Examining the current state of professionalism and ethics in cardiology.

A Need for Change: Tackling Professionalism and Ethics in Cardiology

Research from the Yonsei University College of Medicine in South Korea is underlining the importance of prioritizing cardiovascular health during young adulthood as a way to reduce risk of premature cardiovascular disease in midlife.

An analysis of data from more than 3.5 million patients with a median follow-up of 16.1 years, results demonstrate associations between lower cardiovascular health scores in young adulthood were linked to increased risk of cardiovascular events in midlife, but also suggested these scores could be improved to reduce risk.

"Most people lose ideal cardiovascular health before they reach midlife, yet few young people have immediate health concerns and many do not usually seek medical care until approaching midlife," said senior investigator Hyeon Chang Kim, MD, PhD, Professor in the Department of Preventive Medicine at Yonsei University College of Medicine, in 

a statement from the American Heart Association

. "We need strategies to help preserve or restore heart health in this population because we know poor heart health in young adults is linked to premature cardiovascular disease."

To learn more about how declines in cardiovascular health during young adulthood might influence risk of premature cardiovascular and mortality, Kim and a team of colleagues designed their study as an analysis of data from the Korean National Health Insurance Service, which is a nationwide, single-provider database. Using data from adults who complete routine health exams in 2003-2004, investigators identified 3,565,189 participants for potential inclusion in their analyses.

For the purpose of analysis, investigators classified patients according to ideal cardiovascular health scores, which were calculated as the number of nondietary ideal components met from the American Heart Association’s Life Simple 7 metrics. The primary outcome of interest for their analyses was a composite cardiovascular disease event defined as first hospitalization for myocardial infarction, stroke, or heart failure, or cardiovascular death by December 31, 2019, which was the end of the follow-up period.

The 3,565,189-patient cohort had a median age of 31 years and 65.6% were male. Among this patient population, approximately 13% had a baseline cardiovascular health score of 1 or less, 25.6% had a score of 3, and just 1.4% had a score of 6. After exclusion of those with incomplete information, previous cardiovascular disease, or less than 1 year of follow-up, a group of 3,325,420 were included in the final analyses.

During a median follow-up period of 16.1 years, a total of 39,165 incident cardiovascular disease events occurred. Investigators pointed out all these events occurred at the age of 55 or younger and were considered premature.

Results of their analyses indicated the cumulative incidence of events was greatest for those with a baseline score of 0, with an incidence rate of 0.23% per year compared to a rate of less than 0.02% per year among those with a score of 6. In adjusted analyses, those with scores of 1, 2, 3, 4, 5, and 6, respectively were at 26%, 49%, 65%, 75%, 82%, and 85% lower risk for the primary outcome compared to those with a baseline score of 0.

Further analysis of a subgroup of 2,881,115 patients with data from health examinations in 2003-2004 and 2005-2008 indicated an increase in cardiovascular health score was associated with a lower risk of the primary outcome (HR, 0.79; 95% CI, 0.78-0.80, per each 1-point increase in score). Investigators went on to highlight that these patients were still at an increased risk of cardiovascular events when compared to those with maintained higher scores at baseline and subsequent follow-up visits.

Investigators cautioned the findings of their study may be limited by the design. Specifically, reliance on a population of Korean ancestry and limitations associated with use of routine health screening data.

Associations of Ideal Cardiovascular Health and Its Change During Young Adulthood with Premature Cardiovascular Events: A Nationwide Cohort Study

Articles

New research indicates improvements in cardiovascular health during young adulthood among patients with low baseline cardiovascular health could reduce the rates of premature cardiovascular disease as the population ages. 

Prioritizing Heart Health in Young Adults Could Have Substantial Impact on Rates of Premature Cardiovascular Events

This article was originally published on 

New research suggests the burden of angina in patients with coronary artery disease (CAD) may be greater than previously thought. 

A team of investigators, led by Daniel M. Blumenthal, MD, Cardiology Division, Department of Medicine, Massachusetts General Hospital, found 21.2% of patients surveyed with CAD reported undergoing angina at least once monthly.

The team administered the Seattle Angina Questionnaire-7 (SAQ-7) to a sample of outpatients with diagnosed CAD who receive care in a large primary care network.

Investigators conducted a cross-sectional survey of primary care clinic-based sample of adults with CAD.

The SAQ-7 was administered by telephone between February– July 2017.

Patients were sampled from 15 primary care clinics and community health centers part of the Massachusetts General Hospital (MGH) Primary Care Practice Based Research Network (PBRN). The PBRN contains health record data on 161,000 MGH primary care patients.

Of these patients, those with CAD aged ≥30 years were eligible for study participation, including those with asymptomatic and non-obstructive CAD.

Baseline demographic and clinical characteristics were accessed in 12 months prior to survey administration from the PBRN.

In addition, the team stratified responders into daily or weekly angina, monthly angina, or no angina and evaluated if baseline CAD burden was association with angina frequency assessed by the SAQ-7.

Further, they estimated multivariable multinomial logistic regression that included 4 covariate categories, including demographic covariates, clinical covariates other than medications, medications, and baseline CAD burden.

Investigators identified 9356 patients with CAD aged ≥30 years who were alive in June 2016.

After screening, 4139 of 4789 (86.4%) were deemed eligible for survey completion and contacted to complete a survey.

Data show the mean age of survey respondents was 71.8 years, with 577 (35.8%) women, 1447 (89.8%) spoke English, 147 (9.1%) spoke Spanish, 1336 (82.8%) were White, 76 (4.7%) were Black, 92 (5.7%) were Hispanic, 974 (60.4%) had Medicare, and 83 (5.2%) had Medicaid.

The team found that the mean SAQ-7 score was 93.7. Of the total respondents, 1270 (78.8%) reported no angina and 342 (21.2%) reported experiencing angina at least once monthly.

Further, 201 (12.5%) respondents reported daily, or weekly angina and 141 (8.7%) respondents reported monthly angina.

Investigators observed covariates associated with more frequent angina after multivariable regression,

These included speaking a language other than Spanish or English (odds ratio (OR), 5.07; 95% CI, 1.39 - 18.50), Black race (OR 2.01; 95% CI, 1.08 - 3.75), current smoking (OR 1.88; 95% CI, 1.27 - 2.78), former smoking (OR 1.69; 95% CI, 1.13-2.51), atrial fibrillation (OR 1.52; 95% CI, 1.02 - 2.26), and chronic obstructive pulmonary disease (OR 1.61; 95% CI, 1.18 - 2.18).

On the other hand, male sex (OR 0.63; 95% CI, 0.47 - 0.86), peripheral artery disease (OR, 0.63; 95% CI, 0.44 - 0.90), and novel oral anticoagulant use (OR, 0.19; 95% CI, 0.08 - 0.48) were associated with less frequent angina.

The team noted that the findings suggested angina is prevalent in US outpatients with CAD, where proactive angina assessment may later have association with improved treatment and outcomes.

“Systematic evaluation of angina burden using validated assessment tools and prospective estimation of angina burden may improve angina treatment and may be associated with reduced morbidity,” investigators wrote.

Prevalence of Angina Among Primary Care Patients with Coronary Artery Disease

A cross-sectional analysis of data suggests more than 20% of patients with coronary artery disease report experiencing angina at least once a month while 12.5% report experiencing angina daily or weekly. 

More than 20% of CAD Patients Report Monthly Episodes of Angina

A matched analysis of more than 170,000 women with polycystic ovary syndrome (PCOS) suggests these women were at an increased risk of major adverse cardiovascular events. 

Results of the analysis suggest young women with PCOS were at an increased risk of adverse cardiovascular events and also indicate weight and diabetes status stood out as potentially modifiable risk factors for this association.

“This is the largest study to confirm an increased incidence of major cardiovascular morbidity in patients with PCOS and emphasizes the importance of recognizing the disorder as a higher-risk vascular condition,” wrote investigators.

With PCOS the most common endocrine condition impacting young women and the relationship between PCOS and cardiovascular risk unclear, a UK-based team of investigators sought to explore these potential associations using data from the Clinical Practice Research Datalink Aurum database. With more than 200,000 women with PCOS included in the database from 1998-2017, investigators identified a cohort of 181,916 meeting eligibility criteria for inclusion in their matched analyses.

All patients included in the study were at least 18 years of age or older and were matched in a 1:1 ratio to a set of non-PCOS controls based on age, BMI category, and primary care practice. Investigators pointed out patients with a history of myocardial infarction, stroke, angina, or revascularization were excluded from survival analyses.

The primary outcome of interest for the study was time to major adverse cardiovascular event (MACE), which was defined as myocardial infarction, stroke, angina, revascularization, and cardiovascular mortality. The secondary outcomes of interest were individual components of the composite MACE endpoint.

Of the 181,916 deemed eligible for inclusion, 174,660 were matched to non-PCOS controls. The median follow-up time for patients with PCOS was 3.83 (IQR, 1.89-7.78) years and 3.00 (IQR, 1.37-6.36) for controls. Investigators noted significant differences in presence of extreme obesity (4.65% vs 3.12%) were evident at baseline between the cohorts and women with PCOS were also more to have a higher Charlson Index score and higher blood pressure.

Analysis indicated crude rates of the composite endpoint, MI, stroke, angina, revascularization, and cardiovascular mortality were 82.7, 22.7, 27.4, 32.8, 10.5, and 6.97 per 100,000 patient-years, respectively, for women with PCOS and 64.3, 15.9, 25.7, 19.8, 7.13, and 7.75 per 100,000 patient-years, respectively, for matched controls. In adjusted models, women with PCOS were at 26% greater risk of the composite outcome (HR, 1.26; 95% CI, 1.13-1.41) and 38%, 60%, and 50% greater risk for myocardial infarction (HR, 1.38; 95 CI, 1.11-1.72), angina (HR, 1.50; 95% CI, 1.32-1.94), and revascularization (HR, 1.50; 95% CI, 1.08-2.07), respectively, when compared to non-PCOS controls.

In time-dependent models, results suggested weight gain (HR, 1.01; 95% CI, 1.00-1.01), prior type 2 diabetes (HR, 2.40; 95% CI, 1.76-3.30), and social deprivation (HR, 1.53; 95% CI, 1.11-2.11) were factors associated with increased risk of progression to the composite endpoint.

“Our study demonstrates that young women with a diagnosis of PCOS have an increased incidence of major cardiovascular events, whether captured as a composite outcome or as myocardial infarction, angina and revascularization individually,” wrote investigators. “High-quality longitudinal studies are now needed to understand any effect of disease phenotype and ethnicity on risk, and whether screening strategies with targeted intervention can lead to improved cardiovascular outcomes.”

Women with Polycystic Ovary Syndrome have an increased risk of major cardiovascular events: a population study

Journal of Clinical Endocrinology and Metabolism.

A recent review of data from within a major European-based database indicates women with PCOS were at a 26% greater risk of major adverse cardiovascular events when compared to matched controls without polycystic ovary syndrome.

Women with Common Endocrine Disorder at Increased Risk of Cardiovascular Disease Risk

The last slideshow in our multipart series, this slideshow examines the scope of work and conclusions from the AHA/ACC task force who tackled the topics of overcoming hurdles with new care delivery systems in cardiology in cardiology for the American Heart Association/American College of Cardiology Consensus Conference on Professionalism and Ethics.

Challenges with New Care Delivery Systems

2020 American Heart Association and American College of Cardiology Consensus Conference on Professionalism and Ethics: A Consensus Conference Report

Journal of the American College of Cardiology. 

The final slideshow in our multipart series, this slideshow examines the scope of work and conclusions from the AHA/ACC task force who tackled the topics of overcoming hurdles with new care delivery systems for the American Heart Association/American College of Cardiology Consensus Conference on Professionalism and Ethics. 

Challenges with New Care Delivery Systems in Cardiology

This article is the fifth in a series from Practical Cardiology taking a deeper look at professionalism and ethics within cardiology after the release of a report from the American Heart Association/American College of Cardiology Consensus Conference on Professionalism and Ethics.

The fourth of 5 slideshows included in the series, advisory board member Dr. Gregory Weiss examines the work of each of the 5 task forces who took part in creating the report. In this slideshow, Weiss details the efforts of Task Force 4 , which sought to address patient autonomy, privacy, data access, and social justice in cardiology.

Improving Patient Autonomy, Privacy, and Social Justice Efforts

The fourth of 5 slideshows in our multipart series, this slideshow examines the scope of work and conclusions from the AHA/ACC task force who tackled the topics of patient autonomy, privacy, data access, and social justice in cardiology for the American Heart Association/American College of Cardiology Consensus Conference on Professionalism and Ethics. 

Improving Patient Autonomy, Privacy, & Social Justice in Cardiology

Despite the idea that the United States and other nations have won the war on tobacco, a new study suggests a new challenge has arisen in regard to curbing the impact of smoking and tobacco use in patients with a history of cardiovascular disease.

An analysis of survey responses from 2013-2018 among patients within the Population Assessment of Tobacco and Health Study (PATH), results of the study indicate nearly 30% of those with self-reported cardiovascular reported currently smoking or using tobacco products and only 10% reported being actively enrolled in a cessation program.

“The findings of this new study are disturbing, although perhaps not surprising. These results indicate that critical public policies and interventions are needed to address this preventable, leading cause of death and disability not just in the U.S. but around the world,” said Rose Marie Robertson, MD, FAHA, Deputy Chief Science and Medical Officer of the American Heart Association, who was not involved with this study but serves as the co-director of the Association's Tobacco Center of Regulatory Science, which provided support for the study, 

Led by investigators at the Albert Einstein College of Medicine, the current study was designed to compare data from the first and fourth wave of PATH, which occurred in 2013-2014 and 2016-2018. Using response data from these patients, investigators hoped to describe the prevalence of tobacco use, type of tobacco product used, and patient knowledge about the associations between smoking or tobacco use and cardiovascular disease risk.

Overall, 32,172 survey participants were identified for inclusion. Of these, 2615 had self-reported cardiovascular disease. Among these patients, 24.5% reported having had a heart attack, 22.6% reported having had a stroke, 19.1% reported heart failure, and 60.5% reported having some other heart condition.

Baseline analyses indicated 95.9% of patients with prevalent cardiovascular disease reported knowing or believe smoking could cause cardiovascular disease in smokers. Furthermore, those reporting knowing or believing smoking causes cardiovascular disease were 50-70% less likely to report use of any tobacco product.

Among 2615 participants with self-reported cardiovascular disease at wave 1, 28.9% reported current tobacco use. Among current tobacco users, the most commonly used products were cigarettes (82.8%, any type of cigar (23.7%), and e-cigarettes (23.5%). Further analysis suggested e-cigarette use without concurrent cigarette use was rare among this group of patients (1.1%).

Compared to those with cardiovascular disease at baseline who did not report tobacco use, those reporting tobacco use were more likely to be of a younger age, male sex, have lower education level, and lack of knowledge about the association between smoking and cardiovascular disease. Investigators also noted men with cardiovascular disease were less likely than their female counterparts to use e-cigarettes (OR, 0.7; 95% CI, 0.5-0.9).

Additionally, comparing rates of cigarette use among those with cardiovascular disease between waves 1 and 4 indicated a reduction of less than 5% occurred during that time period. Investigators also pointed out results suggested e-cigarette use increased 0.5% during that same time period and less than 12% were in a formal tobacco cessation program at any point during the study.

“Our findings support the need for a stronger commitment from a multidisciplinary team, including the primary care professional, social worker, psychologist and cardiologist, to provide smoking-cessation therapies and counseling to people with cardiovascular disease,” said lead investigator Cristian Zamora, MD, a third-year internal medicine resident at Jacobi Medical Center at Albert Einstein College of Medicine, in the aforementioned statement.

Tobacco Use Prevalence and Transitions From 2013 to 2018 Among Adults With a History of Cardiovascular Disease

Journal of the American Heart Association.

An analysis of survey responses from 2013-2018 indicates many patients with a history of cardiovascular disease who use tobacco continue to do so, despite being aware of the increased risk associated with smoking and tobacco use. 

Despite Awareness of Cardiovascular Risks, Many Smokers Continue Tobacco Use

A new report is sounding the alarm on the potential for magnetic interference with newer Apple iPhones and cardiac implantable electronic devices (CIED), including pacemakers and implantable cardioverter defibrillators.

Despite being a small study, including just 3 patients and ex vivo testing of 11 devices, results demonstrate clinically identifiable magnetic interference among 11 of 14 devices when within 1.5 cm of the iPhone 12 Pro Max, underlining the potential for magnetic interference in devices using MagSafe technology.

“We have always known that magnets can interfere with cardiac implantable electronic devices, however, we were surprised by the strength of the magnets used in the iPhone 12 magnet technology,” said lead study investigator Michael Wu, MD, Assistant Professor of Medicine and Director of the Clinical Cardiac Electrophysiology Fellowship Program in the cardiology division at the Rhode Island and Miriam Hospital’s Lifespan Cardiovascular Institute and Brown University’s Warren Alpert School of Medicine, in a 

statement from the American Heart Association

. “In general, a magnet can change a pacemaker’s timing or deactivate a defibrillator’s lifesaving functions, and this research indicate the urgency for everyone to be aware that electronic devices with magnets can interfere with cardiac implantable electronic devices.”

With Apple’s proprietary MagSafe technology capable of generating magnet field strength greater than 50 gauss (G), investigators sought to determine whether this technology could cause clinically significant magnet interference with CIEDs, which was recently addressed in an 

update by the US Food and Drug Administration

. To determine these devices would interfere with these devices, investigators designed their study to have an in vivo and an ex vivo component.

The in vivo portion of the study included 3 consecutive patients presenting for a generator change or device interrogation. Devices represented within this population included the Medtronic Amplia MRI Quad CRT‐D, Abbott Medical 1231‐40 Fortify VR, and Boston Scientific V273 Intua CRT‐P. Investigators noted a standard donut magnet was used to ensure magnet reversion could be triggered in all 3 patients.

The iPhone 12 Pro Max triggered magnet reversion mode in all 3 devices. Investigators pointed out introduction of the iPhone 12 Pro Max resulted in the inhibition of tachytherapies in the Medtronic and Abbott defibrillators, but the Boston Scientific device appeared to be less susceptible as they were only able to elicit transient temporary asynchronous pacing but no sustained response.

Of the 11 devices included in the ex vivo portion of the study, 5 were implantable cardioverter defibrillators and 6 were pacemakers. This group included 4 Medtronic devices: the Visia AF MRI ICD, the Azure, the Advisa MRI, and the Adapta. Boston Scientific devices included the Dynagen ICD, Emblem MRI S-ICD, Accolade MRI, and U125 Valitude. Abbott devices included the Fortify Assura DR ICD, Ellipse DR ICD, and the Assurity MRI.

Similar to the in vivo portion, a standard donut ring was used to ensure magnet mode activation was possible for each packaged device. For the purpose of analysis, the iPhone 12 Pro Max was placed directory over the packaged CIED and the magnet strength of the iPhone 12 Pro Max was measured using a magnetometer.

Results indicated the selected Medtronic and Abbott devices tested were susceptible to electromagnetic interference, but the Boston Scientific devices appeared to be less susceptible, with no observable effect among all but the U125 Valitude, which experienced temporary asynchronous pacing. Exposure resulted in the inhibition of tachytherapies in the Medtronic and Abbott defibrillators tested, while asynchronous pacing occurred among the Medtronic and Abbott pacemakers exposed to the iPhone 12 Pro Max.

“The American Heart Association and manufacturers of pacemakers and implantable cardioverter defibrillators have long recommended that cell phones be used in the ear opposite the side of the body of an implanted device, and that the cell phones be kept at least 10 cm away from the device, therefore not in a shirt or coat pocket on the same side as the cardiac device,” said N.A. Mark A. Estes, MD, Director of the Clinical Cardiac Electrophysiology Fellowship Program at the Heart and Vascular Institute of the University of Pittsburgh School of Medicine and an American Heart Association volunteer, in the aforementioned statement. “While the risk from temporary interference was only tested with specific devices and cell phones, the Association reminds people with cardiac implantable electronic devices to remain informed of the latest FDA guidance for their heart device, the manufacturers’ safety guidelines and to contact their health care professional with any questions or concerns.“

Magnetic Interference on Cardiac Implantable Electronic Devices From Apple iPhone MagSafe Technology

A study from Brown University demonstrates MagSafe technology used in the iPhone 12 Pro Max could interfere with cardiac implantable electronic devices.

Report: iPhone MagSafe Technology Interferes with Some Pacemakers, Defribrillators

This article is the fourth in a series from Practical Cardiology taking a deeper look at professionalism and ethics within cardiology after the release of a report from the American Heart Association/American College of Cardiology Consensus Conference on Professionalism and Ethics.

The third of 5 slideshows included in the series, advisory board member Dr. Gregory Weiss examines the work of each of the 5 task forces who took part in creating the report. In this slideshow, Weiss details the efforts of the third Task Force, which sought to identify shortcomings and avenues for improving the well-being of cardiologists and cardiology professionals. 


Improving Clinician Well-Being

Journal of the American College of Cardiology. 


The third of 5 slideshows included in our "A Need for Change" series, details the work of Task Force 3 from the American Heart Association/American College of Cardiology Consensus Conference on Professionalism and Ethics, which sought to identify shortcomings and avenues for improving the well-being of cardiologists and cardiology professionals. 

A Need for Change: Enhancing the Well-Being of Cardiology Professionals 

This article is the third in a series from Practical Cardiology taking a deeper look at professionalism and ethics within cardiology after the release of a report from the American Heart Association/American College of Cardiology Consensus Conference on Professionalism and Ethics.

The second of 5 slideshows included in the series, advisory board member Dr. Gregory Weiss examines the work of each of the 5 task forces who took part in creating the report. In this slideshow, Weiss details the efforts of the second Task Force, which sought to address diversity, equity, inclusion, and belonging in cardiovascular medicine. 

While many look back on 2020 and remember the COVID-19 pandemic, the year was transformative in many other ways. Paramount among them is the movement to improve racial-, ethnic-, religious-, and gender-based inequality in the United States. In medicine, the undertones of systemic racism were, and continue to be, confronted  by those within the field. The second Task Force from the American Heart Association/American College of Cardiology Consensus Conference on Professionalism and Ethics sought to identify avenues of eliminating Bias, discrimination, harassment, and racism in professional settings. 



Diversity, Equity, Inclusion, & Belonging in Cardiology

The second of 5 slideshows in our multipart series, this slideshow examines the scope of work and conclusions from the AHA/ACC task force who addressed diversity, equity, inclusion, and belonging in cardiovascular medicine. 

Addressing Equity, Inclusion, & Belonging in Cardiology

This article is the second in a series from Practical Cardiology taking a deeper look at professionalism and ethics within cardiology after the release of a report from the American Heart Association/American College of Cardiology Consensus Conference on Professionalism and Ethics.

In each of the 5 slideshows included in the series, Dr. Gregory Weiss examines the work of each of the 5 task forces who took part in creating the report. In this slideshow, Weiss details the efforts of the task force focused on navigating relationships and conflicts of interest. 


Navigating Relationships with Industry and Conflicts of Interest

The first of 5 slideshows in our multipart series, this slideshow examines the scope of work and conclusions from the AHA/ACC task force who addressed conflicts of interest and relationships with industry. 

Navigating Relationships with Industry and Conflicts of Interest in Cardiology

The American Heart Association is calling attention to a new study detailing the treatment of temporary myocarditis among patients who received a COVID-19 vaccine.

With perimyocarditis reported as a rare vaccination complication, the study reports a case series of 7 patients hospitalized with acute myocarditis-like illness following vaccination and provides insight into treatment of these patients, all of whom had symptoms resolve and were discharged within 4 days of admission.

“The clinical course of vaccine-associated myocarditis-like illness appears favorable, with resolution of symptoms in all patients. Given the potential morbidity of COVID-19 infection even in younger adults, the risk-benefit decision for vaccination remains highly favorable. Vaccine adverse event reporting remains of high importance and further studies are needed to elucidate the pathophysiological mechanism to potentially identify or prevent future occurrences,” said the researchers.

, details a cohort of 7 male patients treated at 2 medical centers in Virginia and Texas. All patients included in the study were under the age of 40 years, with the youngest being 19 years and the oldest being 39 years of age. All of the patients were White, with the exception of 1 Hispanic individual.

Among this cohort, only 1 patient reported a history of previous COVID-19 infection. All patients in the study were admitted to the hospital within 3-7 days of receiving a COVID-19 vaccine with sudden onset chest pain. Investigators noted 6 of these patients had received an mRNA vaccine from Moderna or Pfizer and 1 patient had received the adenovirus vaccine from Johnson & Johnson.

The presence of myocardial injury was confirmed in all patients through cardiac troponin I or elevated high sensitivity troponin testing. In ECG testing, patterns varied from normal to ST-segment elevation. Additionally, 3 patients underwent invasive coronary angiography but none had evidence of blockage. Investigators also noted no patients reported heart palpitations or signs of arrhythmia. Echocardiograms indicated left ventricular ejection ranged from 35-62% with 5 of the 7 patients having some degree of hypokinesis.

All patients underwent CMR between 3-37 days after vaccination. Investigators highlighted multi-focal subepicardial late gadolinium enhancement (LGE) was present in all 7 patients. Additionally, mid-myocardial LGE was observed in 4 of 7 patients and corresponding myocardial edema was found in 3 of 7. Investigators pointed out 2 patients who underwent CMR greater than 7 days from presentation showed no signs of edema and 1 patient’s images were limited by artifacts. An endomyocardial biopsy was performed in 1 patient and it returned no pathological evidence of myocarditis.

Investigators pointed out treatment of these patients varied and included beta-blockers and anti-inflammatory medications. The median length of hospital stay was 3±1 days and symptoms had resolved in patients by time of discharge.

 released around the publication of this study underlined myocarditis-like illnesses are a very rare complication observed among patients who receive a COVID-19 vaccine, with fewer than 1000 cases reported as of May 31, 2021, and nearly 312 million doses administered. The statement also noted the CDC plans to review suspected cases of myocarditis-like illnesses related to COVID-19 vaccinations at the ACIP meeting June 23-25.

Myocarditis Temporally Associated with COVID-19 Vaccination

A case series of 7 patients from a pair of US medical centers details the treatment and presentation of patients with myocarditis-like illness after receiving a COVID-19 vaccine. 

Case Series Details Treatment of Myocarditis-Like Illness Following COVID-19 Vaccination

Results of a randomized trial from investigator in Sweden could have practice-changing implications in regard to care of patients in unconscious cardiac arrest.

"These results will affect the current guidelines,” said senior investigator Niklas Nielsen, MD, PhD, Researcher at Lund University and Consultant in Anesthesiology and Intensive Care at Helsingborg Hospital, 

the 1900-patient, open-label trial demonstrates targeted hypothermia provided no benefit versus normothermia, with results suggesting there were no major differences in incidence of death of 6 months between the approaches.

"It is important to set high standards for clinical studies, partly to determine what should be introduced in healthcare, partly to challenge the practices that are already in use—to ensure that we have got it right and that healthcare is evidence-based. The results produced strongly indicate that normal temperature should be recommended, not hypothermia,” continued Nielsen.

With international guidelines recommending unconscious cardiac arrest patients undergo targeted hypothermia to preserve neurologic function, investigators sought to determine whether the previously purported relationship between fever and adverse neurological outcomes was modifiable. To do so, they designed and conducted the Targeted Hypothermia versus Targeted Normothermia after Out-of-Hospital Cardiac Arrest (TTM2) trial to evaluate the effects of hypothermia versus normothermia and early treatment of fever in patients after cardiac arrest.

TTM2 randomized 1900 adults with coma who had experienced an out-of-hospital cardiac arrest of presumed cardiac or unknown cause to undergo targeted hypothermia at 33°C, followed by controlled rewarming or targeted normothermia with early treatment of fever. The intervention period of the study lasted 40 hours and began at the time of randomization.

The primary outcome of interest for the trial was incidence of death from any cause at 6 months. The secondary outcome of interest included functional outcome at 6 months, which was measured using the modified Rankin scale. Investigators pointed out plans to assess these outcomes in prespecified subgroups defined by sex, age, initial cardiac rhythm, time to return of spontaneous circulation, and presence or absence of shock on admission were planned. Adverse events of interest for the trial included pneumonia, sepsis, bleeding, arrhythmia resulting in hemodynamic compromise, and skin complications related to temperate management device.

Of the 1900 patients who underwent randomization, 1850 were evaluated for the trial’s primary outcome. Upon analysis, results indicated the primary outcome occurred in 50% of the hypothermia group and 48% of the normothermia group (RR for hypothermia, 1.04; 95% CI, 0.94-1.14; 

=.37). The secondary outcome of interest for the trial was assessed in 1747 patients. Results of this analysis indicated 55% of the hypothermia group and 55% of the normothermia group had moderately assure disability or worse, which was defined as a score of 4 or greater using the modified Rankin scale (RR for hypothermia, 1.00; 95% CI, 0.92-1.09).

Results of subgroup analyses indicated outcomes were consistent across prespecified subgroups. Investigators noted that arrhythmia resulting in hemodynamic compromise appeared to be more common among patients in the hypothermia group than those in the normothermia group (24% vs 17%; 

 <.001). Additionally, assessments of other adverse events indicated incidence did not differ significantly between the hypothermia and normothermia groups.

"The results are important, but not unexpected. For 20 years, we have applied and believed in these practices which we now see do not make a difference for survival. Now, we can use the resources on other things and prioritize other aspects of the acute phase of cardiac arrest,” said lead investigator Josef Dankiewicz, MD, PhD researcher at Lund University and resident physician at Skåne University Hospital, in the aforementioned statement.

Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest

Results of an open-label randomized trial suggests targeted hypothermia among unconscious cardiac arrest patients may not provide mortality benefits compared to normothermic patients.

Targeted Hypothermia Provides No Mortality Benefit at 6 Months Compared to Normothermia after Cardiac Arrest

Data from an analysis of the GOULD Registry details the sluggish rates of treatment intensification among patients with suboptimal 

A look at treatment patterns from July 2016-July 2018, results of the analysis suggest fewer than 20% of patients had lipid-lowering therapy intensification after 2 years of treatment, despite more than 50% remaining at an LDL-C above goal.

“Among the patients who had an LDL-C level remeasured during 2 years of follow-up, approximately 1 in 3 achieved an LDL-C level less than 70 mg/dL, and 1 in 10 achieved an LDL-C level less than 55mg/dL. New efforts to facilitate more intensification of LLT are necessary to optimize lipids in this ASCVD population,” wrote investigators.

A prospective, observational registry, GOULD was created with an interest in better understanding trends in guideline-directed use of lipid-lowering therapies in patients with ASCVD. Enrolling more than 5000 patients, GOULD placed patients into one of 3 cohorts for analysis. The first group included those receiving a PCSK9 inhibitor, the second was made up of patients not receiving a PCKS9 inhibitor with an LDL-C of 100 mg/dL or more, and those not receiving a PCSK9 inhibitor and an LDL-C of 70-99 mg/dL.

The primary outcome of interest for the study was change in lipid-lowering therapies over 2 years. Investigators noted this outcome included intimation or discontinuation of statin therapy, ezetimibe, or PCSK9 inhibitor, increasing or decreasing dosage of a statin or PCSK9 inhibitor, switching to a different statin or PCSK9 inhibitor.

The 5006-patient cohort had a mean age of 67.8 (SD, 9.9) years, 39.7% were women, and 86.1% were White individuals. Of these 5006, 554 were already on a PCSK9 inhibitor, 1801 had an LDL-C at or above 100 mg/dL, and 2651 had an LDL-C of 70-99 mg/dL. At 2 years, only 885 had lipid-lowering therapy intensification.

Among those with LDL-C levels of 100 mg/dL or more and 70-99 mg/dL, lipid-lowering therapy intensification occurred in 22.4% and 14.4%, respectively. Further analysis indicated statins were intensified in 6.4% and 6.3%, ezetimibe was added in 6.8% and 4.5%, and PCKS9 inhibitors were added in 6.3% and 2.2%, respectively. Among those in the cohort already taking PCSK9 inhibitors, 91.7% were still taking a PCSK9 inhibitor at 2 years.

During the 2 years of follow-up, 3768 (88.5%) of the study cohort underwent lipid panel measurements at least once. This included 96.1% of patients already taking a PCSK9 inhibitor, 85.9% of the group with an LDL-C level at or above 100 mg/dL, and 88.6% of the group with an LDL-C between 70-99 mg/dL. Based on these measurements, investigators determined the levels of LDL-C fell from medians of 120 (IQR, 108-141) mg/dL to 95 (IQR, 73-118) mg/dL in the cohort with LDL-C levels of 100 mg/dL or more, 82 (IQR, 75-89) to 77 (IQR, 65-90) mg/dL in the cohort with LDL-C levels of 70-99 mg/dL, and 67 (IQR, 42-104) mg/dL to 67 (IQR, 42-96) mg/dL in the PCSK9 inhibitor cohort.

When assessing those who achieved an LDL-C of less than 70 mg/dL at 2 years, results indicated this level was achieved by 21.0% and 33.9% of those in in the groups with LDL-C levels of 100 mg/dL or more and 70-99 mg/dL, respectively. In comparison, 52.4% of the cohort already taking PCSK9 inhibitors achieved an LDL-C of 70 mg/dL or less.

Multiple factors were associated with lipid-lowering therapy intensification and achieving LDL-C target at 2 years. Factors associated with increased likelihood of both these included being treated at a teaching vs non-teaching hospital, presence of lipid protocols, and receiving care from a cardiologist vs an internal or family medicine practitioner.

Use of Lipid-Lowering Therapies Over 2 Years in GOULD, a Registry of Patients With Atherosclerotic Cardiovascular Disease in the US

Analysis of 2-year data from the GOULD Registry indicates new strategies are needed to address the suboptimal levels of lipid-lowering therapy intensification among patients with ASCVD and increased LDL-C. 

GOULD Registry Details Subpar Levels of Intensifying Lipid-Lowering Therapies in ASCVD Patients

: A man in his late 50’s presents to the emergency department for syncope. He has had both generalized weakness and loss of appetite that has been gradually worsening for a few weeks. He denies any injury or any palpitations, chest pain, SOB, fever, cough, or other complaints.

: Vital signs are normal except for a pulse in the low to mid 40’s.

Computer Read: junctional rhythm rate 44, borderline voltage, NSTWA

Our latest case report from Dr. Brady Pregerson features a man in his late 50s presenting to the ED for syncope. Check out the EKG and see if you can determine the correct diagnosis. 

Cardiology Case Report: Syncope and Bradycardia

A new study using data from the National Health Interview Survey suggests the current financial burden imposed by cardiovascular disease was similar, or greater, than the financial burden imposed by cancer.

An analysis of nearly 150,000 non-elderly patients with cancer or cardiovascular disease between 2013 and 2018, results demonstrate financial toxicity associated with cardiovascular disease was equal to or greater than that seen with cancer and also highlighted the significant financial burden imposed by either disease was most severe among those impacted by both.

"Heart disease and cancer are the leading causes of death in the United States, yet most research on financial toxicity has focused on cancer patients. It is important to consider that cancer patients may have short bursts of high expenditures for treatments, while heart disease patients are often incurring a more chronic economic burden due to drug costs, procedures, clinician visits and hospital stays," said senior investigator Khurram Nasir, MD, MPH, MSc, chief of the Division of Cardiovascular Prevention and Wellness at Houston Methodist DeBakey Heart and Vascular Center, 

. "Also, as the rate of cancer survival grows, the population of patients with both heart disease and cancer is growing. The financial burden created by these diseases manifests as another form of affliction. Without the ability to pay, our patients can suffer from financial, health and non-health related difficulties that the health care field must be prepared to address. It does very little good if we can treat the cancer or the heart disease, but the patient can't afford to eat or pay their mortgage."

With an interest in further describing trends of financial toxicity among patients with cancer and cardiovascular disease, Nasir and a team of colleagues designed the current study as an analysis of the National Health Interview Survey, which is a weighted survey conducted by the National Center for Health Statistics/Centers for Disease Control and Prevention. Comprised of 4 components—a Household Composition, Family Core, Sample Child Core, and Sample Adult Core—the survey collected detailed information related to demographic and socioeconomic information as well as data related to health status, health care utilization, and other relevant information.

Using data obtained from the Sample Adult Core and the Household and Family Corte components between 2013-2018, investigators identified a cohort of 141,826 patients aged 18-64 years of age for inclusion in their study. Of these, 6887 had cancer, 6093 had atherosclerotic cardiovascular disease (ASCVD), and 971 had both. Investigator noted 65 years was chosen as a cutoff age as populations younger than this age do not have access to universal financial protections such as public insurance like Medicare. Investigators also pointed out diagnoses of ASCVD or cancer were based on self-reporting by patients.

For the purpose of analysis, the incidence of financial toxicity was chosen as the primary outcome of interest. Financial toxicity was defined as the presence of any of the following criteria: difficulty paying medical bills, high financial distress, cost-related medication nonadherence, food insecurity, and forgoing or delaying medical care due to cost.

Upon analysis, investigators found the prevalence of financial toxicity was 54% among those with self-reported ASCVD and 41% among those with cancer (

<.001). In assessments of individual components of financial toxicity, results of adjusted analyses indicated those with ASCVD were more likely to report difficulty paying medical bills, inability to pay bills (OR, 1.25; 95% CI, 1.04-1.50), cost-related medication nonadherence (OR, 1.28; 95% CI, 1.08-1.51), food insecurity (OR, 1.39; 95% CI, 1.17-1.64), and foregone/delayed care due to cost (OR, 1.17; 95% CI, 1.01-1.36).

Further analysis suggested the presence of 3 or more of these factors was significantly greater among those with ASCVD and those with both ASCVD and cancer compared to those with cancer (23% vs 30% vs 13%, respectively; 

Investigators also noted they conducted analyses using a sample of elderly patients from within the National Health Interview Survey and the results of these analyses were consistent with those observed in the study population.

"The current manuscript gives us an overall picture of the economic burden suffered by patients with heart disease and/or cancer on a national level, and to tackle the two top causes of mortality in the U.S., we have to more aggressively consider the financial toxicity associated with both these diseases, and their treatment," said lead investigator Javier Valero-Elizondo, MD, MPH, from the Division of Cardiovascular Prevention and Wellness at Houston Methodist DeBakey Heart and Vascular Center, in the aforementioned statement. "While this study is amongst the first of its kind, we hope it helps not only to build on current literature, but also serve as an idea generating paper to fight financial toxicity."

Atherosclerotic Cardiovascular Disease, Cancer, and Financial Toxicity Among Adults in the United States

A comparison of data from patients with cancer and ASCVD from a nationally representative survey suggests the financial burden of cardiovascular disease was similar to or exceeded the burden imposed by cancer. 

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GOULD Registry Details Subpar Levels of Intensifying Lipid-Lowering Therapies in ASCVD Patients

Cardiology Case Report: Syncope and Bradycardia

Financial Burden of Cardiovascular Disease Equals or Exceeds Burden Imposed by Cancer