Cardionerds: A Cardiology Podcast

The following question refers to Section 7.8 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by Stony Brook University Hospital medicine resident and CardioNerds Intern Dr. Chelsea Tweneboah, answered first by Mayo Clinic Cardiology Fellow and CardioNerds Academy Chief Dr. Teodora Donisan, and then by expert faculty Dr. Michelle Kittleson. The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #29 A 69-year-old man was referred to the cardiology clinic after being found to have a reduced left ventricular ejection fraction and left ventricular hypertrophy. For the last several months he has been experiencing progressively worsening fatigue and shortness of breath while getting to the 2nd floor in his house. He has a history of bilateral carpal tunnel syndrome and chronic low back pain. He takes no medications. On exam, his heart rate is 82 bpm, blood pressure is 86/60 mmHg, O2 saturation is 97% breathing ambient air, and BMI is 29 kg/m2. He has a regular rate and rhythm with normal S1 and S2, bibasilar pulmonary rales, and 1+ pitting edema in both legs. EKG shows normal sinus rhythm with a first-degree AV delay and low voltages. Transthoracic echocardiogram shows a moderately depressed LVEF of 35-39%, severe concentric hypertrophy with a left ventricular posterior wall thickness of 1.5 cm and strain imaging showing globally reduced longitudinal strain with apical sparring. There is also biatrial enlargement and a small pericardial effusion. A pharmacologic nuclear stress test did not reveal any perfusion defects. A gammopathy panel including SPEP, UPEP, serum and urine immunofixation studies, and serum free light chains are unrevealing. A 99mTc-Pyrophosphate scan was positive with grade 3 uptake. In addition to starting diuretics, what is the next most appropriate step for managing for this patient? A Start metoprolol succinate B Start sacubitril/valsartan C Perform genetic sequencing of the TTR gene D Perform endomyocardial biopsy Answer #29 Explanation The correct answer is C – perform genetic sequencing of the TTR gene.   This patient has findings which raise suspicion for cardiac amyloidosis. There are both cardiac (low voltages on EKG and echocardiogram showing marked LVH with biatrial enlargement and small pericardial effusion as well as a characteristic strain pattern) and extra-cardiac (bilateral carpal tunnel syndrome and low back pain) features to suggest amyloidosis. The diagnosis of cardiac amyloidosis requires a high index of suspicion and most commonly occurs due to a deposition of monoclonal immunoglobulin light chains (AL-CM) or transthyretin (ATTR-CM). ATTR may cause cardiac amyloidosis as either a pathogenic variant (ATTRv) or as a wild-type protein (ATTRwt).   Patients for whom there is a clinical suspicion for cardiac amyloidosis should have screening for serum and urine monoclonal light chains with serum and urine immunofixation electrophoresis and serum free light chains (Class 1, LOE B-NR). Immunofixation electrophoresis (IFE) is preferred because serum or urine plasma electrophoresis (SPEP or UPEP) are less sensitive. Together, measurement of serum IFE, urine IFE, and serum FLC is >99% sensitive for AL amyloidosis. Negative studies as in our patient essentially exclude AL amyloidosis from consideration.   In patients with high clinical suspicion for cardiac amyloidosis, without evidence of serum or urine monoclonal light chains, bone scintigraphy should be performed to confirm the presence of transthyretin cardiac amyloidosis (Class 1, LOE B-NR). As in this patient’s case, the 99mTc-Pyrophosphate scan with a grade 2/3 cardiac uptake in the absence of a serum or urinary monoclonal protein has a very high specificity and positive predictive value for ATTR-CM. This allows for a noninvasive diagnosis of ATTR-CM, obviating the need for an endomyocardial biopsy and so option D is inaccurate.   In patients for whom a diagnosis of transthyretin cardiac amyloidosis is made, genetic testing with TTR gene sequencing is recommended to differentiate hereditary variant from wild-type transthyretin cardiac amyloidosis (Class 1, LOE B-NR). Differentiating ATTRv from ATTRwt is important because confirmation of ATTRv would trigger genetic counseling and potential cascade screening of family members and TTR silencer therapies, such as inotersen and patisiran (currently only approved for the treatment of polyneuropathy caused by ATTRv amyloidosis).   Routine guideline-directed medical treatment (GDMT) for neurohormonal blockade may be poorly tolerated in patients with ATTR-CM and EF ≤40%. Due to restrictive physiology, they may be predisposed to more hypotension with ARNi, ACEi, and ARB. Similarly, patients with ATTR-CM rely on their heart rate response to preserve the cardiac output, thus BB may worsen HF symptoms. In this case, our patient already has a borderline blood pressure without these medications. Both options A and B are false.   Main Takeaway In patients for whom a diagnosis of transthyretin cardiac amyloidosis is made, TTR gene sequencing is recommended to differentiate pathologic variant (ATTRv) from wild-type transthyretin cardiac amyloidosis (ATTRwt). This has implications in terms of screening for family members and management options for ATTRv.   For patients with ATTR-CM and EF ≤40%, GDMT may be poorly tolerated.   Guideline Loc. Section 7.8, Figure 13 Decipher the Guidelines: 2022 Heart Failure Guidelines PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!

Dr. Gregg Fonarow, Professor of Medicine and Interim Chief of UCLA’s Division of Cardiology, discusses the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. Topics include the management of heart failure in patients with renal insufficiency and the use of hydralazine-nitrate combination therapy. The combination helps attenuate tolerance commonly seen with nitrates and preserves arterial and venous dilation. However, mortality outcomes differ, particularly in African American patients, emphasizing the need for long-term renal and cardiovascular protection.

Dr. Joshua Levenson, an expert in Cardio Oncology, discusses thromboembolic disease in Cardio-oncology. They explore risk factors and clinical biomarkers for identification. The episode also covers anticoagulation treatment for patients with acute PE, including the use of low molecular weight heparins and Coumadin. Additionally, they discuss the use of IVC filters in emergency situations and the increased risk of cardiovascular events in cancer patients with existing cardiovascular disease.

Join CardioNerds Co-Founder Dr. Dan Ambinder, Dr. Nino Isakadze (EP Fellow at Johns Hopkins Hospital), Dr. Karan Desai (Cardiology Faculty at Johns Hopkins Hospital and Johns Hopkins Bayview) join Digital Health Expert, Dr. La Princess Brewer (Associate Professor of Medicine Mayo Clinic Rochester) for another installment of the Digital Health Series. In this specific episode, we discuss how digital health can both reduce and amplify health disparities. This series is supported by an ACC Chapter Grant in collaboration with Corrie Health.  Notes were drafted by Dr. Karan Desai. Audio editing was performed by student Dr. Shivani Reddy. In this series, supported by an ACC Chapter Grant and in collaboration with Corrie Health, we hope to provide all CardioNerds out there a primer on the role of digital heath in cardiovascular medicine. Use of versatile hardware and software devices is skyrocketing in everyday life. This provides unique platforms to support healthcare management outside the walls of the hospital for patients with or at risk for cardiovascular disease. In addition, evolution of artificial intelligence, machine learning, and telemedicine is augmenting clinical decision making at a new level fueling a revolution in cardiovascular disease care delivery. Digital health has the potential to bridge the gap in healthcare access, lower costs of healthcare and promote equitable delivery of evidence-based care to patients. This CardioNerds Digital Health series is made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Nino Isakadze and Dr. Karan Desai.   Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. CardioNerds Digital Health Series PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls and Quotes Digital redlining occurs when a particular group has limited access to key services based on race and ethnicity, perpetuating inequities. Throughout this podcast episode, Dr. Brewer emphasizes how community engagement early in the creation of digital health technologies can mitigate structural inequities.  Dr. Brewer spoke about methods to develop innovative digital health tools that are culturally sensitive and inclusive, specifically community-based participatory research (CBPR). In CBPR, community members are partners with researchers in each step of the intervention. While certain individuals and communities may have physical access to digital health tools, they still may remain inaccessible for several reasons. Notes In this episode, we focus on achieving digital health equity and how the very technologies meant to reduce health disparities can widen them. We started by discussing a paper from Dr. Brewer and colleagues that crystallized how digital health disparities can occur with the example of Pokémon Go. As described in this paper, this mobile application was one of the most used applications worldwide. It incentivized users to collect virtual goods at various physical locations termed PokéStops. For public health professionals, this mobile app represented an engaging way to promote physical activity amongst users. However, some racial and ethnic minority groups in low-income, urban areas quickly took notice of the lack of PokéStops within their neighborhoods. As researchers noted, this could be considered examples of digital redlining, or limiting a particular group from key services based on race and ethnicity. As Dr. Brewer notes in the paper, the Pokémon Go developers relied on maps that were crowdsourced from a majority white male demographic. While it may not have been deliberate, the development process created a structural digital inequity placing certain communities at a home-court disadvantage. Throughout this podcast episode, Dr. Brewer emphasizes how community engagement early in the creation of digital health technologies can mitigate structural inequities.  Dr. Brewer spoke about methods to develop innovative digital health tools that are culturally sensitive and inclusive, specifically community-based participatory research (CBPR). In CBPR, community members are equal partners with researchers and included at every phase of the project (or development of a digital health tool. Learn more about CBPR from Dr. Brewer and her FAITH! application by listening to our Narratives in Cardiology Series with Episode #131. As demonstrated by in Dr. Brewer’s own research and digital health tool creation, early and consistent community involvement led to high recruitment and retention rates of study participants (100% and 98%, respectively). We also discussed that one of the misunderstood aspects of the discussion around digital health equity is the concept of access. Access can mean many different things including broadband internet infrastructure or internet-enabled devices. But even if the infrastructure is available – as Dr. Brewer has noted in her research for instance, African Americans have similar smartphone ownership to the general populations – digital health tools may be inaccessible because digital health interventions are not tailored to specific populations References Brewer LC, Fortuna KL, Jones C, Walker R, Hayes SN, Patten CA, Cooper LA. Back to the Future: Achieving Health Equity Through Health Informatics and Digital Health. JMIR Mhealth Uhealth. 2020 Jan 14;8(1):e14512. Brewer LC, Hayes SN, Jenkins SM, Lackore KA, Breitkopf CR, Cooper LA, Patten CA. Improving cardiovascular health among African-Americans through mobile health: the FAITH! app pilot study. J Gen Intern Med. 2019 Aug;34(8):1376–8. Brewer LC, Jenkins S, Lackore K, Johnson J, Jones C, Cooper LA, Breitkopf CR, Hayes SN, Patten C. mHealth intervention promoting cardiovascular health among African-Americans: recruitment and baseline characteristics of a pilot study. JMIR Res Protoc. 2018 Jan 31;7(1):e31. Israel BA, Schulz AJ, Parker EA, Becker AB. Review of community-based research: Assessing partnership approaches to improve public health. Annu Rev Public Health. 1998;19:173–202. Weinstein JN, Geller A, Negussie Y, Baciu A. Communities in Action: Pathways to Health Equity. Washington, DC: National Academies Press; 2017.

CardioNerds co-founder Dr. Dan Ambinder joins CardioNerds join Dr. Pooja Prasad, Dr. Khoa Nguyen and expert Dr. Abigail Khan (Assistant Professor of Medicine, Division of Cardiovascular Medicine, School of Medicine) from Oregon Health & Science University and discuss a case of mechanical valve thrombosis. Audio editing by CardioNerds Academy Intern, student doctor Adriana Mares.  A 23-year-old pregnant woman with a mechanical aortic valve presented to the maternal cardiac clinic for a follow-up visit. On physical exam, a loud grade three crescendo-decrescendo murmur was audible and transthoracic echocardiography revealed severely elevated gradients across the aortic valve.  Fluoroscopy confirmed an immobile leaflet disk. Thrombolysis was successfully performed using a low dose ultra-slow infusion of thrombolytic therapy, leading to normal valve function eight days later. Treatment options for mechanical aortic valve thrombosis include slow-infusion, low-dose thrombolytic therapy or emergency surgery. In addition to discussing diagnosis and management of mechanical valve thrombosis, we highlight the importance of preventing valve thrombosis during the hypercoagulable state of pregnancy with careful pre-conception counseling and a detailed anticoagulation plan. See this case published in European Heart Journal – Case Reports. “To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.” – Sir William Osler. CardioNerds thank the patients and their loved ones whose stories teach us the Art of Medicine and support our Mission to Democratize Cardiovascular Medicine. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. US Cardiology Review is now the official journal of CardioNerds! Submit your manuscript here. CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls – mechanical valve thrombosis The hypercoagulable state of pregnancy presents a risk for women with mechanical heart valves with contemporary data estimating the rate of valve thrombosis during pregnancy at around 5%. Thrombolytic therapy is a (relatively) safe alternative to surgery and should be considered first line for treatment of prosthetic valve thrombosis in all patients, especially in pregnant women. Pre-conception counselling and meticulous anticoagulation management for patients with mechanical heart valves are key aspects of their care. The evaluation for prosthetic valve thrombosis in pregnant persons requires a review of anti-coagulation history and careful choice of diagnostic testing to confirm the diagnosis and minimize risks to the parent and the baby. Multi-disciplinary care with close collaboration between cardiology and obstetrics is critical when caring for pregnant persons with cardiac disease. Show Notes – mechanical valve thrombosis How can we counsel and inform women with heart disease who are contemplating pregnancy? Use the Modified World Health Organization classification of maternal cardiovascular risk to counsel patients on their maternal cardiac event rate and recommended follow-up visits and location of delivery (local or expert care) if pregnancy is pursued. To learn about normal pregnancy cardiovascular physiology and pregnancy risk stratification in persons with cardiovascular disease, enjoy CardioNerds Episode #111. Cardio-Obstetrics: Normal Pregnancy Physiology with Dr. Garima Sharma. Adapted from the 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy What is the differential diagnosis for a new murmur in a pregnant person who has undergone heart valve replacement? Normal physiology – elevated flow from hyperdynamic state and/or expansion of blood volume in pregnancy. Pathologic – increased left ventricular outflow tract flow from turbulence of flow due to pannus ingrowth, new paravalvular leak, or obstructive mechanical disk motion from vegetation or thrombus. What are diagnostic modalities for the evaluation of suspected prosthetic valve thrombosis? The 2020 ACC/AHA guidelines gave a class I recommendation for evaluation of suspected mechanical prosthetic valve thrombosis using transthoracic echocardiogram, transesophageal echocardiogram (TEE), fluoroscopy, and/or multidetector computer tomography. The goals multi-modality imaging are to assess valve function, leaflet motion, and presence and extent of thrombus while weighing the risks, benefits, and limitations of each modality. The hemodynamic effects with sedation required for TEE and radiation involved with each modality should be carefully assessed when choosing what modalities to pursue, particularly with regards to both parent and baby health. What are the treatment options for prosthetic valve thrombosis in pregnant patients? The 2020 ACC/AHA guidelines gave a class I recommendation for treatment options using slow-infusion, low-dose fibrinolytic therapy or undergoing emergency surgery. Cardiac surgeries during pregnancy are associated with high rates of maternal and fetal adverse outcomes; therefore, a slow-infusion, low-dose fibrinolytic therapy is an attractive alternative option in hemodynamically stable patients. What are the anticoagulation and antiplatelet strategies for pregnant patients with mechanical heart valves? All patients should be on aspirin 81mg daily unless they have active bleeding contraindications. No anticoagulation strategy has been proven to be superior for both the parent and the fetus. If low molecular weight heparin is used, strict monitoring of anti-Xa levels is recommended to optimize anticoagulation and prevent complications. Warfarin can be used throughout pregnancy if the therapeutic doses is ≤5 mg/day to reduce the risk of fetal toxicity. Warfarin teratogenicity is highest during the first trimester. However, after the 36th week patients require admission for transition to heparin to minimize risk of fetal intracranial hemorrhage and maternal bleeding during delivery. To learn more about anticoagulation during pregnancy, enjoy CardioNerds Episode #163. Cardio-Obstetrics: Pregnancy and Anticoagulation with Dr. Katie Berlacher. References Van HI, Roos-Hesselink JW, Ruys TPE, Merz WM, Goland S, Gabriel H, et al. Pregnancy in women with a mechanical heart valve. Circulation 2015;132:132–142. Özkan M, Gündüz S, Gürsoy OM, Karakoyun S, Astarcioʇlu MA, Kalçik M, et al. Ultraslow thrombolytic therapy: a novel strategy in the management of PROsthetic MEchanical valve Thrombosis and the prEdictors of outcomE: the ultra-slow PROMETEE trial. Am Heart J 2015;170:409–418.e1. 5. Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines. Circulation 2021;143:e35–e71. Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, et al. 2021 ESC/ EACTS guidelines for the management of valvular heart disease: developed by the task force for the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2022;43:561–632. Özkan M, Gündüz S, Biteker M, Astarcioglu MA, Çevik C, Kaynak E, et al. Comparison of different TEE-guided thrombolytic regimens for prosthetic valve thrombosis: the TROIA trial. JACC Cardiovasc Imaging 2013;6:206–216. Özkan M, Çakal B, Karakoyun S, Gürsoy OM, Çevik C, Kalçik M, et al. Thrombolytic therapy for the treatment of prosthetic heart valve thrombosis in pregnancy with lowdose, slow infusion of tissue-type plasminogen activator. Circulation 2013;128:532–540. Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, Blomström-Lundqvist C, Cífková R, De BM, et al. 2018 ESC guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J 2018;39:3165–3241. D’Souza R, Ostro J, Shah PS, Silversides CK, Malinowski A, Murphy KE, et al. Anticoagulation for pregnant women with mechanical heart valves: a systematic review and meta-analysis. Eur Heart J 2017;38:1509–1516.

The following question refers to Section 4.5 of the 2021 ESC CV Prevention Guidelines. The question is asked by Dr. Maryam Barkhordarian, answered first by pharmacy resident Dr. Anushka Tandon, and then by expert faculty Dr. Noreen Nazir. Dr. Nazir is Assistant Professor of Clinical Medicine at the University of Illinois at Chicago, where she is the director of cardiac MRI and the preventive cardiology program. The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #33 Mr. V is a 37-year-old man who presents to clinic after a recent admission for anterior STEMI and is status-post emergent percutaneous intervention to the proximal LAD. He has mixed hyperlipidemia and a 10 pack-year history of (current) tobacco smoking. Which of the following points related to tobacco use is LEAST appropriate for today’s visit? A Providing assessment and encouragement for smoking cessation, even if for only a 30-second “very brief advice” intervention. B Reviewing and offering pharmacotherapy support options for smoking cessation if Mr. V expresses readiness to quit today. C Recommending a switch from traditional cigarettes to e-cigarettes as a first step towards cessation, as e-cigarettes are safer for use. D Discussing that smoking cessation is strongly recommended for all patients, regardless of potential weight gain. Answer #33 Explanation Answer C is LEAST appropriate and therefore is the correct answer. Answer C is not appropriate. Although e-cigarettes may be more effective than nicotine replacement therapy (NRT) for smoking cessation, the long-term effects of e-cigarettes on cardiovascular and pulmonary health are unknown. According to the 2019 ACC/AHA prevention guidelines, e-cigarettes may increase the risk of CV and pulmonary diseases; their use has been reportedly associated with arrhythmias and hypertension. Therefore, neither the ESC nor ACC/AHA suggest clinicians recommend e-cigarettes over traditional cigarettes to patients. Answer A: Smoking cessation is one of the most effective CVD risk-lowering preventive measures, with significant reductions in (repeat) myocardial infarctions or death. ESC guidelines emphasize the importance of encouraging smoking cessation even in settings where time is limited. “Very brief advice” on smoking is a proven 30-second clinical intervention, developed in the UK, which identifies smokers, advises them on the best method of quitting, and supports subsequent quit attempts. While ESC does not explicitly suggest a frequency of assessment, the 2019 ACC/AHA guidelines specifically recommend that “all adults should be assessed at every healthcare visit for tobacco use and their tobacco use status recorded as a vital sign to facilitate tobacco cessation.” Answer B: The ESC suggests (class 2) that offering follow-up support, nicotine replacement therapy, varenicline, and bupropion individually or in combination should be considered in smokers. A meta-analysis of RCTs in patients with ASCVD reflects that varenicline (RR 2.6), bupropion (RR 1.4), telephone therapy (RR 1.5), and individual counselling (RR 1.6) all increased quit rates versus placebo; NRT therapies were well-tolerated but had inconclusive effects on quit rates (RR 1.22 with 95% CI 0.72-2.06). The 2019 ACC/AHA recommendation to combine behavioral and pharmacotherapy interventions to maximize quit rates is a class 1 recommendation. Answer D: The ESC gives a class 1 recommendation to recommending smoking cessation regardless of weight grain. Smokers who quit may expect an average weight gain of 5 kg, but the health benefits of tobacco cessation (both CVD and non-CVD related) consistently outweigh risks from weight gain. Weight gain does not lessen the ASCVD benefits of cessation. The 2019 ACC/AHA guidelines do not specifically comment on weight considerations with smoking cessation. Main Takeaway Stopping smoking is potentially the most effective of all preventive measures. All smoking of tobacco should be stopped, as tobacco use is strongly and independently causal of ASCVD (Class 1). Smoking cessation should be regularly assessed for and encouraged, and pharmacotherapy and follow-up support for cessation should be considered for patients who are ready for a quit attempt. Guideline Loc. Section 4.5, Table 9 CardioNerds Decipher the Guidelines – 2021 ESC Prevention Series CardioNerds Episode Page CardioNerds Academy Cardionerds Healy Honor Roll CardioNerds Journal Club Subscribe to The Heartbeat Newsletter! Check out CardioNerds SWAG! Become a CardioNerds Patron!

The following question refers to Section 7.2 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by Cleveland Clinic internal medicine resident and CardioNerds Intern Akiva Rosenzveig, answered first by UPMC Harrisburg cardiology fellow and CardioNerds Academy House Faculty Leader Dr. Ahmed Ghoneem, and then by expert faculty Dr. Randall Starling. Dr. Starling is Professor of Medicine and an advanced heart failure and transplant cardiologist at the Cleveland Clinic where he was formerly the Section Head of Heart Failure, Vice Chairman of Cardiovascular Medicine, and member of the Cleveland Clinic Board of Governors. Dr. Starling is also Past President of the Heart Failure Society of America in 2018-2019. Dr. Staring was among the earliest CardioNerds faculty guests and has since been a valuable source of mentorship and inspiration. Dr. Starling’s sponsorship and support was instrumental in the origins of the CardioNerds Clinical Trials Program.  The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #27 Which of the following sentences regarding diuretics in the management of heart failure is correct? A In HF patients with minimal congestive symptoms, medical management with diuretics alone is sufficient to improve outcomes. B Prescribing a loop diuretic on discharge after a HF hospitalization may improve short term mortality and HF rehospitalization rates. C The combination of thiazide (or thiazide-like) diuretics with loop diuretics is preferred to higher doses of loop diuretics in patients with HF and congestive symptoms. D The maximum daily dose of furosemide is 300 mg. Answer #27 Explanation Choice B in correct. The guidelines give a Class 1 recommendation for diuretics in HF patients who have fluid retention to relieve congestion, improve symptoms, and prevent worsening heart failure. Recent data from the non-randomized OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) registry revealed reduced 30-day all-cause mortality and hospitalizations for HF with diuretic use compared with no diuretic use after hospital discharge for HF. Choice A is incorrect. With the exception of mineralocorticoid receptor antagonists (MRAs), the effects of diuretics on morbidity and mortality are uncertain. As such, diuretics should not be used in isolation, but always combined with other GDMT for HF that reduce hospitalizations and prolong survival. Choice C is incorrect. The use of a thiazide or thiazide-like diuretic (e.g., metolazone) in combination with a loop diuretic inhibits compensatory distal tubular sodium reabsorption, leading to enhanced natriuresis. In a propensity-score matched analysis in patients with hospitalized HF, the addition of metolazone to loop diuretics was found to increase the risk for hypokalemia, hyponatremia, worsening renal function, and mortality, whereas use of higher doses of loop diuretics was not found to adversely affect survival. The guidelines recommend that the addition of a thiazide (e.g., metolazone) to treatment with a loop diuretic should be reserved for patients who do not respond to moderate- or high-dose loop diuretics to minimize electrolyte abnormalities (Class I, LOE B-NR).   Choice D is incorrect. The guidelines recommend a maximum total daily dose of 600mg of furosemide or 10mg of bumetanide or 200mg of torsemide. Main Takeaway In summary, diuretics are recommended in heart failure patients who have fluid retention to relieve congestion, improve symptoms, and prevent worsening heart failure. Maintenance diuretics on HF hospitalization discharge may help prevent recurrent HF hospitalizations. They should be used in combination with other GDMT to improve HF outcomes. Combining loop and thiazide diuretics may cause serious electrolyte abnormalities and should be reserved for patients who do not respond to moderate- or high-dose loop diuretics.   Guideline Loc. Section 7.2, Table 12   Decipher the Guidelines: 2022 Heart Failure Guidelines PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!

Dr. Alexander Sasha Opotowsky, an expert in Eisenmenger Syndrome, discusses the diagnosis and management of this end-stage complication of congenital heart disease. Topics include pathophysiology, cyanosis-related complications, risks of pregnancy, treatment options, and a case study on SVC syndrome and ACHD physiology.

Dr. Cezar Iliescu discusses the spectrum of cardiovascular diseases encountered by interventional onco-cardiologists. Topics include endovascular therapies, special scenarios in critically ill cancer patients, adjustments to standard care for cancer patients with chronic thrombocytopenia, post-PCI care in cancer patients, treating aortic stenosis in cancer patients, and the passion for interventional cardiology.

The following question refers to Section 3.4 of the 2021 ESC CV Prevention Guidelines. The question is asked by student Dr. Adriana Mares, answered first by early career preventive cardiologist Dr. Dipika Gopal, and then by expert faculty Dr. Michael Wesley Milks. Dr. Milks is a staff cardiologist and assistant professor of clinical medicine at the Ohio State University Wexner Medical Center, where he serves as the Director of Cardiac Rehabilitation and an associate program director of the cardiovascular fellowship. He specializes in preventive cardiology and is a member of the American College of Cardiology’s Cardiovascular Disease Prevention Leadership Council. The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #32 Mr. Daniel Collins is a 58-year-old man with hypertension, chronic kidney disease (CKD), and obesity who presents to your clinic for a routine physical examination. Vitals are as follows: BP 143/79 mmHg, HR 89 bpm, O2 99% on room air, weight 106 kg, BMI 34.5 kg/m2. Recent laboratory testing revealed: creatinine 1.24 mg/dL, total cholesterol 203 mg/dL, HDL 39 mg/dL, LDL 112 mg/dL, TG 262 mg/dL. His current medications include lisinopril and rosuvastatin. You recommend increasing the dose of lisinopril to treat uncontrolled hypertension. What additional step(s) are indicated at this visit? A Order urine albumin-to-creatinine ratio B Ask the patient how often they have been bothered by trouble falling or staying asleep, or sleeping too much C Perform depression screening D All of the above Answer #32 Explanation   The correct answer is D – all of the above. Answer A is correct. The ESC gives a Class I (LOE C) indication that all CKD patients, with or without diabetes, should undergo appropriate screening for ASCVD and kidney disease progression, including monitoring for changes in albuminuria. Cardiovascular disease is the leading cause of morbidity and death among patients with CKD. Even after adjusting for risk factors, including diabetes and hypertension, there is a linear increase in CV mortality with decreasing GFR below ~60-75 mm/min/1.73m2. Specific CKD-related risk factors include uremia-mediated inflammation, oxidative stress, and vascular calcification. Answer choice B is also correct. In patients with ASCVD, obesity, and hypertension, the ESC gives a Class I (LOE C) indication to regularly screen for non-restorative sleep by asking the question related to sleep quality as follows: “‘How often have you been bothered by trouble falling or staying asleep or sleeping too much?”. Additionally, if there are significant sleep problems that are not responding within four weeks to improving sleep hygiene, referral to a specialist is recommended (Class I, LOE C). However, despite the strong association of OSA with CVD, including hypertension, stroke, heart failure, CAD, and atrial fibrillation, treatment of OSA with CPAP has failed to improve hard CVD outcomes in patients with established CVD. Interventions that focus on risk factor modification, including reduction of obesity, alcohol intake, stress, and improvement of sleep hygiene, are important. Answer choice C is also correct. The ESC gives a Class I (LOE C) recommendation that mental health disorders with either significant functional impairment or decreased use of healthcare systems be considered as influencing total CVD risk. All mental disorders are associated with the development of CVD and reduced life expectancy. Additionally, the onset of CVD is associated with an approximately 2-3x increased risk of mental health disorders compared to a healthy population. As such, screening for mental health disorders should be performed at every consultation (2-4x/year). Main Takeaway In addition to traditional ASCVD risk factors, other clinical conditions, including sleep apnea, CKD, and mental health conditions, are important to screen for and treat if present. Guideline Loc. Sections 3.4.1, 3.4.9, 3.4.10 CardioNerds Decipher the Guidelines – 2021 ESC Prevention SeriesCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!