Weitere Episoden von „Cardionerds: A Cardiology Podcast“
334. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #28 with Dr. Gregg Fonarow
9:27The following question refers to Section 7.3 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by Palisades Medical Center medicine resident & CardioNerds Academy Fellow Dr. Maryam Barkhordarian, answered first by Hopkins Bayview medicine resident & CardioNerds Academy Faculty Dr. Ty Sweeny, and then by expert faculty Dr. Gregg Fonarow. Dr. Fonarow is the Professor of Medicine and Interim Chief of UCLA's Division of Cardiology, Director of the Ahmanson-UCLA Cardiomyopathy Center, and Co-director of UCLA's Preventative Cardiology Program. The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #28 Mr. Gene D’aMeTi, a 53-year-old African American man with ischemic cardiomyopathy and heart failure with reduced ejection fraction (LVEF 30-35%), is recently admitted with acutely decompensated heart failure and acute kidney injury on chronic kidney disease stage III. His outpatient regiment includes sacubitril-valsartan 97-103mg BID, carvedilol 25mg BID, and hydralazine 50mg TID. Sacubitril-valsartan was held because of worsening renal function. Despite symptomatic improvement with diuresis, his renal function continues to decline. He is otherwise well perfused & with preservation of other end organ function. Throughout this hospitalization, he has steadily become more hypertensive with blood pressures persisting in the 170s/90s mmHg. What would be an appropriate adjustment to his medication regimen at this time? A Resume Losartan only B Start Amlodipine C Increase current Hydralazine dose D Start Isosorbide dinitrate therapy E Both C & D Answer #28 ExplanationThe correct answer is E – both increasing the current hydralazine dose (C) and starting isosorbide dinitrate therapy (D). Although ACEI/ARB therapy (choice A) has shown a mortality and morbidity benefit in HFrEF, caution should be used in patients with renal insufficiency. In this patient with ongoing decline in renal function, RAAS-inhibiting therapies (ACEi, ARB, ARNI, MRA) should be avoided. In this case, as his RAAS-I has been stopped, it would be reasonable to increase current therapies to target doses (or nearest dose tolerated), as these demonstrated both safety and efficacy in trials (Class 1, LOE A). Considering that his high dose ARNI was stopped, it is unlikely that either hydralazine or isosorbide dinitrate alone, even at maximal doses, would be sufficient to control his blood pressure (Options C and D, respectively). Interestingly, in the original study by Massie et. Al (1977), the decision was made to combine these therapies as the result was thought to be superior to either medication alone. ISDN would provide preload reduction, while Hydralazine would decrease afterload. Consequently, we do not have data looking at the individual benefit of either medication in isolation. In self-identified African Americans with NYHA class III or IV HFrEF already on optimal GDMT, the addition of hydralazine & isosorbide dinitrate is recommended to improve symptoms and reduce mortality and morbidity (Class 1, LOE A). In this case, as the patient has evidence of progressive renal disfunction, we are limited in using traditional RAAS-I, such as ACEI, ARB, or ARNI.
333. Cardio-Oncology: Thromboembolic Disease in Cardio-oncology with Dr. Joshua Levenson
50:50In this episode, CardioNerds Dr. Daniel Ambinder, Dr. Giselle Suero Abreu, and Dr. Saahil Jumkhawala discuss thromboembolic disease in cardio-oncology with faculty expert Dr. Joshua Levenson, the Associate Program Director of the cardiology fellowship and an Assistant Professor of Medicine at the University of Pittsburg School of Medicine. Venous (VTE) and arterial thromboembolic (ATE) events are precipitants of morbidity and mortality in patients with cancer. Here, we discuss the pathophysiology of thromboembolism, risk factors and epidemiology for ATE and VTE, the role of risk prediction and patient stratification, and the approach to treatment for and prophylaxis of thromboembolic events with anticoagulation. Show notes were drafted by Dr. Saahil Jumkhawala and episode audio was edited by CardioNerds Intern Dr. Tina Reddy. This episode is supported by a grant from Pfizer Inc. This CardioNerds Cardio-Oncology series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Giselle Suero Abreu, Dr. Dinu Balanescu, and Dr. Teodora Donisan. CardioNerds Cardio-Oncology PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls and Quotes - Thromboembolic Disease in Cardio-oncology Patients with cancer are at higher risk of developing both arterial and venous thromboembolic events compared to the general population. Certain cancer subtypes are associated with a relatively higher risk of developing thromboembolic complications. Anticoagulation type and duration should be dependent on patient characteristics and risk factors, with shared decision-making between the patient and their providers. Subgroups of patients may benefit from more aggressive management of their atherosclerotic cardiovascular risk factors while being treated for cancer to reduce the risk of thromboembolic complications. Show notes - Thromboembolic Disease in Cardio-oncology What are the incidence and main manifestations of thromboembolic events (venous and arterial) in patients with active malignancy? Approximately 10% of outpatients with active cancer have venous thromboembolic events, many of which are asymptomatic. Clinically relevant VTEs are predominantly deep venous thrombosis (DVTs) with pain and/or swelling of the involved extremities or pulmonary emboli (PEs) resulting in chest pain and/or shortness of breath. VTE is the number one preventable cause of death for all hospitalized patients, and the ability to prevent and treat these events is crucial, particularly in high-risk populations such as patients with cancer. Are there any high-risk associations with specific cancer subtypes? Patients with metastatic disease and those receiving chemotherapy are more likely to develop arterial or venous thromboembolic events. Patients with acute myelogenous leukemia (AML) and thrombocytopenic patients are at the lowest risk for thromboembolic events. Multiple myeloma patients on medication such as proteasome inhibitors or lenalidomide appear at particular risk. Patients with localized, early-stage cancers such as breast, prostate, and melanoma are also at lower risk. What are the main risk factors to identify patients at a higher risk of developing thrombotic complications? Patients with a sedentary lifestyle, deconditioning, and undergoing active treatment with chemotherapy are at the highest risk of developing DVT or PE. How should we approach choosing the optimal type and duration of anticoagulation for acute pulmonary embolism (PE) in the setting of malignancy? This remains an area of active research. Historically, patients would receive systemic anticoagulation with heparin followed by warfarin.
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332. Digital Health: Digital Health and Health Equity with Dr. LaPrincess Brewer
34:34Join CardioNerds Co-Founder Dr. Dan Ambinder, Dr. Nino Isakadze (EP Fellow at Johns Hopkins Hospital), Dr. Karan Desai (Cardiology Faculty at Johns Hopkins Hospital and Johns Hopkins Bayview) join Digital Health Expert, Dr. La Princess Brewer (Associate Professor of Medicine Mayo Clinic Rochester) for another installment of the Digital Health Series. In this specific episode, we discuss how digital health can both reduce and amplify health disparities. This series is supported by an ACC Chapter Grant in collaboration with Corrie Health. Notes were drafted by Dr. Karan Desai. Audio editing was performed by student Dr. Shivani Reddy. In this series, supported by an ACC Chapter Grant and in collaboration with Corrie Health, we hope to provide all CardioNerds out there a primer on the role of digital heath in cardiovascular medicine. Use of versatile hardware and software devices is skyrocketing in everyday life. This provides unique platforms to support healthcare management outside the walls of the hospital for patients with or at risk for cardiovascular disease. In addition, evolution of artificial intelligence, machine learning, and telemedicine is augmenting clinical decision making at a new level fueling a revolution in cardiovascular disease care delivery. Digital health has the potential to bridge the gap in healthcare access, lower costs of healthcare and promote equitable delivery of evidence-based care to patients. This CardioNerds Digital Health series is made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Nino Isakadze and Dr. Karan Desai. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. CardioNerds Digital Health Series PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls and Quotes Digital redlining occurs when a particular group has limited access to key services based on race and ethnicity, perpetuating inequities. Throughout this podcast episode, Dr. Brewer emphasizes how community engagement early in the creation of digital health technologies can mitigate structural inequities. Dr. Brewer spoke about methods to develop innovative digital health tools that are culturally sensitive and inclusive, specifically community-based participatory research (CBPR). In CBPR, community members are partners with researchers in each step of the intervention. While certain individuals and communities may have physical access to digital health tools, they still may remain inaccessible for several reasons. Notes In this episode, we focus on achieving digital health equity and how the very technologies meant to reduce health disparities can widen them. We started by discussing a paper from Dr. Brewer and colleagues that crystallized how digital health disparities can occur with the example of Pokémon Go. As described in this paper, this mobile application was one of the most used applications worldwide. It incentivized users to collect virtual goods at various physical locations termed PokéStops. For public health professionals, this mobile app represented an engaging way to promote physical activity amongst users. However, some racial and ethnic minority groups in low-income, urban areas quickly took notice of the lack of PokéStops within their neighborhoods. As researchers noted, this could be considered examples of digital redlining, or limiting a particular group from key services based on race and ethnicity. As Dr. Brewer notes in the paper, the Pokémon Go developers relied on maps that were crowdsourced from a majority white male demographic. While it may not have been deliberate, the development process created a structural digital inequity placing certain communities at a home-cour...
331. Case Report: New Onset Murmur In A Pregnant Woman With A Mechanical Heart Valve – Oregon Health & Science University
30:58CardioNerds co-founder Dr. Dan Ambinder joins CardioNerds join Dr. Pooja Prasad, Dr. Khoa Nguyen and expert Dr. Abigail Khan (Assistant Professor of Medicine, Division of Cardiovascular Medicine, School of Medicine) from Oregon Health & Science University and discuss a case of mechanical valve thrombosis. Audio editing by CardioNerds Academy Intern, student doctor Adriana Mares. A 23-year-old pregnant woman with a mechanical aortic valve presented to the maternal cardiac clinic for a follow-up visit. On physical exam, a loud grade three crescendo-decrescendo murmur was audible and transthoracic echocardiography revealed severely elevated gradients across the aortic valve. Fluoroscopy confirmed an immobile leaflet disk. Thrombolysis was successfully performed using a low dose ultra-slow infusion of thrombolytic therapy, leading to normal valve function eight days later. Treatment options for mechanical aortic valve thrombosis include slow-infusion, low-dose thrombolytic therapy or emergency surgery. In addition to discussing diagnosis and management of mechanical valve thrombosis, we highlight the importance of preventing valve thrombosis during the hypercoagulable state of pregnancy with careful pre-conception counseling and a detailed anticoagulation plan. See this case published in European Heart Journal - Case Reports. US Cardiology Review is now the official journal of CardioNerds! Submit your manuscript here. CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls - mechanical valve thrombosis The hypercoagulable state of pregnancy presents a risk for women with mechanical heart valves with contemporary data estimating the rate of valve thrombosis during pregnancy at around 5%. Thrombolytic therapy is a (relatively) safe alternative to surgery and should be considered first line for treatment of prosthetic valve thrombosis in all patients, especially in pregnant women. Pre-conception counselling and meticulous anticoagulation management for patients with mechanical heart valves are key aspects of their care. The evaluation for prosthetic valve thrombosis in pregnant persons requires a review of anti-coagulation history and careful choice of diagnostic testing to confirm the diagnosis and minimize risks to the parent and the baby. Multi-disciplinary care with close collaboration between cardiology and obstetrics is critical when caring for pregnant persons with cardiac disease. Show Notes - mechanical valve thrombosis How can we counsel and inform women with heart disease who are contemplating pregnancy? Use the Modified World Health Organization classification of maternal cardiovascular risk to counsel patients on their maternal cardiac event rate and recommended follow-up visits and location of delivery (local or expert care) if pregnancy is pursued. To learn about normal pregnancy cardiovascular physiology and pregnancy risk stratification in persons with cardiovascular disease, enjoy CardioNerds Episode #111. Cardio-Obstetrics: Normal Pregnancy Physiology with Dr. Garima Sharma. Adapted from the 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy What is the differential diagnosis for a new murmur in a pregnant person who has undergone heart valve replacement? Normal physiology - elevated flow from hyperdynamic state and/or expansion of blood volume in pregnancy. Pathologic - increased left ventricular outflow tract flow from turbulence of flow due to pannus ingrowth, new paravalvular leak, or obstructive mechanical disk motion from vegetation or thrombus. What are diagnostic modalities for the evaluation of suspected prosthetic valve thrombosis? The 2020 ACC/AHA guidelines gave a class I recommendation for evaluation of susp...
330. Guidelines: 2021 ESC Cardiovascular Prevention – Question #33 with Dr. Noreen Nazir
11:14The following question refers to Section 4.5 of the 2021 ESC CV Prevention Guidelines. The question is asked by Dr. Maryam Barkhordarian, answered first by pharmacy resident Dr. Anushka Tandon, and then by expert faculty Dr. Noreen Nazir. Dr. Nazir is Assistant Professor of Clinical Medicine at the University of Illinois at Chicago, where she is the director of cardiac MRI and the preventive cardiology program. The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #33 Mr. V is a 37-year-old man who presents to clinic after a recent admission for anterior STEMI and is status-post emergent percutaneous intervention to the proximal LAD. He has mixed hyperlipidemia and a 10 pack-year history of (current) tobacco smoking. Which of the following points related to tobacco use is LEAST appropriate for today’s visit? A Providing assessment and encouragement for smoking cessation, even if for only a 30-second “very brief advice” intervention. B Reviewing and offering pharmacotherapy support options for smoking cessation if Mr. V expresses readiness to quit today. C Recommending a switch from traditional cigarettes to e-cigarettes as a first step towards cessation, as e-cigarettes are safer for use. D Discussing that smoking cessation is strongly recommended for all patients, regardless of potential weight gain. Answer #33 Explanation Answer C is LEAST appropriate and therefore is the correct answer. Answer C is not appropriate. Although e-cigarettes may be more effective than nicotine replacement therapy (NRT) for smoking cessation, the long-term effects of e-cigarettes on cardiovascular and pulmonary health are unknown. According to the 2019 ACC/AHA prevention guidelines, e-cigarettes may increase the risk of CV and pulmonary diseases; their use has been reportedly associated with arrhythmias and hypertension. Therefore, neither the ESC nor ACC/AHA suggest clinicians recommend e-cigarettes over traditional cigarettes to patients. Answer A: Smoking cessation is one of the most effective CVD risk-lowering preventive measures, with significant reductions in (repeat) myocardial infarctions or death. ESC guidelines emphasize the importance of encouraging smoking cessation even in settings where time is limited. “Very brief advice” on smoking is a proven 30-second clinical intervention, developed in the UK, which identifies smokers, advises them on the best method of quitting, and supports subsequent quit attempts. While ESC does not explicitly suggest a frequency of assessment, the 2019 ACC/AHA guidelines specifically recommend that “all adults should be assessed at every healthcare visit for tobacco use and their tobacco use status recorded as a vital sign to facilitate tobacco cessation.” Answer B: The ESC suggests (class 2) that offering follow-up support, nicotine replacement therapy, varenicline, and bupropion individually or in combination should be considered in smokers. A meta-analysis of RCTs in patients with ASCVD reflects that varenicline (RR 2.6), bupropion (RR 1.4), telephone therapy (RR 1.5), and individual counselling (RR 1.6) all increased quit rates versus placebo; NRT therapies were well-tolerated but had inconclusive effects on quit rates (RR 1.22 with 95% CI 0.72-2.06). The 2019 ACC/AHA recommendation to combine behavioral and pharmacotherapy interventions to maximize quit rates is a class 1 recommendation. Answer D: The ESC gives a class 1 recommendation to recommending smoking cessation regardless of weight grain. Smokers who quit may expect an average weight gain of 5 kg, but the health benefits of tobacco cessation (both CVD and non-CVD related) consistently outweigh risks from weight...
329. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #27 with Dr. Randall Starling
9:29The following question refers to Section 7.2 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by Cleveland Clinic internal medicine resident and CardioNerds Intern Akiva Rosenzveig, answered first by UPMC Harrisburg cardiology fellow and CardioNerds Academy House Faculty Leader Dr. Ahmed Ghoneem, and then by expert faculty Dr. Randall Starling. Dr. Starling is Professor of Medicine and an advanced heart failure and transplant cardiologist at the Cleveland Clinic where he was formerly the Section Head of Heart Failure, Vice Chairman of Cardiovascular Medicine, and member of the Cleveland Clinic Board of Governors. Dr. Starling is also Past President of the Heart Failure Society of America in 2018-2019. Dr. Staring was among the earliest CardioNerds faculty guests and has since been a valuable source of mentorship and inspiration. Dr. Starling’s sponsorship and support was instrumental in the origins of the CardioNerds Clinical Trials Program. The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #27 Which of the following sentences regarding diuretics in the management of heart failure is correct? A In HF patients with minimal congestive symptoms, medical management with diuretics alone is sufficient to improve outcomes. B Prescribing a loop diuretic on discharge after a HF hospitalization may improve short term mortality and HF rehospitalization rates. C The combination of thiazide (or thiazide-like) diuretics with loop diuretics is preferred to higher doses of loop diuretics in patients with HF and congestive symptoms. D The maximum daily dose of furosemide is 300 mg. Answer #27 Explanation Choice B in correct. The guidelines give a Class 1 recommendation for diuretics in HF patients who have fluid retention to relieve congestion, improve symptoms, and prevent worsening heart failure. Recent data from the non-randomized OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) registry revealed reduced 30-day all-cause mortality and hospitalizations for HF with diuretic use compared with no diuretic use after hospital discharge for HF. Choice A is incorrect. With the exception of mineralocorticoid receptor antagonists (MRAs), the effects of diuretics on morbidity and mortality are uncertain. As such, diuretics should not be used in isolation, but always combined with other GDMT for HF that reduce hospitalizations and prolong survival. Choice C is incorrect. The use of a thiazide or thiazide-like diuretic (e.g., metolazone) in combination with a loop diuretic inhibits compensatory distal tubular sodium reabsorption, leading to enhanced natriuresis. In a propensity-score matched analysis in patients with hospitalized HF, the addition of metolazone to loop diuretics was found to increase the risk for hypokalemia, hyponatremia, worsening renal function, and mortality, whereas use of higher doses of loop diuretics was not found to adversely affect survival. The guidelines recommend that the addition of a thiazide (e.g., metolazone) to treatment with a loop diuretic should be reserved for patients who do not respond to moderate- or high-dose loop diuretics to minimize electrolyte abnormalities (Class...
328. ACHD: Eisenmenger Syndrome with Dr. Alexander Sasha Opotowsky
1:15:27Eisenmenger syndrome is an end-stage complication of congenital heart disease that occurs when a left to right shunt causes pulmonary over-circulation, leading to vascular remodeling, increased vascular resistance, and ultimately even shunt reversal. Aside from cardiac complications, this pathology has unique complications secondary to chronic cyanosis. In this episode of CardioNerds co-founder Dr. Amit Goyal, ACHD series co-chair Dr. Josh Saef, and Dr. Khaled Tuwairqi (ACHD cardiologist at King Faisal / Elite Hospitals) join Dr. Alexander (Sasha) Optowsky (Director of the Adult Congenital Heart Disease Program at Cincinnati Childrens) to discuss diagnosis and management of Eisenmenger syndrome. Show notes were drafted by Dr. Anna Scandinaro and episode audio was edited by CardioNerds Academy Intern Dr. Akiva Rosenzveig. 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 CardioNerds Adult Congenital Heart Disease PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls - Eisenmenger Syndrome First described in 1897 by Victor Eisenmenger, Eisenmenger syndrome is a long-term complication of unrepaired left to right shunts, resulting from pulmonary vascular remodeling and pulmonary hypertension. This eventually leads to reversal of the shunt, with right to left flow causing cyanosis. Evaluation for Eisenmenger syndrome should include a comprehensive history, physical exam, ECG, echocardiogram, cardiac catheterization, and laboratory work to identify multi-system complications of cyanosis and secondary erythrocytosis. The most definitive means to diagnose Eisenmenger syndrome in a patient with a prior left-to-right shunt lesion is with a right heart cardiac catheterization showing right to left shunting (Qp:Qs < 1). Eisenmenger syndrome is a multi-organ disease and many manifestations occur due to secondary erythrocytosis. Prevention and treatment of these complications are the major goals of care in this population. Complications of Eisenmenger syndrome include gout, bilirubin gallstones, stroke, paraganglioma/pheochromocytoma, thrombophilia, retinal changes, hypertrophic osteoarthropathy, and kyphoscoliosis. Emergency non-cardiac complications of Eisenmenger syndrome include cerebral abscess and hemoptysis. Pregnancy is contraindicated in Eisenmenger syndrome due to high maternal and fetal mortality. Notes- Eisenmenger Syndrome 1. How does Eisenmenger syndrome develop? Does everyone with a left-to-right shunt develop it? Can it develop as an iatrogenic complication? The pulmonary vasculature is not used to seeing the increased flow it receives in the context of a left to right shunt. Over time this leads to an increase in pulmonary vascular resistance and pulmonary hypertension. When pulmonary pressures exceed systemic pressures, this causes shunt reversal with right to left shunting causing deoxygenated blood to cross from right side of the heart to the left side bypassing the lungs and causing cyanosis. The process of developing Eisenmenger syndrome is chronically progressive and so adaptive changes have time to occur. Not all persons with unrepaired shunts will develop Eisenmenger syndrome ...
327. Cardio-Oncology: Interventional CardioOncology with Dr. Cezar Iliescu
49:45CardioNerds CardioOncology Series Co-Chairs, Dr. Teodora Donisan and Dr. Dinu Balanescu, and FIT Lead Dr. Bala Pushparaji discuss Interventional CardioOncology with Prof. Cezar Iliescu. In this episode, we discuss the spectrum of cardiovascular diseases encountered by the interventional onco-cardiologist, with a focus on nuances in endovascular therapies tailored to cancer patients and their unique comorbidities and complications. We also discuss certain special scenarios seen in the critically ill cancer patient, such as chronic thrombocytopenia, and how they alter standard of care compared to non-cancer patients. Show notes were drafted by Dr. Bala Pushparaji and episode audio editing was performed by Dr. Akiva Rosenzveig. This episode is supported by a grant from Pfizer Inc. This CardioNerds Cardio-Oncology series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Giselle Suero Abreu, Dr. Dinu Balanescu, and Dr. Teodora Donisan. CardioNerds Cardio-Oncology PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls and Quotes - Interventional CardioOncology Cancer should be treated as a chronic illness akin to hypertension or diabetes and should not deprive patients from receiving appropriate cardiovascular treatment if otherwise indicated (e.g., PCI for acute coronary syndromes, etc.). In cancer patients with stable angina, along with maximizing medical therapy, multimodality imaging (CTA/PET), intravascular imaging (IVUS/OCT), and physiologic testing (iFR/FFR) should be used routinely to prevent unnecessary stenting. Caution is required in the cath lab for the cancer patient with thrombocytopenia. Techniques include utilizing micropuncture access, transfusing appropriate blood products based on thromboelastogram (TEG), and adjusting antiplatelet therapy regimens and duration. Transcatheter aortic valve replacement (TAVR) is now the recommended treatment for most cancer patients with symptomatic/severe aortic stenosis and, if otherwise indicated, should preferably be pursued prior to cancer treatment to optimize the patient’s cardiovascular fitness and tolerance of anti-cancer therapy. Pericardiocentesis in the cancer patient should be performed preferably under fluoroscopy with echocardiography and vascular ultrasound guidance (“triple guidance”). Show notes - Interventional CardioOncology What is the general approach to cardiovascular illness in the cancer patient? Cancer and cardiovascular diseases share numerous risk factors. In addition, cancer and cancer therapies can be atherogenic, by means of inducing pro-inflammatory and hyprecoagulable states, increasing the risk of ischemic heart disease, stroke, and peripheral arterial disease.1 In the outpatient setting, emphasis should be placed on optimizing cardiovascular risk factors and improving overall cardiovascular fitness by exercising, having a healthy diet, and having regular sleep hours as these favor survivorship after cancer treatment. Questions to be answered in the clinic are - Is the patient cardiovascularly fit? Will the patient’s heart withstand cancer treatment? Is there concern for coronary artery disease, valvular disease, pericardial disease, or pulmonary hypertension? Risk assessment and treatment for cancer patients with suspected or known cardiovascular disease should generally follow established ACC/AHA guidelines, with special considerations as outlined by the Society of Cardiovacular Angiography and Interventions (SCAI).2 Pre-chemotherapy cardioprotection for patients without coronary artery disease (CAD) with prophylactic beta-blockers, ACEi/ARB, and statins should be considered when appropriate.
326. Guidelines: 2021 ESC Cardiovascular Prevention – Question #32 with Dr. Michael Wesley Milks
9:51The following question refers to Section 3.4 of the 2021 ESC CV Prevention Guidelines. The question is asked by student Dr. Adriana Mares, answered first by early career preventive cardiologist Dr. Dipika Gopal, and then by expert faculty Dr. Michael Wesley Milks.Dr. Milks is a staff cardiologist and assistant professor of clinical medicine at the Ohio State University Wexner Medical Center, where he serves as the Director of Cardiac Rehabilitation and an associate program director of the cardiovascular fellowship. He specializes in preventive cardiology and is a member of the American College of Cardiology's Cardiovascular Disease Prevention Leadership Council.The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #32 Mr. Daniel Collins is a 58-year-old man with hypertension, chronic kidney disease (CKD), and obesity who presents to your clinic for a routine physical examination. Vitals are as follows: BP 143/79 mmHg, HR 89 bpm, O2 99% on room air, weight 106 kg, BMI 34.5 kg/m2. Recent laboratory testing revealed: creatinine 1.24 mg/dL, total cholesterol 203 mg/dL, HDL 39 mg/dL, LDL 112 mg/dL, TG 262 mg/dL. His current medications include lisinopril and rosuvastatin. You recommend increasing the dose of lisinopril to treat uncontrolled hypertension. What additional step(s) are indicated at this visit? A Order urine albumin-to-creatinine ratio B Ask the patient how often they have been bothered by trouble falling or staying asleep, or sleeping too much C Perform depression screening D All of the above Answer #32 Explanation The correct answer is D – all of the above.Answer A is correct. The ESC gives a Class I (LOE C) indication that all CKD patients, with or without diabetes, should undergo appropriate screening for ASCVD and kidney disease progression, including monitoring for changes in albuminuria. Cardiovascular disease is the leading cause of morbidity and death among patients with CKD. Even after adjusting for risk factors, including diabetes and hypertension, there is a linear increase in CV mortality with decreasing GFR below ~60-75 mm/min/1.73m2. Specific CKD-related risk factors include uremia-mediated inflammation, oxidative stress, and vascular calcification.Answer choice B is also correct. In patients with ASCVD, obesity, and hypertension, the ESC gives a Class I (LOE C) indication to regularly screen for non-restorative sleep by asking the question related to sleep quality as follows: “‘How often have you been bothered by trouble falling or staying asleep or sleeping too much?”. Additionally, if there are significant sleep problems that are not responding within four weeks to improving sleep hygiene, referral to a specialist is recommended (Class I, LOE C). However, despite the strong association of OSA with CVD, including hypertension, stroke, heart failure, CAD, and atrial fibrillation, treatment of OSA with CPAP has failed to improve hard CVD outcomes in patients with established CVD. Interventions that focus on risk factor modification, including reduction of obesity, alcohol intake, stress, and improvement of sleep hygiene, are important.Answer choice C is also correct. The ESC gives a Class I (LOE C) recommendation that mental health disorders with either significant functional impairment or decreased use of healthcare systems be considered as influencing total CVD risk. All mental disorders are associated with the development of CVD and reduced life expectancy. Additionally, the onset of CVD is associated with an approximately 2-3x increased risk of mental health disorders compared to a ...
325. Guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure – Question #26 with Dr. Eldrin Lewis
17:02The following question refers to Section 4.3 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.The question is asked by Texas Tech University medical student and CardioNerds Academy Intern Dr. Adriana Mares, answered first by Rochester General Hospital cardiology fellow and Director of CardioNerds Journal Club Dr. Devesh Rai, and then by expert faculty Dr. Eldrin Lewis.Dr. Lewis is an Advanced Heart Failure and Transplant Cardiologist, Professor of Medicine and Chief of the Division of Cardiovascular Medicine at Stanford University. The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #26 A 45-year-old man presents to cardiology clinic to establish care. He has had several months of progressive dyspnea on exertion while playing basketball. He also reports intermittent palpitations for the last month. Two weeks ago, he passed out while playing and attributed this to exertion and dehydration. He denies smoking and alcohol intake. Family history is significant for sudden cardiac death in his father at the age of 50 years. Autopsy has shown a thick heart, but he is unaware of the exact diagnosis. He has two children, ages 12 and 15 years old, who are healthy. Vitals signs are blood pressure of 124/84 mmHg, heart rate of 70 bpm, and normal respiratory rate. On auscultation, a systolic murmur is present at the left lower sternal border. A 12-lead ECG showed normal sinus rhythm with signs of LVH and associated repolarization abnormalities. Echocardiography reveals normal LV chamber volume, preserved LVEF, asymmetric septal hypertrophy with wall thickness up to 16mm, systolic anterior motion of the anterior mitral valve leaflet with 2+ eccentric posteriorly directed MR, and resting LVOT gradient of 30mmHg which increases to 60mmHg on Valsalva. You discuss your concern for an inherited cardiomyopathy, namely hypertrophic cardiomyopathy. In addition to medical management of his symptoms and referral to electrophysiology for ICD evaluation, which of the following is appropriate at this time? A Order blood work for genetic testing B Referral for genetic counseling C Cardiac MRI D Coronary angiogram E All of the above Answer #26 Explanation The correct answer is B – referral for genetic counseling. Several factors on clinical evaluation may indicate a possible underlying genetic cardiomyopathy. Clues may be found in: · Cardiac morphology – marked LV hypertrophy, LV noncompaction, RV thinning or fatty replacement on imaging or biopsy · 12-lead ECG – abnormal high or low voltage or conduction, and repolarization, altered RV forces · Presence of arrhythmias – frequent NSVT or very frequent PVCs, sustained VT or VF, early onset AF, early onset conduction disease · Extracardiac features – skeletal myopathy, neuropathy, cutaneous stigmata, and other possible manifestations of specific syndromes In select patients with nonischemic cardiomyopathy, referral for genetic counseling and testing is reasonable to identify conditions that could guide treatment for patients and family members (Class 2a, LOE B-NR). In first-degree relatives of selected patients with genetic or inherited cardiomyopathies, genetic screening and counseling are recommended to ...