Gregory M. Weiss, MD

ACC Guidance on Cardiovascular Consequences of COVID-19

The impact of the novel coronavirus (COVID-19) pandemic on the world has been unprecedented in modern times. While respiratory involvement is the characteristic presentation of infection with COVID-19, it has become increasingly apparent that cardiovascular complications are common as well. A diverse list of cardiovascular testing anomalies and complications have been reported and range from biomarker elevations and echocardiographic abnormalities to myocardial injury, thrombosis, and arrhythmias.

It also appears that long COVID-19 cardiovascular symptoms and laboratory findings may persist following acute illness and may include chest pain, shortness of breath, fatigue, palpitations and diagnostic results indicating myocardial injury in both symptomatic and asymptomatic COVID-19 patients.

 In light of these facts the American College of Cardiology (ACC) thought it prudent to issue guidance with regards to three specific areas of post COVID-19 cardiovascular care: Myocarditis and other Myocardial Involvement, Post-acute Sequelae of SARS-CoV-2 Infection, and Return to Play (exercise) for athletes after COVID-19.

Myocarditis is a term used to describe nonspecific inflammation of the heart muscle. It is often accompanied by symptoms such as chest pain, shortness of breath, and the feeling of palpitations. Clinically, patients with myocarditis may have variable presentations so the ACC workgroup chose to separate myocarditis into three diagnostic categories:

Possible myocarditis: Patients who are symptomatic with elevated troponin values and abnormal electrocardiographic and or echocardiographic findings but without positive cardiac biopsy.

Probable myocarditis: Features of possible myocarditis with follow-up biopsy within six months consistent with previous myocarditis.

Definite myocarditis: Features of possible myocarditis but with positive biopsy or cardiac resonance imagery.

Data suggests that men are at higher risk for COVID-19 related myocarditis. The workgroup recommends that patients with mild to moderate or deteriorating symptoms be hospitalized for close monitoring, follow-up testing, and treatment. Those with severe disease should be hospitalized at facilities with advanced heart failure programs and mechanical circulatory support availability.

While recognized, the development of myocarditis after a second mRNA COVID vaccine is rare. The ACC recommends that, unless contraindicated, anyone eligible for a COVID-19 mRNA vaccine should get one.

The mainstays of treatment for clinically significant myocarditis remain supportive. Beta-blocking drugs and angiotensin inhibiting medications may be used in less severe disease without significantly diminished heart function. Corticosteroids may be employed when confirmed inflammation is present. Patients in cardiogenic shock may benefit from extracorporeal membrane oxygenation (ECMO) support until the inflammation recedes. Cardiac MRI should be performed to evaluate long term damage after improvement.

Long COVID is defined by a constellation of new, returning, or persistent health problems lasting four or more weeks after COVID-19 infection.

 This condition appears to affect as many as 10-30% of infected individuals and is characterized by fatigue, tachycardia, and exercise intolerance. The ACC workgroup suggest that these patients should undergo evaluation from a cardiovascular standpoint with additional evaluation if a specific condition such as myocarditis is suspected. Management should be targeted to specific symptoms. A “downward spiral” has been recognized whereby patients who suffer from fatigue exercise less and spend more time in bed leading to a worsening of symptoms. The workgroup suggests that low level exercise be encouraged with non-upright or recumbent exercise being used to avoid worsening fatigue. Beta blocking medications may be employed for tachycardia and nonsteroidal anti-inflammatory drugs sparingly for chest pain without evidence of ischemia.

The workgroup has issued guidelines for the return to competitive sports and intense exercise training. The group recommends that athletes recovering from COVID-19 with ongoing cardiopulmonary symptoms or those requiring hospitalization undergo further evaluation with electrocardiogram, troponin assays, and echocardiogram. These athletes should abstain from exercise for three to six months if diagnosed with myocarditis. Cardiac testing is not recommended for asymptomatic athletes. These athletes should abstain from training for three days to ensure that symptoms do not develop. For those with symptoms, they may return to training once symptoms resolve. Repeat cardiac testing and cardiac MRI are not recommended once symptoms have resolved.

In conclusion, the ACC continues to set the benchmarks in cardiovascular care. In this recent consensus statement on the cardiovascular implications following COVID-19 infection, the college addresses post infections myocarditis, long COVID syndrome, and returning to play for athletes infected with COVID-19. While these guidelines will undoubtedly aid clinicians in caring for patients the workgroup co-chair, Ty Gluckman, MD, MHA, warns that the best means to diagnose and treat myocarditis and long COVID continues to evolve.

Gluckman, T. J., Bhave, N. M., Allen, L.A., et al. 2022 ACC Expert consensus decision pathway on cardiovascular sequelae of COVID-19 in adults: myocarditis and other myocardial involvement, post-acute Sequelae of SARS-CoV-2 infection, and return to play: A report of the american college of cardiology solution set oversight committee. J Am Coll Cardiol. Mar 16, 2022. Epublished DOI: 10.1016/j.jacc.2022.02.003

Articles

Dr. Gregory Weiss, a cardiovascular anesthesiologist, provides perspective into the American College of Cardiology's recently released guidance related to the long-term consequences of COVID-19, which includes information on myocarditis, return to athletics, and more.

ACC Guidance on CV Consequences of COVID-19, with Gregory Weiss, MD

Cancer and heart disease are the leading killers of women in the United States.

 Sex-specific cardiovascular disease (CVD) markers have become an area of focus in cardiology. Even though women generally have lower burdens of obstructive coronary disease they are at higher risk for heart attack as their presenting event and have a worse prognosis than men following myocardial infarction.

Mammography is a well-established screening tool for breast cancer. Current recommendations call for yearly screening mammograms to begin at age 45 with more frequent scans commencing at 55 years of age.

 With screening visits of any kind at a premium, any chance we get to screen for multiple health problems should be taken advantage of.

Around two-thirds of women attend their screening mammograms through all age groups with the exception of women in managed care who attend at a rate of 88.4%.

 While breast arterial calcification (BAC) is a common finding on routine mammograms, it has not been used as an indicator for further investigation.

Carlos Iribarren, MD, MPH, PhD, of Kaiser Permanente Northern California, along with colleagues sought to determine the association if any between BAC and atherosclerotic cardiovascular disease. To this end, the authors performed a cohort study of 5059 women between 60 and 79 years of age who had attended mammography screening during the study period. The primary outcome was incident hard atherosclerotic CVD in this population.

The results indicated that the presence of BAC on digital mammograms was independently associated with incident atherosclerotic CVD.

 In fact, Iribarren and his team found that women with BAC on mammogram had a 51% higher risk for heart disease and stroke than those without BAC.

 Further, women with BAC were 23% more likely to develop any type of CVD including stroke, heart failure, and peripheral arterial disease.

 While these results are promising the authors could find no dose-response association between total burden of BAC and atherosclerotic CVD.

Iribarren points out that currently there is no standard for reporting or grading BAC. The authors suggest that grading technology could be incorporated in next-generation mammography equipment using a technology currently used to examine aortic arterial calcification.

“We hope that our study will encourage an update of the guidelines for reporting breast arterial calcification from routine mammograms. Our study has moved the needle toward recommending routine assessment and reporting of breast arterial calcification in postmenopausal women,” Iribarren said.

It should also be noted that no new screening visits or increased radiation dosage would be necessary to implement a BAC reporting practice since women would already be attending screening mammography visits regardless of a new recommendation to include BAC in the report. These findings give clinicians a tool already in use to improve sex specific risk stratification.

“Research has confirmed the calculators we currently use to assess an individual’s 10-year risk of developing cardiovascular disease are not as accurate in women as they are in men. In our current study, we evaluated if breast arterial calcification, which can be easily seen on a mammogram, provides more information about a woman’s risk of developing heart disease,” Iribarren added.

Of note, while the authors found an association between the presence of BAC and risk for developing atherosclerotic cardiovascular disease, having no BAC did not translate into low risk for CVD.

 While BAC may emerge as an important screening tool for CVD more study is required before it’s routine use is adopted. 

“Optimal risk factor control is equally important for all women with and without breast arterial calcification,” said Sadiya Khan, MD, MSc, FAHA, a cardiologist at Northwestern University.

Virani SS, Alonso A, Aparicio HJ, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Cheng S, Delling FN, et al.; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2021 update: a report from the American Heart Association.

. 2021; 143:e254–e743. doi: 10.1161/CIR.0000000000000950

Iribarren, C., MD, MPH, PhD, Chandra, M., MS, Lee, C., PhD, et al. Breast Arterial Calcification: a Novel Cardiovascular Risk Enhancer Among Postmenopausal Women,

Oeffinger KC, Fontham ET, Etzioni R, Herzig A, Michaelson JS, Shih YC, Walter LC, Church TR, Flowers CR, LaMonte SJ, et al.; American Cancer Society. Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society.

. 2015; 314:1599–1614. doi: 10.1001/jama.2015.12783

https://newsroom.heart.org/news/mammograms-may-provide-clues-about-womens-risk-for-cardiovascular-disease

Dr. Gregory Weiss expounds on recent data indicating routine mammography in postmenopausal women could help identify women at increased risk of cardiovascular disease based on breast arterial calcification.  

Predicting Cardiovascular Risk Using Routine Mammograms in PostMenopausal Women

With every new year come new hopes, resolutions, and hopefully progress toward meeting our goals. The cardiology community is no different.

However, while many look to drop a few pounds after the holidays or put a little money aside for the future our wish lists as cardiovascular clinicians are often lengthier and loftier by comparison. In a time when we all desperately need something to look forward to here are a few thoughts on what’s ahead in 2022.

The surgical care of patients with cardiovascular disease dates back to the 1960s. Many advances have been made over the decades including better myocardial preservation, longer-lasting bioprosthetic valves, and better preoperative and postoperative care. One of the most exciting advancements over the last two decades has been the introduction of routine transcatheter aortic valve implantations (TAVI). Initial research was focused on utilizing the procedure for only those at highest risk for complications from open valve replacement surgery.

Over the last 2 decades, investigators have studied the technique in lower risk populations. While we have known that patients with aortic stenosis and a tricuspid aortic valve that were of high or intermediate risk for open surgery had at least as good outcomes if not better when compared to surgery we are now seeing data in low-risk patients and those with bicuspid aortic valves. A recent study looking at TAVI for low-risk patients with bicuspid or tricuspid aortic valves showed that the risk for mortality and stroke at 30 days and at one year were comparable between groups.

The reason I am excited about this study is because open-heart surgery, while an effective treatment for aortic valve stenosis, involves longer hospital stays, more pain, a longer recovery, and the potential for a myriad of complications not seen with transcatheter techniques. I have personally participated in hundreds of these procedures and am awestruck each time as a patient with a life-threatening anatomic condition undergoes a relatively brief and painless procedure with simple sedation only to be essentially cured two hours later. While there are complications associated with TAVI the evidence suggests that it could be a game-changer going forward.

You may have read about the second thing I am most excited about this year. On January 7, 2022, surgeons at the University of Maryland successfully transplanted a heart from a genetically modified pig into a human recipient. I am old enough to remember Baby Fae who received a baboon’s heart back in 1984 but died 21 days later due to acute rejection of the organ. 

The technique was abandoned for nearly 30 years due to genetic incompatibility and the high risk for rapid rejection. Now, with the widespread use of CRISPR gene-editing technology doctors were able to remove genetic elements responsible for rejection while inserting six human genes that induce the organ's acceptance by the recipient.

 The pig heart was transplanted into a 57-year-old man with no other options. So far, he is recovering well with no signs of rejection. With more than 100,000 people waiting for an organ transplant in the U.S. today and over 6000 of them dying on the list each year, this innovation may be transformational.

It may be obvious why I am excited about this amazing breakthrough. But beyond the fact that countless lives could be saved it is the process that impresses me. As with most quantum leaps in science, this achievement is built on the back of decades of research with countless setbacks, enormous costs, and often a lot of heartbreak. I think of all the lost loved ones waiting and now those hoping. Dr. David Klassen, chief medical officer of the United Network for Organ Sharing states,

“This is a watershed event. Doors are starting to open that will lead, I believe, to major changes in how we treat organ failure.”

These two technologies have a common thread. Only through good science and rigorous study do we make groundbreaking discoveries. COVID-19 has taken the spotlight for two years now and put a shadow over almost everything. As clinicians, we are tired but hopeful. The reason we are hopeful is because hard work and science keep going and keep offering us light in the darkness.

Makkar RR, Yoon SH, Chakravarty T, Kapadia SR, Krishnaswamy A, Shah PB, Kaneko T, Skipper ER, Rinaldi M, Babaliaros V, Vemulapalli S, Trento A, Cheng W, Kodali S, Mack MJ, Leon MB, Thourani VH.Association Between Transcatheter Aortic Valve Replacement for Bicuspid vs Tricuspid Aortic Stenosis and Mortality or Stroke Among Patients at Low Surgical Risk. 

https://www.washingtonpost.com/science/2022/01/11/pig-heart-transplant-genetically-modified/

https://www.organdonor.gov/learn/organ-donation-statistics

https://www.nytimes.com/2022/01/10/health/heart-transplant-pig-bennett.html 

Dr. Gregory Weiss provides insight into what he is most excited about in the field of cardiovascular medicine heading into 2022. 

Looking Ahead: Cardiology in 2022, with Gregory Weiss, MD

Technology is ubiquitous in our lives from our smartphones to advanced artificial intelligence algorithms telling us what we want to buy on social media platforms. Nowhere has technology played a more crucial role in improving human lives than in the healthcare industry.

We, as clinicians, rely on countless technological instruments in the diagnosis, treatment, and long-term management of nearly every condition in the medical lexicon. Still, following the over 300 million operations taking place across the world yearly, over 4 million people die in the first month making postoperative mortality the third highest cause of death globally.

One reason this is occurring is that we are seeing a more diverse patient population undergoing more complicated surgical procedures. Add to this the fact that nursing shortages are at critical levels with one nurse often looking after more than a half-dozen patients on the hospital wards. Frederick Michard, MD, PhD, is a leading expert in the field of patient safety.

Dr. Michard believes that the evidence shows many of these deaths occur due to failure to rescue and could be prevented through continuous monitoring.

 Failure to rescue describes a foreseeable deterioration in a patient’s vital status that is missed by clinicians due to inadequate often intermittent monitoring and broadly timed nursing spot checks.

Nurses are stretched thin today. Nearly every nurse surveyed believes that poor nursing staffing and high patient-to-nurse ratios lead to reduced quality of care and reduced nursing job satisfaction.

 The current model on the wards has nurses rounding for spot checks and vital signs with gaps as large as 8 hours between checks unless something alerts them to a problem.

With patients encouraged to ambulate and warning signs often subtle and subclinical it is difficult to keep an eye on everyone all the time. This is where advances in technology can make the biggest difference.

If it were possible to continuously monitor patient vital data and even process it into a score that could predict a downward trajectory long before rescue becomes difficult; that would be a game-changer. If we had a choice on what to monitor on the wards to prevent failure to rescue what would we choose?

Several studies point to respiratory rate monitoring as the best predictor of adverse outcomes on hospital wards.

 The latest in continuous monitoring goes a step beyond. We already know that clinical staff are at a critical minimum necessitating a simplification tool as well as a way to alert the appropriate clinician when deterioration is suspected.

Enter artificial intelligence and edge computing technologies capable of processing gigantic volumes of patient data such as respiratory rate, oxygen saturation, and heart rate while accessing the patient’s lab values and imaging reports and alerting their nurse or physician in real-time when subtle signs of deterioration occur.

Unfortunately, even with AI and early warning algorithms, patients cannot be hooked up to a monitor all the time. Over the past year, a surge in small, wearable sensors have been in development that will allow patients to be monitored even when they are not in their rooms. Current best practices call for surgical patients to be on their feet as soon as possible after their procedure.

With robust, reliable wearable monitors and powerful new software and hardware solutions it is possible to catch patient deterioration before a point of no return, reducing costly intensive care admissions, hospital length of stay, and preventing significant morbidity and mortality.

We all rely on wireless communication in one way or another. New Bluetooth technologies, Wi-fi, and emerging technologies such as 5G transmission have applications far beyond social media and personal communications. With these technologies and increasingly miniaturized hardware, patients can comfortably wear sensors that transmit respiratory rate, blood pressure, heart rate, and blood oxygen levels even when they are in the bathroom or at physical therapy.

Furthermore, during the pandemic, clinicians are exploring monitoring patients continuously at home so that hospitals aren’t burdened by COVID-19 patients that do not require inpatient treatment. It’s a brave new world, to say the least.

Protecting ward patients. ICU Mgmt & Pract. 

https://healthmanagement.org/c/icu/issuearticle/protecting-ward-patients

Is the shortage of hospital registered nurses getting better or worse? Findings from two recent national surveys of RNs. Nurs Econ, 2005. 

https://www.researchgate.net/profile/Karen_Donelan/publication/7860597_Is_the_Shortage_of_Hospital_Registered_Nurses_Getting_Better_or_Worse_Findings_from_Two_Recent_National_Surveys_of_RNs/links/5711063108ae846f4ef05cb5/Is-the-Shortage-of-Hospital-Registered-Nurses-Getting-Better-or-Worse-Findings-from-Two-Recent-National-Surveys-of-RNs.pdf

Predicting Cardiac Arrest on the Wards, A Nested Case-Control Study. Chest, 2012. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3342781/

Dr. Gregory Weiss discusses the topic of wearable technology for remote patient monitoring through the lens of a cardiovascular anesthesiologist. 

The Latest Fashion: Wearables in Cardiology

It is well known that cigarette smoking is strongly associated with early death and both cardiovascular (CV) and respiratory disease. Over the years, increasing awareness and public health initiatives have led to some reductions in smoking at least in certain populations. 

Still, it is estimated that as many as 34 million adults in the United States smoke, with tobacco use representing the leading cause of disability and the second leading risk factor for death in this country.

 While countless studies show a link between smoking and overall CV health including associations with stroke, heart failure, and heart attack, few investigations have looked at the long-term morbidity and mortality among the CV disease subtypes while taking into account competing risk for death posed by respiratory disease and lung cancer. The authors of this study sought to determine the long-term rates of incident CV disease related to smoking.

Sadiya Khan, MD, assistant professor of medicine at Northwestern University Feinberg School of Medicine, states,

“Most people are aware about the risks of lung cancer with smoking, but many people who smoke do not realize that dying from cardiovascular disease is more likely than dying from lung cancer.”

The authors looked at nearly 2-million-person years of follow-up from over 100,000 individuals. In subjects 40 to 59 years of age there were over 7000 fatal or nonfatal coronary heart disease events, 3527 fatal or non-fatal strokes, and 4559 heart failure events.

 The cumulative risk for CVD and non-CVD deaths were higher in those who reported smoking.

 Across all groups smoking significantly lowered the number of years lived free from CVD.

The most alarming result reported was that death as the first CV or non-CV event occurred in a larger proportion of middle-aged men and women who reported smoking than those who did not.

“One of the most important findings of this analysis is that the first sign of cardiovascular disease is more likely to be a fatal event in those who smoke. Smoking is more likely to kill people from heart disease even before someone may know they have heart disease.”

These data are alarming. At first glance it seems just a confirmation of what is already know. Smoking causes CVD. It appears, however, that the magnitude of the problem and its impact on middle-aged adults is far graver. The fact that, in this study, smoking was associated with a fatal event as the first manifestation of clinical cardiovascular disease is breathtaking. That means that smokers are dying from cardiovascular disease before they even know they have it.

It is easy to correlate smoking with CVD. These data put a magnifying glass on the known risk by zeroing in on specific subgroups of cardiovascular endpoints. Points added to the narrative by this investigation include:

People who smoke are more likely to develop CVD at a younger age leading to up to a 5-year reduction in their lives.

Over half of middle-aged adults who smoked went on to develop CVD with nearly a 2-fold increase in their likelihood of dying from a heart attack, stroke, or heart failure.

Young people who smoked were twice as likely to die from a cardiovascular event as their first sign of CVD than those who did not smoke.

Fellow researcher Ranya Sweis, MD, also at Northwestern emphasizes that,

“Our findings show putting an emphasis on smoking cessation counseling is the most important preventable cause of death in the United States.”

While smoking cessation counseling has been a large part of clinical medicine for some time these data should add to the sense of urgency, we as clinicians feel. Many patients still believe that lung cancer is the greatest killer of smokers. We see now that this isn’t the case. While respiratory disease and cancer remain a significant consequence of smoking CVD and death as the first presenting sign of that disease should fuel a renewed effort on our part to convince our patients to quit smoking now.

Wang TW, Asman K, Gentzke AS, Cullen KA, Holder‐Hayes E, Reyes‐Guzman C, Jamal A, Neff L, King BA. Tobacco product use among adults—United States, 2017. MMWR Morb Mortal Wkly Rep. 2018; 67:1225–1232. doi: 10.15585/mmwr.mm6744a2

Khan, S. S., Ning, H., Sinha, A., et al. Cigarette smoking and competing risks for fatal and nonfatal cardiovascular disease subtypes across the life course. JAHA. 17 Nov 2021; 0:e021751 https://doi.org/10.1161/JAHA.121.021751

A new study from Northwestern breaks down the risk of cardiovascular mortality associated with smoking among younger patients. Dr. Gregory Weiss breaks down the study and offers further perspective.

Cigarette Smokers Twice as Likely to Die from Cardiovascular Causes

Cumulative salt intake has long been associated with cardiovascular health. Specifically, we know that there is a linear relationship between sodium intake and blood pressure which in turn increases the risk of cardiovascular morbidity and mortality.

 Armed with this information clinicians have long encouraged a low sodium diet especially in patients with other cardiovascular risk factors. One challenge is the lack of consistency in sodium content across a wide variety of foods. Meats and fish, especially when processed, have been identified as a source for high levels of sodium.

The World Health Organization recommends a maximum daily sodium intake of 2000mg. In contrast to this goal the average global sodium intake exceeds 4000mg as of 2010.3 While the task of reducing overall sodium intake appears daunting steps have been taken globally to examine the sodium content in processed meats and fish in an effort to provide data that will allow us to target specific products to be avoided or modified to be less detrimental. To this end the George Institute for Global Health created the first global food composition database in 2010. The collection of food composition data from more than 10 countries has allowed the institute to compare sodium content in processed meats and fish on an unprecedented scale. Professor Yuxia Ma and colleagues in the Department of nutrition and food hygiene at Hebei Medical University in Shijiazhuang, China sought to compare sodium content and achievements in sodium reduction for different countries.

The group was able to examine over 30,000 processed meat and fish products. The following countries were identified from the highest sodium levels (China) to the lowest overall (Australia and the UK).

While these rankings represent the overall sodium content in products examined, there were some variations between processed meat, fish and within specific categories of meats such as hot dogs and bacon.

This comparison of sodium content in processed meat and fish products shows a wide discrepancy within and between countries. No wonder it is so difficult for clinicians to target education towards avoidance of certain products in an effort to reduce sodium intake and promote better cardiovascular health. While some countries had lower levels of sodium all countries included fell short or WHO recommendations with only 10% of UK and USA products and less than 5% of Chinese processed meats and fish falling in what is considered the “green light” category of acceptable sodium content for a food.2 This underscores the magnitude of this problem as well as the utility of this study.

As clinicians, we need targets to reach with our patients. The first step in making a target is defining the problem which in this case is high sodium content in processed meat and fish. With guidance from the WHO as to how much sodium patients should consume, we must then define where the salt is coming from. The authors have shown that processed meat and fish from a variety of countries is responsible for a significant portion of sodium intake worldwide.

 We know where the salt is coming from, but what is the next step?

It would be a daunting task to replace or reformulate high sodium containing products already in existence. However, these data suggest that there is a wide range of sodium content in the same or similar products in different countries. The authors suggest that this is an opportunity for manufacturers to heed the increasing call from consumers for lower sodium products.

 Further, countries and municipalities can set sodium targets for processed foods which has been shown effective in the handful of cases this has been tried. While concern for consumer driven flavor demands have been cited as a reason for higher sodium contents, it is possible that these concerns are unfounded.

We can see through this investigation that there are many layers to the problem of sodium consumption and cardiovascular disease. Even though much variability exists from product to product and country to country we see that even more diligent countries like the UK have sodium contents per 100 grams of processed meat and fish that constitute up to one-half of the WHO maximum sodium intake for an entire day. We can and must do better. The authors believe that we must set feasible sodium lowering targets with regular re-evaluation aimed at ensuring adequate implementation. Consumers are better educated than ever before. Efforts must be made by clinicians to provide information, encourage meaningful behavior and nutritional changes, while working on the policy changes aimed at reducing the sodium content of the foods our patients eat.

Forouzanfar MH, Alexander L, Anderson HR, 

. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the global burden of disease study 2013. The Lancet 2015;

:2287–323.doi:10.1016/S0140-6736(15)00128-2

Song, Y., Li, Y, Ma, Y., et al. Cross-sectional comparisons of sodium content in processed meat and fish products amoung five countries: potential for feasible targets and reformulation. 

2021;11:e046412. doi:10.1136/bmjopen-2020-046412

Powles J, Fahimi S, Micha R, et al. Global, regional and national sodium intakes in 1990 and 2010: a systematic analysis of 24 h urinary sodium excretion and dietary surveys worldwide. 

Dr. Gregory Weiss reviews a recent BMJ article detailing sodium content in processed meats and fish in different countries throughout the world and the implications it could have on cardiovascular health at a national level.