Examining the current state of professionalism and ethics in cardiology.

A Need for Change: Tackling Professionalism and Ethics in Cardiology

This article was originally published on 

A systematic review and meta-analysis presented at AACE 2021 provide a comprehensive overview of the risk of cardiovascular disease in patients with thyroid cancer from current literature.

Using data from nearly 200,000 patients with thyroid cancer receiving thyroidectomy, investigators were able to shed light on the incidence of cardiovascular disease, 

(AF), and cardiovascular mortality among patients with thyroid cancer as a whole and based on whether or not they received treatment with radioactive iodine.

“To our knowledge, this study is the first meta-analysis to examine the association of thyroid cancer with cardiovascular disease. These results provide insights toward optimizing thyroid cancer strategies that should consider the potential harms and benefits during cancer treatment,” wrote study investigators.

Presented by Wen Hsuan Tsai, MD, the study was designed as a systematic review and meta-analysis with the intent of detailing the association between thyroid cancer and cardiovascular disease from literature available in the PubMed, Embase, and Cochrane Library databases from inception through November 25, 2020. For the purpose of analysis, investigators limited their review to prospective and retrospective studies and keywords used in their search of the aforementioned databases included thyroid cancer, AF, cardiovascular disease, and thyroxine.

The primary outcomes of interest for the analyses were incidence of cardiovascular disease, AF, and cardiovascular mortality among thyroid cancer compared to the general population and secondary outcomes included incidence of these outcomes among patients with and without radioactive iodine treatment.

In total, 9 studies met inclusion criteria. From these 9 studies, investigators obtained data related to 197,202 patients with thyroid cancer receiving thyroidectomy.

In a pair of studies, risk estimates indicated patients with thyroid cancer were at a 15% greater risk of cardiovascular disease than the general population (RR, 1.15; 95% CI, 1.10-1.21). In an analysis of 3 studies measuring incidence of AF, results suggested a significant difference in a fixed-effect model (RR, 1.37; 985% CI, 1.15-1.62) but no significant difference in the random effect model (RR, 1.47; 95% CI, 0.96-2.23) when compared to the general population.

When assessing cardiovascular mortality in a group of 3 studies, results indicated the association between cardiovascular mortality and thyroid cancer was insignificant (RR, 0.82; 95% CI, 0.66-1.01). Additionally, analysis of pooled data from 3 studies indicated there was no significant difference in risk of cardiovascular disease among patients based on whether they received RAI treatment after thyroidectomy (RR, 1.01; 95% CI, 0.81-1.26).

Association of thyroid cancer with cardiovascular disease, atrial fibrillation and cardiovascular-specific mortality: A systematic review and meta-analysis

Articles

Data from AACE 2021 suggests the risk of cardiovascular disease was 15% greater among patients with thyroid cancer who underwent thyroidectomy than the general population, but found no significant difference in risk of cardiac mortality and atrial fibrillation.

Meta-Analysis Details CVD Risk After Thyroidectomy in Patients with Thyroid Cancer

The latest scientific statement from the American Heart Association (AHA) is underlining the importance of physical activity as a first-line treatment for some patients with elevated blood pressure or cholesterol.

The statement, which was composed on behalf of the AHA Council on Lifestyle and Cardiometabolic Health, Council on Cardiovascular and Stroke Nursing, and Council on Clinical Cardiology, outlines patient populations meeting the criteria for lifestyle-only treatment for elevated blood pressure or cholesterol, which encompasses more than 20% and the writing committee highlights is an often-overlooked patient population.

"The current American Heart Association guidelines for diagnosing high blood pressure and cholesterol recognize that otherwise healthy individuals with mildly or moderately elevated levels of these cardiovascular risk factors should actively attempt to reduce these risks. The first treatment strategy for many of these patients should be healthy lifestyle changes beginning with increasing physical activity," said Bethany Barone Gibbs, PhD, chair of the statement writing group and associate professor in the department of health and human development and clinical and translational sciences at the University of Pittsburgh, 

Titled “Physical Activity as a Critical Component of First Line Treatment for Elevated Blood Pressure or Cholesterol: Who, What, and How?,”, the statement, which is broken down into 3 sections, was created with the aim of highlighting at-risk patient groups, describing recommendations, and providing guidance and resources for clinical decision-making.

Using estimates based on current literature, authors underline an estimated 28% of US adults had an LDL score above 70 mg/dL and otherwise low risk of cardiovascular disease, an estimated 21% of US adults had a systolic blood pressure of 120-139 mmHg or diastolic blood pressure between 80-89 mmHg. All of these patients, investigators suggest, are candidates for lifestyle-only interventions as first-line treatment.

Within each of the 3 sections, investigators also provide information related to the impact of various lifestyle interventions on blood pressure and cholesterol levels through references to 

Among the excerpts of the statement highlighted within the aforementioned statement from the AHA include research indicating physical activity was associated with a 21% lower risk of developing cardiovascular disease and a 36% lower risk of death from cardiovascular causes. Additionally, statement authors referenced the US Department of Health and Human Services 2018 Physical Activity Guidelines for Americans, which recommend a cumulative 150 minutes of moderate-intensity aerobic exercise, or 75 minutes of vigorous aerobic activity weekly plus two or more strength training sessions each week.

Statement authors noted prescribing exercise should include multiple components, such as screening patients, use of a wearable device, providing ideas and resources for patient support, exploring multiple activity options, and encouraging or celebrating small increases in physical activity.

"In our world where physical activity is increasingly engineered out of our lives and the overwhelming default is to sit - and even more so now as the nation and the world is practicing quarantine and isolation to reduce the spread of coronavirus - the message that we must be relentless in our pursuit to 'sit less and move more' throughout the day is more important than ever," added Gibbs.

Physical Activity as a Critical Component of FirstLine Treatment for Elevated Blood Pressure or Cholesterol: Who, What, and How?,”

The AHA has released a scientific statement highlighting the importance of prescribing physical activity as a first-line treatment in patient populations with elevated blood pressure or elevated cholesterol. 

AHA Recommends Physical Activity as a First-Line Treatment for Many Patients with Elevated Blood Pressure, Cholesterol

An analysis of data from nearly a dozen studies is providing insight into the relationship between various risk factors and risk of peripheral artery disease (PAD) in 

Presented by Martha Rosana, MD, of the Department of Internal Medicine at the University of Indonesia, at the American Academy of Clinical Endocrinology’s 30th Annual Meeting (AACE 2021), results of the study detail the impact of increased age, increased duration of diabetes, and disease history can have on risk of PAD in patients with type 2 diabetes.

Led by Rosana and colleagues from the University of Indonesia, the current study was designed to provide clinicians and researchers with a comprehensive review of risk factors associated with incidence of PAD in patients with type 2 diabetes. With this in mind, investigators designed their study as a systematic review and meta-analysis of studies detailing incidence of PAD in populations with type 2 diabetes from major databases and other sources.

Risk factors of interest for the investigators’ analyses included age, sex, duration of diabetes, hypertension status, history of coronary artery disease (CAD) or stroke, obesity, HbA1c levels, eGFR, dyslipidemia, smoking status, and fibrinogen level.

For the purpose of analysis, investigators designed their study using the PRISMA standard and data obtained from the PubMed, MEDLINE, ProQuest, and EMBASE database. Their specific search sought to identify cohort or case-control studies reporting risk factors of PAD incidence among patient populations with type 2 diabetes mellitus.

From their search of databases, investigators identified 14,129 articles for possible inclusion in the systematic review and meta-analysis and 39 articles from other sources. After exclusion of duplicates and screening, 51 full-text articles were assessed for eligibility. Of these, 10 were included in the qualitative synthesis and 9 were included in the meta-analysis.

Among the articles assessed but that were ultimately excluded, the most common reason for exclusion was a different diagnosis criterion for PAD (n=13) followed by a different outcome measure (n=11), patient population did not have type 2 diabetes mellitus (n=5), and used the same subject as another study (n=5). All 10 studies included in the qualitative synthesis had a low risk of bias according to the 

 and included a total population of 73,834 patients with type 2 diabetes.

Upon analysis, investigators found being 70 years of age or older (OR, 3.44; 95% CI, 2.11-5.62), having diabetes for 5 years or more (OR, 1.81; 95% CI, 1.24-2.64), a history of CAD (OR, 1.55; 95% CI, 1.30-1.83), hypertension (OR, 1.43; 95% CI, 1.10-1.86), and elevated LDL-C (2.51; 95% CI, 1.38-4.58) were associated with an increase in odds of developing PAD. Investigators noted all evidence had a grade of moderate certainty.

Risk Factors of Peripheral Arterial Disease in Type 2 Diabetes Mellitus Patients: A Systematic Review and Meta-analysis

A systematic review and meta-analysis presented at AACE 2021 sheds light on risk factors associated with increased odds of developing peripheral artery disease among patients with type 2 diabetes. 

Multiple Risk Factors Play Role in Odds of Developing Peripheral Artery Disease in Patients with Type 2 Diabetes

: A man in his late 50’s presents to the emergency department with palpitations, which he describes as a rapid but regular heart rate. His fit bit has registered it up to 160 bpm at rest, whereas normally he is at about 80. He denies syncope, feeling light-headed, chest discomfort, dyspnea, fever, cough, any pain, melena, or other complaints. He also denies use of alcohol or recreational drugs.

: Vital signs are normal except for a pulse of 142. BP is 139/87. Otherwise, vitals and physical exam are normal including no thyroid mass, tremor, pupillary abnormalities, or other findings.

Computer Read: sinus tachycardia, inferior MI, probably old.

Check out the latest case report from Dr. Brady Pregerson. This case report features a man in his 50s presenting to the ED with palpitations. Can you determine the correct diagnosis?

Cardiology Case Report: Tachycardia and Bradycardia

Analysis of the Lifetime Risk Pooling Project indicates women who experience premature menopause were at an increased lifetime risk of coronary heart disease (CHD). 

Presented at the American Heart Association’s Epidemiology, Prevention, Lifestyle and Cardiometabolic Health Conference 2021, results of the analysis suggest nonsurgical premature menopause was associated with a 40% greater risk of CHD and also shed light on disparities in incidence of premature menopause among women of different racial/ethnic backgrounds.

“These results indicate premature menopause is associated with higher lifetime risk of coronary heart disease. To mitigate this risk, clinicians need to start asking women about their menopause status earlier,” said Priya Freaney, MD, a cardiology fellow at Northwestern University’s Feinberg School of Medicine, 

. “If a woman experiences menopause before the age of 40, she should let her doctor know so they can be more proactive about optimizing her cardiovascular health—such as weight management and blood pressure—throughout her mid-life years and preventing heart disease over the course of her lifetime.”

With the 2019 AHA/ACC Primary Prevention Guidelines highlighting women who enter menopause before the age of 40 as being at risk for CHD, Freaney and a team of colleagues sought to explore race-specific prevalence of premature menopause and lifetime risk of CHD with the aim of improving risk stratification and prevention. Using pooled data from 6 cohorts within the Lifetime Risk Pooling Project, investigators obtained data related to a cohort of more than 10,000 women between 55-69 years of age with no history of CHD at baseline.

The earliest enrollment among women in the cohort began in 1964 and the latest follow-up date occurred in 2017. Of note, women who underwent surgical menopause were not included in the study. For the purpose of analysis, investigators used modified Kaplan Meier analysis and competing Cox models to estimate for risk for CHD or non-CV death with adjustment for clinical risk factors, such as age, smoking status, obesity, and presence of other comorbidities.

Of the 10,036 individuals identified for inclusion, 3522 were Black and 6514 were White—the mean age of these groups was 61.2±4.3 and 60.0±4.4 years, respectively.

Initial analysis indicated premature menopause was more common among Black women (15.5%) than White women (4.8%). Adjusted analyses indicated the lifetime risk of CHD morbidity and mortality was 41% (HR, 1.41; 95% CI, 1.04-1.90) greater in Black women and 39% (HR, 1.39; 95% CI, 1.03-1.87) greater in White women with premature menopause compared to their counterparts without premature menopause.

“We need to better understand what factors contribute to a woman’s lifetime risk of heart disease, and specifically, how timing of menopause may be connected to risk,” Freaney said.

Association Between Premature Menopause And Lifetime Risk Of Coronary Heart Disease: Lifetime Risk Pooling Project

,” was presented at AHA EPI Lifestyle Conference 2021.

An analysis of data from 10k women in the Lifetime Risk Pooling Project presented at EPI Lifestyle 2021 suggests premature menopause was associated with a 40% increase in risk of coronary heart disease. 

Women Who Experience Premature Menopause at Increased Risk of Coronary Heart Disease

The American Heart Association and American Stroke Association have released new clinical practice guidelines aimed at reducing secondary stroke risk in patients with 

stroke or transient ischemic attack (TIA)

Endorsed by the American Association of Neurological Surgeons, Congress of Neurological Surgeons, and the Society of Vascular and Interventional Neurology, the 104-page guideline update addresses secondary prevention in this patient population in 4 sections: diagnostic evaluation, vascular risk factor management, management by etiology, and systems of care for secondary prevention of ischemic stroke. An accompanying data review article was published simultaneously, outlining the current available evidence related to short-term and long-term dual versus single antiplatelet therapy.

“It is critically important to understand the best ways to prevent another stroke once someone has had a stroke or a TIA,” said Dawn O. Kleindorfer, MD, FAHA, chair of the guideline writing group, and professor and chair of the department of neurology at the University of Michigan School of Medicine, in 

. “If we can pinpoint the cause of the first stroke or TIA, we can tailor strategies to prevent a second stroke.”

This latest guideline update, which is the first to address secondary prevention of stroke in this population since the ASA’s 2014 guidelines, was designed to provide updated evidence-based recommendations and relay information in a manner that is more accessible for clinicians. Atop the guidelines is a list of the top 10 take-home messages from within the guideline.

The accompanying systematic review detailed a systematic review and meta-analysis performed on behalf of the AHA Stroke Council detailing relevant data comparing dual versus single antiplatelet therapy for secondary stroke prevention. After a search of multiple databases from 1999-2019, investigators identified 3 short-duration randomized controlled trials and 2 long-duration treatment randomized controlled trials for inclusion in the meta-analyses.

Upon analysis, DAPT was associated with a lower 90-day risk of recurrent ischemic stroke (pooled RR, 0.68; 95% CI, 0.55–0.83; 

2=37.1%) than single antiplatelet therapy. Investigators also pointed out there was no increase in major bleeding observed with DAPT in short-duration trials (pooled RR, 1.88; 95% CI, 0.93-3.83; 

When examining data from a pair of long-duration randomized clinical trials (mean duration 18-40 months), DAPT was not associated with a significant reduction in recurrent ischemic stroke (pooled RR, 0.89; 95% CI, 0.79-1.02; 

2=8.9%) and was also associated with increased risk of major bleeding (pooled RR, 2.42; 95% CI, 1.37-4.30; 

2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association

,”, and accompanying review article, titled “

Benefits and Risks of Dual Versus Single Antiplatelet Therapy for Secondary Stroke Prevention: A Systematic Review for the 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack

The American Heart Association and American Stroke Association have released an updated version of their guidelines for prevention of secondary stroke in patients with stroke or TIA, which had not been updated since 2014. 

AHA/ASA Release Updated Guidelines for Secondary Prevention After Stroke or TIA

An analysis of data within the Multi-Ethnic Study of Atherosclerosis (MESA) study suggests using computed tomography to measure pericardial fat volume could help predict risk of incident 

The study, which was funded in part by the National Heart, Lung, and Blood Institute and the National Center for Advancing Translational Sciences, concluded elevated pericardial fat volume was associated with a 2-fold increase in risk among women and 53% greater risk in men while also providing insight into the impact of incremental increases in pericardial fat volume on incident heart failure.

"For nearly two decades we have known that obesity, based on simple measurement of height and weight, can double one's risk of heart failure, but now, we have gone a step further by using imaging technology to show that excess pericardial fat, perhaps due to its location close to the heart muscle, further augments the risk of this potentially fatal condition--heart failure" explains lead researcher Satish Kenchaiah, MD, MPH, Associate Professor of Medicine at the Icahn School of Medicine at Mount Sinai, 

. "This work provides us with an important tool to stratify patients into higher and lower risk of heart failure, which can possibly lead to early intervention and heart failure prevention to ultimately save people's lives."

With an apparent knowledge gap existing related to the association of pericardial fat and incident heart failure, Kenchaiah and a team of colleagues sought to fill this gap by performing an analysis of a large, community-based, ethnically diverse, prospective cohort. Using the MESA study, investigators identified a cohort of 6785 patients, including 3584 women and 3201 men, without cardiovascular and with information related to pericardial fat volume ascertained through cardiac CT and complete follow-up data.

From this cohort, investigators obtained 90,686 person-years of follow-up data. During this time period, 385 (164 women, 221 men) participants developed incident heart failure. Overall, pericardial fat volume was lower among women included in the study than men (69±33cm

For the purpose of analysis, investigators planned to use Cox proportional hazards regression to evaluate pericardial fat volume as a continuous and dichotomous variable. Information related to demographic variables, medical history, medication use, and other factors were used as covariates in adjusted analyses.

) increase in pericardial fat volume was associated with a 44% increase in risk of incident heart failure among women (HR, 1.44; 95% CI, 1.21-1.71; 

 <.001) and a 13% increase in risk among men (HR, 1.13; 955 CI, 1.01-1.27; 

.03). When comparing those with elevated pericardial fat volume, which was defined as greater than 70 cm

 in men, elevated pericardial fat volume was associated with more than double the risk of heart failure among women (HR, 2.06; 95% CI, 1.48-2.87; 

 <.001) and a 53% increase in risk among men (HR, 1.53; 95% CI, 1.13-2.07; 

The increased risk of heart failure remained robust in sex-stratified analyses, even after adjustment for indicators of obesity (

 ≤.008), abdominal subcutaneous or visceral fat (

 ≤0.03), or biomarkers of inflammation and hemodynamic stress (

 <.001). Investigators also pointed out this trend was similar across multiple racial/ethnic subgroups.

Investigators pointed out the effect of pericardial fat volume was more significant among patients with preserved ejection fraction (

 <.001) than those with reduced ejection fraction (

"Our research provides strong evidence that excess pericardial fat substantially raises the risk of heart failure,” added Kenchaiah. "Additional studies are needed to confirm our findings. Future research in this field should also focus on ways and means, such as eating a heart-healthy diet and staying physically active, to achieve and maintain optimal body weight and reduce and avoid fat deposition around the heart."

Pericardial Fat and the Risk of Heart Failure,

Journal of the American College of Cardiology.

Results of an analysis of the MESA study suggest increased pericardial fat volume was associated with a 2-fold increase in heart failure risk in women and a 53% increase in risk among men. 

Pericardial Fat Volume Helps Predict Incident Heart Failure, Even After Adjustment for Obesity

Research from clinicians at Brigham and Women’s Hospital and Harvard Medical School is describing the effects of sodium reduction on cardiac biomarkers.

An analysis of the DASH-Sodium Trial, results demonstrate the impact of sodium reduction alone or combine with the DASH diet on biomarkers of cardiac injury, strain, and inflammation—suggesting an approach aimed at sodium reduction was linked to lowering a pair of mechanisms associated with subclinical cardiac damage.

"Our study represents some of the strongest evidence that diet directly impacts cardiac damage, and our findings show that dietary interventions can improve cardiovascular risk factors in a relatively short time period," said study investigator Stephen Juraschek, MD, PhD, Assistant Professor of Medicine at BIDMC and Harvard Medical School, 

. "The data reinforce the importance of a lifestyle that includes a reduced-sodium, DASH diet rich in fruits, vegetables and whole grains to minimize cardiac damage over time."

An investigator-initiated controlled feeding study conducted at 4 US medical centers from 1997-1999, DASH-Sodium enrolled 412 patients with elevated blood pressure who were randomized to the DASH diet or a control diet designed to reflect the typical American diet. Patients included in the study underwent measurements of cardiac biomarkers including high-sensitivity cardiac troponin I (hs-cTnI), N-terminal pro–B-type natriuretic peptide (NT-proBNP), and high-sensitivity C-reactive protein (hs-CRP), at baseline and at the end of each feeding period. These measurements represent markers of cardiac injury, cardiac strain, and inflammation, respectively.

Specific inclusion criteria for DASH-Sodium included being at least 22 years of age, mean systolic blood pressure between 120-159 mmHg, and mean diastolic blood pressure of 80-95 mmHg. Patients were excluded based on history of cardiovascular disease, renal insufficiency, dyslipidemia, or diabetes and based on use of antihypertensive agents or insulin.

To assess the impact of sodium intake, investigators further grouped patients in each diet group to one of 3 levels of sodium intake. These levels were tested using a crossover design, with each of the 3 periods lasting 4 weeks in length, and the order of assignment to each level was random. To limit variability, all meals and snacks were provided to participants who ate one main meal per day under observation and consumed the rest off-site.

At the end of the study period, investigators had data related to 1543 biomarker assessments of a possible 1648. Investigators also pointed out the limits of detection for biomarker assays were more than 1.60 ng/l for hs-cTnl, more than 5 pg/ml for NT-proBNP, and greater than 0.160 mg/l for hs-CRP.

The mean age of the study population was 48 years, 56% were women, and 56% were Black, and, at baseline, the mean systolic/diastolic blood pressure was 135/86 mmHg. Initial analyses indicated use of a FASH diet was associated with an 18% reduction in hs-CTnl (18%; 95% CI, -27 to -7), and a 13% reduction in hs-CRP (13%; 95% CI, -24 to -1), but this trend was not noted for NT-proBNP.

Further analysis indicated lowering sodium from high to low levels reduced NT-proBNP independent of diet (19%; 95% CI, -24 to -14) but was not associated with changes in hs-cTnl and increased hs-CRP (9%; 95% CI, 0.4-18). When combining DASH with low sodium, investigators found this approach was associated with a 20% reduction in hs-cTnl and a 23% reduction in NT-proBNP, but hs-CRP was not significantly changed when compared against this eon a high-sodium control diet.

"Our study has important clinical implications, and these findings should strengthen public resolve for public policies that promote the DASH dietary pattern and lower sodium intake in the United States and globally,” Juraschek said.

Effects of Diet and Sodium Reduction on Cardiac Injury, Strain, and Inflammation: The DASH-Sodium Trial

An analysis of data from DASH-Sodium sheds further light on the impact of increased sodium intake on cardiovascular risk. 

Low Sodium Diet Linked to Reductions in Cardiac Injury, Strain in DASH-Sodium Trial 

New data from the SPRINT trial provides evidence further supporting use of a more intensive blood pressure goal in patients with 

Results of the most recent analysis of SPRINT data indicate targeting a systolic blood pressure less than 120 mmHg was associated with significant reductions in risk of myocardial infarction, acute coronary syndromes, and stroke, as well as cardiovascular and all-cause mortality when compared to a standard treatment target of less than 140 mmHg.

"One criticism of the original SPRINT findings was that, of the components of the primary outcome, only heart failure and death due to CVD were significantly lower in the intensively treated group," Cora Lewis, MD, Professor and Chair of the Department of Epidemiology in the University of Alabama at Birmingham School of Public Health, 

. "The final results found that risk of heart attack, along with heart failure, and death from CVD, was significantly lower in the group treated to less than 120, and the risk of the primary outcome excluding heart failure was still significantly lower in the more intensively treated group."

Funded in part by the National Institutes of Health, the Systolic Blood Pressure Intervention Trial (SPRINT) was conducted between November 2010 and 2015 and enrolled more than 9000 patients with elevated systolic blood pressure to a blood pressure target of less than 140 mmHg or less than 120 mmHg. The trial was halted by the Data and Safety Monitoring Board due to apparent benefit seen with the intensive blood pressure on risk of the study’s composite endpoint, which was a composite outcome made up of myocardial infarction, other acute coronary syndromes, stroke, acute decompensated heart failure, or death from cardiovascular causes. The current analysis of SPRINT details the incidence of efficacy and safety events occurring in the post-trial observational follow-up occurring from August 20, 2015 through July 29, 2016.

Briefly, the original trial enrolled and randomized 9361 patients in a 1:1 ratio to either of the aforementioned blood pressure targets. Patients included in the study were required to be at least 50 years of age, have a systolic blood pressure of 130-180 mmHg, and at least one clinical indicator of cardiovascular risk. Participants were excluded based on presence of diabetes mellitus, history of stroke, or presence of dementia. Upon conclusion, results indicated the intensive blood pressure goal was associated with a 25% decrease in the primary composite endpoint and a 27% decrease in all-cause mortality compared to the standard target.

For the most recent analysis, which had a median follow-up of 3.3 years, suggested the intensive blood pressure goal was associated with a 27% reduction in risk of the primary composite outcome (1.77% vs 2.40%; [HR, 0.73; 95% CI, 0.63-0.86; 

=.001)]) and a 25% reduction in risk of all-cause mortality (1.06% vs 1.41%; [HR, 0.75; 95% CI, 0.61-0.92; 

=.006]). Investigators pointed out no significant differences were observed in the composite renal outcome among those with chronic kidney disease at baseline.

When assessing incidence of adverse events, investigators noted rates of serious adverse events did not differ significantly between the study groups. However, investigators did note incidence of hypotension, electrolyte abnormalities, acute kidney injury or failure, and syncope were greater among those with a more intensive blood pressure goal.

"We know a lot about how to prevent and treat hypertension and SPRINT continues to greatly expand this knowledge, including the benefits of treatment on the heart, kidney and brain," said David Goff, MD, PhD, director of the Division of Cardiovascular Sciences at NHLBI. "As we implement what we know, more research is still needed to develop more effective prevention strategies for hypertension, improve its monitoring and control, and reduce the large health disparities associated with this disorder. Research teams supported by the NIH are continuing to work on these challenges."

Final Report of a Trial of Intensive versus Standard Blood-Pressure Control,

New observational data from the SPRINT trial provides further support of using a more intense blood pressure goal, suggesting use of 120 mmHg as a goal rather than 140 mmHg could reduce the risk of major adverse cardiovascular events. 

SPRINT Analysis Supports Intensive Blood Pressure Goal for Further Reducing Cardiovascular Risk

Research from Brigham and Women’s Hospital is underlining the impact of an approach integrating digital care on blood pressure management in patients with 

An analysis of patients from the Digital Care Transformation (DCT) program, results indicate nearly 90% of patients were able to achieve blood pressure control after a median of 4 months within the program after a median of 9 years of uncontrolled hypertension.

A team-based care program designed to improve care through medical titration and education using physician-designed algorithms, DCT was created with the aim of addressing areas of need in multiple disease states, including hypertension. The present study, which was presented at the American College of Cardiology’s 70th Annual Scientific Session (ACC.21), sought to assess the benefits of the program on blood pressure control among patients who reached goal within the program.

For the purpose of analysis, investigators designed their analyses with the goal of qualifying time of exposure to hypertensive blood pressure in routine office care prior to referral and after enrollment in the program. Uncontrolled hypertension was defined as two or more blood pressure measurements exceeding 140/90 mmHg at separate visits in the same calendar year.

A cohort of 687 patients was identified for inclusion. These patients had been followed within the health system for a mean of 7.4 years prior to referral to DCT. The median time spent with blood pressure above goal was 4.6 years and the median time between first uncontrolled blood pressure year and enrollment in DCT was 8 years.

After a median of 4 months within the program, blood pressure control, defined as 130/80 mmHg or below, was achieved by 89% of patients. The mean blood pressure among this cohort was 125/72 mmHg and the mean number of medication changes was 2.8. The final mean blood pressure among the remaining patients was 135/82 mmHg. Investigators noted the mean total reduction of blood pressure observed within this cohort was 17±13/9±8 mmHg.

For more on the results of this study and how adoption of digital care practices could improve management of hypertension, check out this interview with lead investigator Naomi Fisher, MD, Director of Hypertension Service and the Hypertension Specialty Clinic at Brigham and Women’s Hospital.

Time to Control: Routine Clinical Care vs. Virtual Hypertension Management

An analysis of patients who achieved blood pressure goal within a digital care program details the potential ability of digital health interventions to improve management of patients with hypertension. 

DCT Demonstrates Ability of Digital Programs to Improve Care, Blood Pressure Management

This article is the first 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.



Analysis of survey responses of cardiologists from across the globe underlines the need for reform in the field.

Using responses from nearly 6000 cardiologists, investigators found 44% of cardiologists reported having a hostile work environment with 29% reporting emotional harassment, 30% reporting discrimination, and 4% reporting sexual harassment.

“Our study demonstrates a high prevalence of reported hostile work environment in cardiology. Although there is some geographic, gender, and race variation, no region, gender, or race is immune,” wrote investigators.

Led by Laxmi Mehta, MD, Vice Chair of Wellness for the Department of Internal Medicine at the Ohio State University Wexner Medical Center and Chair of the ACC’s Task Force on Clinician Well-Being, the current study was an analysis of data from a 50-item online survey returned by 5931 cardiologists around the world between September 13, to October 22, 2019. In total, 71,022 cardiologists were sent survey invitations. Among those who responded, 77% were men, 54% were white, and 73% were 54 years of age or older.

As mentioned above, a hostile work environment was reported by 44% of respondents. Upon analysis, higher rates were observed among women versus men (68% vs 37%; OR, 3.58; 95% CI, 3.14-4.07), Black cardiologists versus White cardiologists (53% vs 43%; OR, 1.68; 95% CI, 1.25-2.26), and North American cardiologists compared to South American cardiologists (54% vs 38%; OR, 1.90; 95% CI, 1.51-2.41).

When assessing individual aspects of hostile work environments, results indicated emotional harassment was reported by 29% (n=1743) of cardiologists, while 30% (n=1750) reported experiencing discrimination and 4% (n=221) reported experiencing sexual harassment. Investigators pointed out reports of emotional harassment (43% vs 26%), discrimination (56% vs 22%), and sexual harassment (12% vs 1%) were more common among women cardiologists than men.

Hear from Laxmi Mehta, MD, on the impact of COVID-19 on burnout among cardiologists.

Further analysis indicated gender was the most common cause of discrimination, accounting for 44% of reports. Other common causes included age (37%), race (24%), religion (15%), and sexual orientation (5%). In a multivariable analysis, results suggested women (OR, 3.39; 95% CI, 2.97-3.86; 

 <.001) and cardiologists early in their career (OR, 1.27; 95% CI, 1.14-1.43; 

<.001) had the greatest odds of experiencing a hostile work environment.

“A renewed focus on organizational structure, processes, and practices to mitigate hostile work environments across the globe in cardiology is critical to ensuring workforce well-being and optimal patient care,” wrote investigators.

Global Prevalence and Impact of Hostility, Discrimination, and Harassment in the Cardiology Workplace

An analysis of survey data from cardiologists in multiple regions throughout the world portrays a field in need of reform, with more than 4-in-10 reporting a hostile work environment and some form of discrimination reported by 3-in-10 cardiologists. 

Survey Suggests Nearly 50% of Cardiologists Report Having a Hostile Work Environment

In recognition of the American Heart Association/American College of Cardiology Consensus Conference on Professionalism and Ethics, 

is hosting a multipart series highlighting the topic.

Titled, “A Need for Change” the first portion of the series highlighted a recent study examining the impact and prevalence of discrimination and harassment among cardiology professionals while the remaining pieces included in the series focus on the recommendations and guidance of each of the 5 task forces who composed the AHA/ACC statement. Every day from June 7-June 12, 2021, this article will be updated to include links to the latest segment of the series.


An analysis of survey data from cardiologists in multiple regions throughout the world portrays a field in need of reform, with more than 4-in-10 reporting a hostile work environment and some form of discrimination reported by 3-in-10 cardiologists. 

Navigating Relationships with Industry and Conflicts of Interest in Cardiology


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.

Addressing 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.

Enhancing the Well-Being of Cardiology Professionals


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.

Improving Patient Autonomy, Privacy, & Social Justice in Cardiology


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.

Challenges with New Care Delivery Systems in 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.


A multipart series from Practical Cardiology, "A Need for Change" highlights a recent report from the AHA/ACC and the current state of professionalism in cardiology from recent data. 

Arnold Meshkov MD. is a cardiologist, heart health expert, and was a Professor of Medicine at Temple University School of Medicine until 2015 when he returned to private practice. He is Board Certified in Internal Medicine, Cardiology, and Echocardiography and has lectured on a broad range of topics in cardiology and bioethics. Dr. Meshkov served for many years as the Chairman of the Ethics Committee at Temple University Hospital and was the coordinator of Cardiology Grand Rounds, a weekly lecture series at Temple. 

There is that well-known saying that you’re entitled to your own opinion, but not your own facts. The COVID-19 pandemic that has rocked our world has engaged some of the brightest among us to use the methods of science to try to reign in this horrible virus. Vaccinations have been used to combat human disease since the 18th century when the Englishman Edward Jenner developed a vaccine to prevent smallpox. 

Almost none of us who are alive have seen smallpox—it 

 a very deadly disease, and even survivors were often left them with life-altering facial scars. Why don’t we see smallpox? 

BECAUSE VACCINES HAVE ERADICATED THE DISEASE

! Prior to worldwide vaccination, there were 300 MILLION cases in the 20th century.

Still, there are the doubters worldwide, for reasons that truly escape me. When the pharmaceutical companies went to work on vaccines, they used the very latest in biochemical and molecular biology techniques that rapidly accelerated their ability to produce vaccines.

At the end of the last year, Pfizer and BioNTech together reported their results of a multinational trial in the New England Journal of Medicine. The study involved over 43,000 people in the US, Brazil, South Africa, and Turkey. Half of the group received two vaccine doses separated by 21 days, and half were just left to live their normal lives. The vaccine, named BNT162b2, is a lipid nanoparticle that contained the RNA code for the “spike protein” of the COVID-19 virus, so that when it entered the cells of the body, the foreign RNA would get into the cells and start to make numerous copies of not the entire virus, but just the “spike protein.”

When the RNA-manufactured spike protein gets into the bloodstream, the white blood cells recognize it as a foreign invader, and chew it up. Then, they are primed to attack any new “spike proteins” they encounter – like from a viral infection of Covid-19. The white cells have “immunologic memory.”

Do we need to know anything else about the effectiveness of the Pfizer/BioNTech vaccine? Well, maybe. How about that there was only ONE case of serious Covid-19 in the vaccine group. The major side effect was fatigue – seen in less than one percent of vaccinated patients.

The new vaccines using the RNA code will prove to be a revolution in not just vaccine production but in so many other uses in medicine. The historical track record of vaccinations is a triumph of science and medicine.

The previously mentioned Dr. Jenner discovered that using a strain of cowpox virus, a bovine disease that does not cause human disease, was able to protect humans from smallpox. Later in the 19th century, Louis Pasteur was able to cure rabies, a fearful disease caused by a virus that attacks the central nervous system. How did he do that? He infected rabbits with rabies, putting himself and all of his lab workers at great risk, then sacrificed the rabbits, and dried out their spinal cords. He didn’t even know that rabies was a virus, but he knew that the disease attacked the nervous system. He then ground up the spinal cords, put the material into a solution, and injected it into a young boy who had been bitten by a rabid dog. Pasteur’s treatment worked and the world was changed forever.

By the 20th century, scientists and doctors had two examples about how “attenuated” viruses, those of cowpox and rabies, could safely stimulates the human immune system of white blood cells and antibodies to protect against many of the great ravages of human history. Let’s look at the scorecard:

 – first developed in the 1940’s, and newer vaccine using DNA technology introduced in 2013. In the 2019-2020 flu season, the vaccine prevented an estimated 7.5 million infections, 105,000 hospitalizations, and 6,300 deaths

 – poliomyelitis is a virus that also attacks the nervous system, leading to death and even in recovery often severe disability, especially in children. I am old enough to remember the Salk vaccine “sugar cube” given on Sunday mornings in my elementary school. Polio is GONE from the United States now.

 the yellow fever virus caused epidemics in cities for centuries; now gone in most parts of the world because of vaccines and measure to stop mosquitos, the carriers of the virus. Yellow fever raged through the workers on the Panama Canal, and it was the public health work of Walter Reed that saved that project.

 – the vaccine has prevented 2-3 million cases, 50,000 hospitalizations, and 500 deaths EACH YEAR in the United States. Measles in far more contagious than Covid-19, and outbreaks have occurred in the US in recent years in communities that have not vaccinated their children.

 – a nasty virus that causes severe gastrointestinal symptoms, dehydration, and death if not treated. A vaccine for this disease has thwarted a disease that once killed 500,000 people worldwide each year.

 – a virus in children that was once a common cause of deafness; now gone in vaccinated people

– a form of the measles virus. Usually a mild disease in adults, but a major cause of severe disability in children whose mothers were infected while pregnant, as well as spontaneous abortion. Also, now almost gone in vaccinated women of childbearing age.

 – this virus that attacks the liver has several forms, and both hepatitis A and B can be eliminated with vaccines.

The Covid-19 vaccines will enter this growing list. Tragically, epidemics have killed far more people over history than all of the wars combined. There is more work to be done, and not all viruses can be stopped by vaccines. There is still no vaccine for the AIDS virus, in spite of three decades of research, but there is an effective medication to control the disease. I wish there was a vaccine for the “common cold,” but there are too many different viruses that cause this disease.

We, as a society, need to reflect on our obligation not just to ourselves but to our families, friends, and the rest of our community. There has been a perversion of the idea of the sanctity of the belief in individual freedom by too many people. Your freedom does not entitle you to harm others. Vaccination against Covid-19 is not optional if we want our world to return to “normal,” and the scientific data are there to prove the case.

Polack F., Thomas S. et al. The safety and efficacy of the BNT162b2 mRNA Covid-19 vaccine. New England Journal of Medicine 383:2603-2615, December 31, 2020.

Desmond, A, and Offit, P. On the shoulders of giants – from Jenner’s cowpox to mRNA Covid vaccine. New England Journal of Medicine 384:1081-1083. March 25 2021.

Arnold Meshkov, MD, discusses the rollout of the COVID-19 vaccines and gives perspective on the history of how vaccines have been used to help eradicate pandemics. 

A Picture is Worth a Thousand Words! An Anti-Vaxxer's Nightmare, with Arnold Meshkov, MD

Less than a decade after receiving approval from the US Food and Drug Administration, Medtronic Inc. has asked providers to halt new implants of the HeartWare Ventricular Assist Device (HVAD) System as a result of observational data suggesting instances of internal pump delay or failure to restart were associated with increased risk of adverse events and mortality.

Announced by the FDA in a statement on June 3, Medtronic Inc. will be ceasing distribution and sale of the system after receiving more than 100 complaints, including 14 reports involving mortality, and the company has issued an Urgent Medical Device Communication Notification Letter providing clinicians and patients further guidance moving forward.

“The FDA’s highest priority is patient health and safety. We have been carefully monitoring the adverse events associated with this device and support its removal from the marketplace. The FDA is working closely with both Medtronic and Abbott to ensure patient care is optimized during this transition period and that there is an adequate supply of devices available to provide this patient population with options for end-stage heart failure treatment,” said Bram Zuckerman, MD, director of the Office of Cardiovascular Devices in the FDA’s Center for Devices and Radiological Health, in the 

The decision to halt the sale and distribution of the HVAD System comes on the heels of Medtronic’s voluntary recall of a subset of the pumps in December 2020. According to the FDA, Medtronic has received more than 100 complaints involving delay or failure to restart, including 14 reports of patient deaths and 13 requiring explant. According to Medtronic, there are approximately 2000 US patients and 4000 patients worldwide that have been implanted with the device.

, Medtronic marketed the system as the world’s smallest centrifugal-flow VAD that was designed to reduce surgical invasiveness, improve recovery times, and enhance patients outcomes.

The statement from the FDA called for clinicians to halt implantation of the device and instead use an alternative, such as the Abbott Heartmate 3 Left Ventricular Assist System. The statement also urged clinicians to advise patients who have the HVAD System to continue normal use and contact Medtronic for replacement items.

“The FDA’s alert is designed to quickly inform health care providers of this critical information so that patients with the current HVAD System continue to receive appropriate care and management. The FDA is committed to facilitating the development of safe and effective devices that can provide patients living with the devastating condition of end-stage heart failure with the opportunity for improved quality of life,” added Zuckerman.

Later in their statement, the FDA pointed out the HVAD System was approved based on comparisons to other commercially approved LVADs at the time. Both the FDA statement and 

 urge patients and clinicians to report adverse events or safety problems with the Medtronic HVAD System to the FDA’s MedWatch Adverse Event Reporting program.

After receiving more than 100 complaints, including some involving death, Medtronic has halted sale of the HeartWare Ventricular Assist Device System and the FDA has issued a warning to clinicians to stop new implants of the device. 

Survey Suggests Nearly 50% of Cardiologists Report Having a Hostile Work Environment

A Need for Change: Tackling Professionalism and Ethics in Cardiology

A Picture is Worth a Thousand Words! An Anti-Vaxxer's Nightmare, with Arnold Meshkov, MD

Medtronic Halts Sale of HVAD System, FDA Issues Warning to Stop New Implants

Pair of Trials Demonstrate Reveal LINQ's Ability to Improve Detection of Atrial Fibrillation