to focus on heart disease in women with an expertise in cardiac rehabilitation and geriatric medicine.Dr. Wenger has received numerous awards including the Distinguished Achievement Award from the Scientific Councils of the American Heart Association and its Women in Cardiology Mentoring Award, the James D. Bruce Memorial Award of the American College of Physicians for distinguished contributions in preventive medicine, the Gold Heart Award, the highest award of the American Heart Association, a Lifetime Achievement Award in 2009 and the Inaugural Bernadine Healy Leadership in Women’s CV Disease Distinguished Award, American College of Cardiology. She chaired the U.S. National Heart, Lung, and Blood Institute Conference on Cardiovascular Health and Disease in Women, is a Past President of the Society of Geriatric Cardiology and is past Chair, Board of Directors of the Society for Women’s Health Research. Dr. Wenger serves on the editorial boards of numerous professional journals and is a sought-after lecturer for issues related to heart disease in women, heart disease in the elderly, cardiac rehabilitation, coronary prevention, and contemporary cardiac care. She is listed in Best Doctors in America.

Sharonne N. Hayes, M.D., studies cardiovascular disease and prevention, with a focus on sex and gender differences and conditions that uniquely or predominantly affect women. With a clinical base in the Women’s Heart Clinic, Dr. Hayes and her research team utilize novel recruitment methods, social media and online communities, DNA profiling, and sex-specific evaluations to better understand several cardiovascular conditions. A major area of focus is spontaneous coronary artery dissection (SCAD), an uncommon and under-recognized cause of acute coronary syndrome (heart attack) that occurs predominantly in young women. Dr. Hayes also studies the diagnosis and treatment of nonobstructive (microvascular) coronary artery disease and chest pain syndromes and the subsequent risk of arrhythmias and other cardiac conditions in women who have had hypertension, diabetes or preeclampsia during a pregnancy. With the Pericardial Disease Study Group, Dr. Hayes is assessing the optimal management of pericarditis. Additionally, Dr. Hayes is involved in several research initiatives aimed at addressing health equity and reducing health disparities. Through partnerships with national professional women- and minority-serving organizations, Dr. Hayes assesses barriers faced by women and minorities that prevent or deter them from participating in research studies. Through surveys and national databases, Dr. Hayes is also studying the professional development of women and minorities in the health science professions, including the effects of pregnancy and childbearing during training, and evaluating disparities in academic promotion.

• Natalie Stokes, MD
• Sonia Shah, MD
• Amit Goyal, MD
• Daniel Ambinder, MD