Gregory M. Weiss, MD

Links between mental health disorders and organ system disease have long been known. However, a recent study published in 

 found that men with heart failure died with greater frequency if they had severe depression, bipolar disorder, or schizophrenia. We know that people with serious mental health conditions develop high blood pressure, diabetes and have myocardial infarctions at younger ages than the general population. What we didn’t know is how mental health interacts with heart failure.

The study looked at over 20,000 patients with heart failure seen at Duke University. After entering the study, patients were followed to 7 years at which time it was discovered that men with severe mental illness were 36% more likely to die from any cause than those with normal mental health. In addition to increased mortality the study showed that people with severe mental health conditions were diagnosed with heart failure up to 7 years earlier than those without. The lead author of the Duke study, Christoffer Polcwiartek, MD, states,

“Doctors and heart failure specialists need to become more aware of mental health disorders among their patients and take early preventive steps.”

Polcwiartek further suggest that bringing cardiologists, general practitioners, and psychiatrists together is the best way to reduce the burden of heart failure in patients navigating the mental health system.

Current guidelines for heart failure recommend screening for depression but not more severe forms of mental illness. When other more severe forms of mental illness are discovered, special effort should be made to minimize the possibility of early-onset heart failure which could lead to increased short- and long-term mortality.

The study and its recommendations received a strong endorsement from clinical psychologist James Blumenthal, PhD, a professor of psychiatry at Duke University, who was not involved in the study. Blumenthal states, 

“This is an important study that suggests doctors need to evaluate patients' mental health status in addition to evaluating more traditional heart failure risk factors.”

Blumenthal goes on to suggest that, although this study shines a light on a troubling association between mental health and heart failure, many questions remain. It is still unknown why men with severe mental health problems are more likely to die from heart failure while women are not. From the point of view of the mental health specialist, it could be that mental health conditions in patients with cardiovascular disease may be underrecognized and undertreated. In response to this study, the American Heart Association released a 

 calling for the routine assessment of the mental well-being of all heart patients. The emphasis of the statement was on promoting clinician awareness and the concept of holistic treatment rather than a disease-centered model.

As specialists, cardiologists may fall prey to missing the trees for the forest. They train to focus on the cardiovascular system but failing to recognize the mind-body connection is a disservice to our patients. It is quite possible that, with regular screening and modifications to the treatment plan, cardiac patients with mental health conditions can live long full lives. More research is needed to determine the underpinnings of these data but in the meantime, the focus brought, especially to men with heart disease and severe depression, bipolar disease, or schizophrenia, can only stimulate further investigation and innovation in this area.

Not knowing all the answers is a frustrating but necessary position. The American Heart Association recognizes that having questions is the basis for finding answers to those questions. Now we know that men with severe mental health problems are at significantly higher risk of dying from heart failure. As clinicians, we must treat the whole patient at every visit truly winning for both hearts and minds.

Articles

Gregory Weiss, MD, reflects on recent data and an AHA statement related to mental health and increased risk of mortality among patients with heart failure with mental health disorders.

Troubled Minds, Broken Hearts: The Link Between Mental Health and Heart Failure

Cardiovascular disease remains the predominant cause of health-related morbidity and mortality worldwide.

 While some genetic factors contribute to both risk for and protection from cardiovascular disease (CVD), the European Society of Cardiology (ESC) estimates that up to 90% of heart attack, stroke, and peripheral arterial disease (PAD) risk can be attributed to smoking, poor diet, lack of physical activity, obesity, high blood pressure, raised blood lipids, diabetes, and alcohol consumption.

 The ESC considers promoting CVD prevention a priority and to that end presented updated guidelines at ESC Congress 2021.

Key to preventing CVD is the prevention of atherosclerotic build-up in the arterial system. Fatty atherosclerotic plaque is responsible for most cases of myocardial infarction (MI), stroke, PAD, and sudden cardiac death. The ESC believes that the best way to prevent serious cardiovascular events is through mitigating modifiable risk factors for CVD.

 It all starts with adopting a healthy lifestyle and maintaining it throughout a lifetime.

The ESC recommends that clinicians first identify who will benefit most from preventative treatments such as blood pressure medications and lipid-lowering therapies and considers this risk stratification the cornerstone of these guidelines.

 For patients at higher risk, such as those with high blood pressure, diabetes, and dyslipidemias, targets for all 3 should be set and treatment initiated with escalation as need to meet the needs of the individual patient.

 When patients already have such risk factors for CVD it is of utmost importance that those underlying conditions be treated aggressively.

In healthy people, especially young people who have not yet developed atherosclerotic disease, promoting a healthy lifestyle may stop CVD before it starts. Key to this approach is smoking cessation, maintaining a normal blood pressure, exercise and weight management as well as eating a balanced and healthy diet.

 Cardiologists and other clinicians can set targets for lifestyle modifications based on the 10-year risk for developing CVD using established risk measures.

Frank Visseren, MD, PhD, an epidemiologist and professor in vascular medicine at the University Medical Center in Utrecht, the Netherlands, is the chairperson for the guidelines task force. He underscores the importance of tailoring preventative and treatment strategies to each patient:

“Individualized decisions using risk estimation and a stepwise approach to therapies is more complex than a one-size-fits-all approach but reflects the diversity of patients and patient characteristics in everyday clinical practice, and is essential to give the right patient the right treatment.”

Five key modifiable risk factors were highlighted by the group: Smoking, exercise, nutrition, weight management, mental health, and population-level interventions.

The ESC believes that stopping smoking may be the most effective preventative measure of all with regards to CVD.1 All clinicians should encourage quitting at every visit. Guidelines now recommend smoking cessation regardless of weight gain.

With regards to exercise, the ESC guidelines taskforce recommends that adults avoid sedentary time and strive for at least 150-300 minutes of moderate-intensity, or 75-150 minutes of high intensity exercise each week.

 For the first time the task force has included the use of wearable activity trackers as potentially beneficial in promoting activity and maintaining a healthy weight.

Nutrition is a very important aspect of CVD prevention. The ESC task force recommends plant-based foods such as whole grains, fruits, vegetables, and nuts.

 New for the 2021 guideline is the recommendation that adopting a Mediterranean type of diet along with restricting alcohol intake should be suggested for all patients.

The prior two recommendations are closely related to maintaining appropriate body weight and composition. The ESC recommends that overweight and obese patients lose weight in an effort to lower blood pressure, blood lipids, and the risk of diabetes.

 New to the 2021 guidelines is the recommendation that weight reduction surgery (bariatric) be considered for obese patients with high risk for CVD.

Mental health has been linked to increase CVD risk.

 For the first time the ESC recommends we provide intensified support to patients with mental health problems while encouraging them to comply with lifestyle changes and medication therapy.

Finally, the ESC taskforce highlights the steps we can take on a global level to promote cardiovascular health and prevent CVD. These measures include reducing pollution through reduced fossil fuel use and placing limits on carbon dioxide emissions.

 Further, they recommend more outdoor recreational space, reductions in marketing unhealthy food and E-cigarettes to children, and labeling food and alcohol with nutritional content warnings.

Finally, the task force recommends that cardiovascular disease prevention should be an interdisciplinary effort with frontline clinicians, cardiologists, and other specialists working together to promote best practices and the implementation of these guidelines put forth by the European Society of Cardiology.

https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehab484/6358713

https://www.escardio.org/The-ESC/Press-Office/Press-releases/How-can-I-avoid-heart-disease-or-stroke

Gregory Weiss, MD, provides an overview of the updated cardiovascular disease prevention guidelines from the European Society of Cardiology, which were released at ESC Congress 2021. 

ESC Releases Updated Cardiovascular Disease Prevention Guidelines

The influenza (flu) vaccine has been around for a very long time. Even with highly variable efficacy from year to year, the flu vaccine is routinely recommended for everyone prior to the winter months and especially for high-risk patients. Over the years clinicians began to notice that during flu epidemics, more people were dying of cardiovascular causes than during non-epidemic periods.

Until recently, observational studies suggested that the influenza vaccine may have a protective effect with regards to cardiovascular events. These data were subsequently supported by small, randomized trials.

 While flu vaccination is currently recommended for patients with heart disease it is not the standard of care following myocardial infarction. More recently the Influenza Vaccination After Myocardial Infarction (IAMI) study was completed looking at flu vaccination after myocardial infarction (MI) or percutaneous coronary intervention (PCI) in high-risk patients. The results from this pivotal study were presented this month at the 2021 European Society of Cardiology (ESC) Congress.

The IAMI trial was the first randomized, placebo-controlled, double-blinded, multicenter trial to look at the flu vaccine in the setting of acute coronary syndromes (ACS) and MI.

Ole Frobert, MD, PhD, of Orebro University Hospital, Sweden presented the findings at the ESC congress meeting. The results of the trial were exciting to say the least. Frobert and colleagues found that flu vaccination early after an MI or in high-risk coronary heart disease resulted in a lower risk of all-cause death, MI, or stent thrombosis, as well as a lower risk of all-cause and cardiovascular death at 12 months compared with placebo.

“Our findings suggest that influenza vaccination should be considered as part of in-hospital treatment after myocardial infarction,” Frobert states

These results are very promising. The flu vaccines have become ubiquitous across the world with a long track record of safety. With cardiovascular disease continuing to rise worldwide prevention remains a mainstay of cardiovascular medicine. However, the IAMI study suggests that vaccinating patients hospitalized with ACS within 72 hours may dramatically reduce morbidity and mortality after MI.

Frobert and colleagues speculate that the protective effect from flu vaccination in this setting could be from anti-inflammatory effects from the vaccine and or prevention of acute influenza infection which may trigger acute coronary events.

The authors of the study did want to point out that the study was halted during the COVID-19 global pandemic but that the results remain robust with over 2,500 patients enrolled.

 These results underscore the importance of vaccination programs. The general public generally look at vaccines as a preventative measure when it comes to individual infections. However, the global COVID-19 pandemic has brought vaccines into specific relief these days. 

Frobert and colleagues have uncovered an important secondary preventative function of a well-known flu vaccine. While this study gives hope to many cardiologists and patients a war of information currently plagues the scientific community. This fact makes organizations like the ESC more important than ever. The 2021 ESC Congress is just the vehicle we need to disseminate fact through scientific rigor and a global presence. Moving forward, cardiologists can pass this information on to their patients with confidence rooted in strong consensus and pivotal research.

The IAMI study will have a lasting impact on cardiovascular care. Frobert and colleagues hope that the following take-home points will lead to a change in the acute management of myocardial infarction ultimately saving lives:

The flu vaccine saves lives and should be considered as part of 

 treatment after myocardial infarction (MI).

All patients with cardiovascular disease should get their yearly flu shot.

Influenza illness is linked to cardiovascular disease.

Evidence shows that a flu shot could prevent death caused by cardiovascular disease.

https://www.escardio.org/The-ESC/Press-Office/Press-releases/Flu-jab-after-heart-attack-should-become-standard-care

Phrommintikul A, Kuanprasert S, Wongcharoen W, 

. Influenza vaccination reduces cardiovascular events in patients with acute coronary syndrome. 

Frøbert O, Götberg M, Erlinge D, et al. Influenza Vaccination After Myocardial Infarction: A Randomized, Double-Blind, Placebo-Controlled, Multicenter Trial. 

Gregory Weiss, MD, reviews and offers perspective on a study presented at ESC Congress 2021 examining the association between influenza vaccines and improved outcomes in patients with cardiovascular disease.

Influenza Vaccines: Another Jab at Cardiovascular Disease

Ever since I started out in medicine I have read about and heard about physicians saying enough is enough and simply leaving the field. The chorus of discontent has become deafening over my 20 years in the game. It may seem counterintuitive since physicians have higher compensation, often excellent benefits, and the pleasure of improving the lives of so many. There is no doubt that helping people is rewarding, but at what cost? Life and work are a balance.

As such, clinician well-being and clinician burnout can be seen as opposite sides of the scale. Clinician well-being may be defined as experiencing satisfaction and engagement at work while also feeling professional fulfillment and a sense of meaning or purpose.

 Burnout, on the other hand, may be defined by emotional exhaustion, depersonalization, and a sense of low personal accomplishment in a stressful work environment.

We know that physician burnout is real, but what causes it? Medicine has been changing over the decades with increasing reliance on technology, greater regulatory burdens, and increasing clerical loads stimulated by widespread use of electronic medical records. A key determinant of clinician well-being is time. When job demands outweigh personal and family time the scale tips toward burnout. But time is only one facet of a complex network of stressors weighing on clinicians. In a joint opinion from the American College of Cardiology (ACC), the American Heart Association (AHA), the European Society of Cardiology (ESC), and the World Heart Federation (WHF) seven key drivers of clinician burnout were identified

Social Support and Sense of Community at Work.

Although everyone experiences some level of dissatisfaction on the job clinician burnout may extoll serious personal and professional costs. Burnout is associated with higher rates of alcohol abuse, substance use, dysfunctional relationships, depression, and suicide.

 On the professional side clinicians experiencing burnout make more medical errors, provide lower quality of care, see reduced patient satisfaction, display more disruptive behavior, and see a general reduction in their professionalism and empathy.

 After identifying the ramifications of clinician burnout the joint task force went on to outline potential strategies for combating this growing problem.

Key to identifying conditions leading to clinician burnout is regular assessments of work conditions through clinician surveys.

When areas of stress are identified health care organizations must actively create a culture of well-being, improve practice efficiency, offer programs to strengthen personal resiliency all while destigmatizing mental health conditions.

 By further influencing health care policy an environment of support can exist in essence by changing the rules addressing the previously mentioned seven key drivers of clinician burnout.

Too often health care organizations focus on “fixing the employee” by offering classes on self-resiliency and stress management.

 These strategies are useless when the stressors are systemic and institutionalized. Health care organizations need to provide a foundational means to create a work environment where clinicians may thrive. The workgroup points out that Maslow’s hierarchy of needs supplies a perfect template for health care leaders to address clinician fulfillment

Basic physiological and mental health needs first.

Respect from administrators, colleagues, and patients third.

Appreciation and interpersonal connection fourth.

And finally, resources and time to treat patients and practice medicine fully.

In addition to supplying an environment where these needs can be met for clinicians, institutions must provide employees with a structure that allows for confidential reporting of mistreatment while at the same time destigmatizing access to mental health services. This is not a one-time fix; regular reassessment is essential to judge the effectiveness of implemented projects aimed at increasing clinician well-being.

While institutions have a major part to play in promoting clinician well-being one size does not fit all. Our professional societies can do a lot to support their members. The workgroup recognizes the opportunity here for cardiology-specific tools that may improve practice efficiency and clinician knowledge base while societies develop a sense of community for their members.

 When cardiologists are able to network a greater sense of purpose and meaning is experienced. In conclusion, the ACC, AHA, ESC, and the WHF want their members and all cardiologists to know that clinician well-being is paramount to providing high-quality patient care.1 Further, they are committed to the very highest level of well-being among the cardiovascular workforces.

Mehta, L. S., Achenbach, S., Poppas, Athena, et al. Clinician well-being: addressing global needs for improvements in the health care field. .

Shapiro DE, Duquette C, Abbott LM, Babineau T, Pearl A, Haidet P. Beyond burnout: a physician wellness hierarchy designed to prioritize interventions at the systems level. Am J Med. 2019; 132:556–63.

Dr. Gregory Weiss tackles the topic of physician burnout in cardiology and offers perspective on the most common causes as well as possible methods of intervention to mitigate the impact of burnout. 

Who Heals the Healers? The State of Burnout in Cardiology, With Gregory Weiss, MD

The American College of Cardiology (ACC) has long been the flagship for advancement in cardiovascular science and care. Dedicated to the mission of improving the health and wellbeing of humanity through research and practice aimed at prevention, diagnosis, and treatment of a broad spectrum of cardiovascular diseases, the ACC is constantly evolving to meet the challenges of the day. Key to this mission is a commitment to innovation. Healthcare is changing rapidly. Transformational change has infiltrated nearly every industry as a direct result of consistent technological advances in computing power and data management. Emerging technologies such as machine learning algorithms and artificial intelligence now make it possible to analyze and distill massive amounts of patient data very rapidly. The ACC has seen the writing on the wall and is now seeking answers to questions that have always been too broad to examine, until now.

The ACC recently unveiled its commitment to health care transformation through technology at a summit held in October of 2020. The formation of the Applied Healthcare Innovation Consortium (AHIC) represents an effort on the part of the ACC and industry partners to revolutionize cardiovascular care through what they call a digital transformation.

 To this end, the consortium has identified 3 key innovations that will change practice and impact patient care:

Migration from point of care to virtual care.

An increase in remote monitoring of patients using wearable sensors and telemedicine.

A change to care driven by artificial intelligence (AI) capable of interpreting patient data, risk prediction, and improved care decision making.

The AHIC proceeds from the assumption that all work is collaborative spanning many disciplines with a single patient-centered goal that is to improve the lives of real people. The project has attracted a who’s who of the cardiology world all eager to contribute to this technological transformation. Sanjeev Bhavnani, MD a leading expert in cardiovascular care innovation at Scripps Memorial Hospital In La Jolla, CA highlights the timely rise of virtual care during the COVID-19 pandemic and the unprecedented opportunity we have to expand this technology even further.

 During the 2020 AHIC summit collaboration was a salient point throughout. While change is difficult and often costly the potential impact on patient care could be monumental.

So, what is the vision the consortium has for the future of patient care? Among the most recent advances in healthcare technology, miniaturization and data management stand out as the real game-changers. Previously, the logistics of monitoring and managing large numbers of patients either on inpatient wards or out in the community required more boots on the ground then was feasible. With persistent nursing shortages and financial shortfalls, it has been the patients who have suffered. New technologies such as edge computing, machine learning, and artificial intelligence may be the answer to these problems.

The AHIC envisions small, connected, wearable sensors capable of monitoring the vital signs of patients both on the wards and ultimately in the community. Sensors relaying continuous patient data to hardware and software capable of determining what is important and what is not then communicating to clinicians a global risk score. Such a score would be based on validated metrics and capable of alerting clinicians to potential deterioration in health. In addition, artificial intelligence can instantaneously provide the treating provider best evidence treatment options while alerting a multidisciplinary team.

The 2020 AHIC summit was a major step forward for the American College of Cardiology. John Rumsfeld MD, the ACC’s chief innovation officer believes that collaboration is the key to successfully achieving transformational change in the practice of modern cardiology. While still in the brainstorming and team-building phase of this endeavor the broad strokes have been drawn with the AHIC serving as a catalyst in identifying priorities, accomplishing tasks, and making progress in specific and practical ways to impact clinical care.

While buzzwords like artificial intelligence and thinking computers garner press and peak interest it is also important to the ACC/AHIC that no one be left behind. To that end the consortium took time to address health care disparities for women and disadvantaged communities while highlighting the need for universal affordable broadband access as crucial if expanded telemedicine and virtual monitoring are to be successful.

There is no doubt we are at a crossroads. The world is much smaller than it has ever been. The internet, like a brain, is constantly making and bridging seemingly neuronal networks connecting previously distant populations and increasingly massive amounts of data. Hopefully, through technology, we can continue to improve the quality of life for everyone.

https://www.acc.org/-/media/Non-Clinical/Images/About-ACC/Innovation/Applied-Health-Consortium/AHIC-Statement.pdf?la=en&hash=1C2BE9F9E83E7A1C4213C1C9A654A0A38F55AC90#:~:text=Our%20premise%20is%20that%20we,start%2Dup%20and%20regulatory%20leaders

https://www.acc.org/Latest-in-Cardiology/Articles/2020/12/01/01/42/Virtual-Care-Moving-Forward-Together

Dr. Gregory Weiss reflects on the history of artificial intelligence in cardiology and offers perspective on its evolving role as artificial intelligence has demonstrated its ability to improve care and clinical decision-making.

No Longer Fiction: Artificial Intelligence and Modern Cardiology

Hypertrophic cardiomyopathy or HCM is one of the most common genetic or congenital cardiac diseases. Affecting as many as 1 in 500 people HCM is characterized by large increases in cardiac mass, in particular, left ventricular mass.

 Such enlargement predisposes seemingly healthy sufferers to sudden death at young ages. While HCM was first documented in the 1800s with quite a few scattered case reports to follow, it wasn’t until the late 1950s that Eugene Braunwald, MD, detailed the clinical characteristics, natural history, and hemodynamics of the condition.

Braunwald described the dynamic nature of the aortic outflow obstruction as well as the frequency of sudden death and its autosomal genetic transmission within families.

 Finally in 1964, Braunwald along with his colleague Morrow published a lengthy monograph in 

that detailed their findings, including its pathophysiology as well as its medical and surgical treatment.

Originally, the National Institutes of Health call this condition idiopathic hypertrophic subaortic stenosis. Without echocardiography in the beginning, the diagnosis was made purely based on history and physical exam with the mainstay of surgical treatment being open heart surgery for removal of excess muscle tissue. In 2020 the American College of Cardiology and the American Heart Association updated their 2011 guidelines for the diagnosis and treatment of patients with hypertrophic cardiomyopathy.

 While it is true that treatments for HCM have not changed very much in the last 50 years, strategies to manage it have made some important advances. Martin Maron, MD, director of the HCM Center at Tufts Medical Center, states,

“We're getting better and better at managing this disease – the risk of sudden cardiac death (SCD), arrhythmias, stroke prevention and reversal of refractory HF symptoms – and the new guideline explains all this.”

Among the take home points from the guideline update are strong recommendations for multi-disciplinary collaboration early on to catch the disease before sudden cardiac death (SCD) occurs.4 The guideline also recommends anticoagulation in patients with HCM and atrial fibrillation as these patients are a higher risk for stroke.4 Finally, the workgroup encourages an individualized approach to diagnosis and treatment especially when working with children at risk.4

So, what is new for the 2020 guidelines? Mihelle Kittleson, MD, PhD is the director of postgraduate education in heart failure and transplantation at Cedars-Sinai. Kittleson points to the guideline and states,

“What has been bumped up in importance is an ejection fraction (EF) less than 50%, the presence of an LV apical aneurysm, and the presence of extensive gadolinium enhancement, which also emphasizes the increased importance given to the role of MRI in risk stratification. MRI in risk stratification.”

The update further stresses that referrals for internal cardioverter defibrillator (ICD) implantation or septal reduction therapies are crucial and that risk stratification and patient selection are key to preventing sudden cardiac death (SCD).

"Risk stratification in HCM has matured to the extent that we can identify almost all patients today who are at risk of SCD and provide them with protection in the form of an ICD. This is a remarkable statement to make and light years different from a time not that long ago when you gave a patient a beta-blocker and hoped you didn't get a phone call that they had died.”

Yet another important change in the recommendations for 2020 relates to exercise. Previously, only low-intensity exercise was recommended but it was found that SCD was rare during exercise and now moderate intensity aerobic exercise is not only allowed but encouraged for most patients with HCM.

While the guideline update is clearly important a new drug called Mavacamten is poised to steal the HCM show. Mavacamten is a first-in-class, cardiac-specific myosin inhibitor that acts by reducing the number of available actin-myosin cross-bridges thus reducing excessive myocardial contractility.

 Patients treated with Mavacamten during the trial saw improvement in symptoms with 37% reaching the primary endpoint of a greater than or equal to 1.5mL/kg/min increase in peak oxygen consumption (pVO2) and at least one NYHA class reduction in heart failure symptoms.

 Daniel Jacoby, MD, founder and director of the cardiomyopathy program at Yale Medical School heralds this news by saying,

“We have never in the 60-year history of this disease had a prospective, randomized, double-blind, placebo-controlled medication trial of this size showing this magnitude of benefit.”

While this is clearly good news it should be noted that two-thirds of the study patients did not improve.

Hypertrophic cardiomyopathy represents a rather common congenital heart condition with a truly devastating course that has seen little advancement in treatment over the last 50 years. However, with better understanding, prompt referrals for counseling and treatment, and new therapies like Mavacamten, progress is being made. This progress offers hope and a better chance for improved quality of life for patients with HCM.

https://www.acc.org/latest-in-cardiology/articles/2021/07/01/01/42/hypertrophic-cardiomyopathy-in-2021-new-insights-new-strategies-and-possibly-a-new-treatment

Braunwald E. Hypertrophic cardiomyopathy: The first century 1869-1969. 

Braunwald E, Lambrew CT, Rockoff SD, Ross J, Morrow AG. Idiopathic hypertrophic subaortic stenosis. I. A description of the disease based upon an analysis of 64 patients. 

https://www.jacc.org/doi/10.1016/j.jacc.2020.08.045?_ga=2.196522532.947864656.1627386722-1297874215.1626701851&

Olivotto I, Oreziak A, Barriales-Villa R, et al. Mavacamten for treatment of symptomatic obstructive hypertrophic cardiomyopathy (EXPLORER-HCM): a randomized, double-blind, placebo-controlled, phase 3 trial. Lancet 2020;396:759-69.