Cardionerds: A Cardiology Podcast

The following question refers to Sections 3.2, 4.1, 4.3, and 4.4 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by Texas Tech University medical student and CardioNerds Academy Intern Dr. Adriana Mares, answered first by Baylor University cardiology fellow and CardioNerds FIT Trialist Dr. Shiva Patlolla, and then by expert faculty Dr. Shelley Zieroth. Dr. Zieroth is an advanced heart failure and transplant cardiologist, Head of the Medical Heart Failure Program, the Winnipeg Regional Health Authority Cardiac Sciences Program, and an Associate Professor in the Section of Cardiology at the University of Manitoba. Dr. Zieroth is a past president of the Canadian Heart Failure Society. She is a steering committee member for PARAGLIE-HF and a PI Mentor for 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 #18 Ms. AH is a 48-year-old woman who presents with a 3-month history of progressively worsening exertional dyspnea and symmetric bilateral lower extremity edema. She has no history of recent upper respiratory symptoms or chest pain. She denies any tobacco, alcohol, or recreational drug use. There is no family history of premature CAD or HF. On exam, her blood pressure is 110/66 mmHg, heart rate is 112 bpm, and respiration rate is 18 breaths/min with oxygen saturation of 98% on ambient room air. She has jugular venous distention of about 12cm H2O, bibasilar crackles, an S3 heart sound, and bilateral lower extremity edema. Complete blood count, serum electrolytes, kidney function tests, liver chemistry tests, glucose level, iron studies, and lipid levels are unremarkable. An electrocardiogram shows sinus tachycardia with normal intervals and no conduction delays. A transthoracic echocardiogram demonstrates a left ventricular ejection fraction of 25%, normal right ventricular size and function, and no valvular abnormalities. Which of the following diagnostic tests has a Class I indication for further evaluation? A Cardiac catheterization B Referral for genetic counseling C Thyroid function studies D Cardiac MRI Answer #18 Explanation  The correct answer is C – thyroid function studies have a Class 1 indication for the evaluation of HF.  The common causes of HF include coronary artery disease, hypertension, and valvular heart disease. Other causes may include arrhythmia-associated, toxic, inflammatory, metabolic including both endocrinopathies and nutritional, infiltrative, genetic, stress induced, peripartum, and more. It is important to evaluate for the etiology of a given patient’s heart failure as diagnosis may have implications for treatment, counseling, and family members. For patients who are diagnosed with HF, laboratory evaluation should include complete blood count, urinalysis, serum electrolytes, blood urea nitrogen, serum creatinine, glucose, lipid profile, liver function tests, iron studies, and thyroid-stimulating hormone to optimize management (Class 1, LOR C-EO). These studies provide important information regarding comorbidities, suitability for and adverse effects of treatments, potential causes or confounders of HF, and severity and prognosis of HF. HF is often caused by coronary atherosclerosis, and evaluation for ischemic heart disease can help in determining the presence of significant coronary artery disease (CAD). Noninvasive stress imaging with echocardiography or nuclear scintigraphy can be helpful in identifying patients likely to have obstructive CAD. Invasive or computed tomography coronary angiography can detect and characterize the extent of CAD. Therefore, in patients with HF, an evaluation for possible ischemic heart disease can be useful to identify the cause and guide management (Class 2a, LOE B-NR). Familial cardiomyopathy is increasingly recognized and may be the underlying etiology of patients previously classified as having idiopathic dilated cardiomyopathy. A detailed family history may provide the first clue to a genetic basis. A 3-generation family pedigree obtained by genetic health care professionals improved the rate of detection of a familial process as compared with routine care. Furthermore, a family history of cardiomyopathy, as determined by a 3-generation pedigree analysis, was associated with findings of gadolinium enhancement on cardiac magnetic resonance imaging (MRI) and increased major adverse cardiac events. The possibility of an inherited cardiomyopathy provides the impetus for cascade screening of undiagnosed family members, thereby potentially avoiding preventable adverse events in affected relatives by implementation of GDMT and other management that otherwise would not be initiated. Therefore, in patients with cardiomyopathy, a 3-generation family history should be obtained or updated when assessing the cause of the cardiomyopathy to identify possible inherited disease (Class 1, LOE B-NR). In selecting patients with nonischemic cardiomyopathy, referral for genetic counseling and testing is reasonable to identify conditions that could guide treatment for patients and family members (Class 2a, LOE B-NR). CMR provides noninvasive characterization of the myocardium that may provide insights into HF cause. Registry data show that CMR findings commonly impact patient care management and provide diagnostic information in patients with suspected myocarditis or cardiomyopathy. However, routine screening with CMR is not recommended. The OUTSMART HF trial recently demonstrated routine cardiac MRI use did not yield more specific HF causes than a selective strategy based on echocardiographic and clinical findings. The guidelines give a Class 2a recommendation for the use of CMR in diagnosis or management in patients with HF or cardiomyopathy (LOE B-NR).   Main Takeaway The common causes of HF include ischemic heart disease, hypertension, and valvular heart disease. When a patient presents with new-onset heart failure, a complete initial evaluation including laboratory testing for potentially reversible causes such as thyroid disease, or other endocrine, metabolic, and nutritional causes should be performed. Guideline Loc. Section 3.2, 4.1, 4.3, and 4.4 Table 5 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!

CardioNerds (Amit Goyal and Daniel Ambinder), ACHD series co-chairs Dr. Dan Clark and Dr. Josh Saef, and ACHD FIT lead Dr. J.D. Serfas (Duke University) and Cardiology Fellow Dr. Victoria Thomas (Vanderbilt University) join ACHD experts Dr. Jamil Aboulhosn (Professor of Medicine at UCLA and the director of the Ahmanson/UCLA Adult Congenital Heart Disease Center) and Dr. Joanna Ghobrial, Medical and Interventional Director of the Adult Congenital Heart Disease Center at Cleveland Clinic. They discuss common ACHD pathologies that benefit from interventional cardiology procedures such as transcatheter pulmonic valve replacement (TPVR) and share new advancements in transcatheter approaches to correct sinus venosus defects. They end with a brief discussion on how to become an adult cardiology interventionalist that performs ACHD interventions. Episode notes were drafted by Dr. Victoria Thomas. Audio editing by CardioNerds Academy Intern, student doctor Akiva Rosenzveig.  Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. The CardioNerds Adult Congenital Heart Disease (ACHD) series provides a comprehensive curriculum to dive deep into the labyrinthine world of congenital heart disease with the aim of empowering every CardioNerd to help improve the lives of people living with congenital heart disease. This series is multi-institutional collaborative project made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Josh Saef, Dr. Agnes Koczo, and Dr. Dan Clark. The CardioNerds Adult Congenital Heart Disease Series is developed in collaboration with the Adult Congenital Heart Association, The CHiP Network, and Heart University. See more Disclosures: None CardioNerds Adult Congenital Heart Disease PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls – ACHD: Interventional Cardiology The ductus arteriosus, which is formed from the distal portion of the left sixth arch, is key to fetal circulation because it allows blood to bypass Transcatheter pulmonic valve replacement (TPVR) is a treatment for many ACHD patients that can spare them repeat sternotomies. This is important as many ACHD patients hava already undergone multiple surgeries in their childhood.   Before any ACHD cardiology intervention, appropriate imaging (TEE, TTE, Cardiac MRI, Cardiac CTA, and/or 3D printing) is imperative to understanding the relevant anatomy and hemodynamics to guide procedural indication and planning.    As with other structural interventions, consider a SENTINEL device (cerebral embolic protection system) to provide embolic protection in procedures that could lead to debris/embolic dislodgement when appropriate. Sinus venosus defects can be repaired via a transcatheter approach with a covered stent in the superior vena cava (SVC).   Consider using 3D printing or 3D digital imaging when preparing for complex ACHD interventions.    Notes- ACHD: Interventional Cardiology 1. When considering a patient for TPVR there are 3 types of landing zones for pulmonic valves in ACHD patients:    Pulmonary conduits or homografts. These are typically seen in patients with TOF or prior Ross or Rastelli procedure. These may be calcified and stenotic and so pre-dilatation is often needed before valve replacement.   Bioprosthetic Valves. (Valve in Valve TPVR) Native outflow tract 2. What are some of the more severe complications to consider when talking to an ACHD patient about a TPVR?   Coronary artery compression Conduit rupture Vessel injury (including the pulmonary bed) Valve embolization Endocarditis 3. What are some of the hemodynamic measurements one would want to pay attention to in a patient with a Fontan heart?    You will see higher CVPs in patients with a Fontan palliation. The CVP will typically be higher than your wedge pressure, as the circuit relies on passive transpulmonary blood flow.    Evaluating the wedge pressure is crucial. Elevation may indicate arrythmias and or ventricular dysfunction.     4. When considering closing a fenestration of a Fontan circuit, what are the measurements that one would want to consider?  You would want to temporarily occlude the fenestration with a balloon on a wedge catheter for 10-15 minutes roughly to observe the patient’s Fontan pressure/CVP, wedge pressure, arterial saturation, PA saturation, and systemic blood pressure.    You may want to reconsider occlusion if there is a significant drop in systemic pressures or cardiac output; or significantly increased Fontan pressure/CVP.    5. What are the technical considerations to consider when occluding a fenestration in a Fontan circuit?   You want to make sure there is no thrombus in the fenestration or Fontan circuit.    Consider using the SENTINEL cerebral protection system/device (a device that can provide embolic protection from dislodged debris or emboli). However, this device is typically unable to be used in ACHD who have undergone a BTT shunt due to stenosis.     6. How does a transcatheter intervention help a sinus venosus defect?  Placement of the covered stent in the SVC with a dilated portion into the right atrium creates the closure of the sinus venosus defect. The covered stent also helps with rerouting the anomalous pulmonary vein(s) posteriorly to drain into the left atrium.   To learn more about PAPVR, enjoy Episode #106. Case Report: A Hole in the HFpEF Diagnosis. 7. What are some of the concerns to consider when closing a sinus venosus defect via a transcatheter approach?  Plan for increased left atrial pressures and pulmonary venous pressures in older patients. This is due to your left heart using the sinus venosus defect as a pop-off mechanism before closure, especially in elderly patients with a small left ventricle or diastolic dysfunction. Once the sinus venosus defect is closed/fixed, the blood is no longer able to shunt over to the right atrium and so more blood returns to the (potentially low compliance) left system. You also must watch for pulmonary vein compression when placing your covered stent in the SVC.  You also need to consider the length of your covered stent, as the superior portion of the stent needs to be well-anchored above the entry point of the anomalous pulmonary vein to prevent embolization.   To counteract this, Dr. Aboulhosn suggests that before placing a covered stent in the SVC to fix the sinus venosus defect consider placing a catheter in the left atrium via the transeptal approach. This will then allow a wire to be placed from the left atrium into the most superior pulmonary veins for protection if there is any stenosis/compression after placing the covered stent in the SVC. The transeptal puncture will then serve as a small defect to allow for some mild left-to-right shunting and decompress the left atrium. The transeptal puncture typically endothelializes over time.   References – ACHD Interventional Cardiology Stout KK, Daniels CJ, Aboulhosn JA, et al. 2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. Apr 2 2019;139(14):e698-e800. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000603  European Society of G, Association for European Paediatric C, German Society for Gender M, et al. ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). European heart journal. Dec 2011;32(24):3147-3197. https://academic.oup.com/eurheartj/article/39/34/3165/5078465  Hansen, J. H., Duong, P., Jivanji, S. G., Jones, M., Kabir, S., Butera, G., … & Rosenthal, E. (2020). Transcatheter correction of superior sinus venosus atrial septal defects as an alternative to surgical treatment. Journal of the American College of Cardiology, 75(11), 1266-1278. https://doi.org/10.1016/j.jacc.2019.12.070  Aboulhosn, J. A., Hijazi, Z. M., Kavinsky, C. J., McElhinney, D. B., Asgar, A. W., Benson, L. N., … & Levi, D. S. (2020). SCAI position statement on adult congenital cardiac interventional training, competencies and organizational recommendations. Catheterization and cardiovascular interventions: official journal of the Society for Cardiac Angiography & Interventions, 96(3), 643-650. https://doi.org/10.1002/ccd.28885  Meet Our Collaborators! Adult Congenital Heart AssociationFounded in 1998, the Adult Congenital Heart Association is an organization begun by and dedicated to supporting individuals and families living with congenital heart disease and advancing the care and treatment available to our community. Our mission is to empower the congenital heart disease community by advancing access to resources and specialized care that improve patient-centered outcomes. Visit their website (https://www.achaheart.org/) for information on their patient advocacy efforts, educational material, and membership for patients and providers CHiP Network The CHiP network is a non-profit organization aiming to connect congenital heart professionals around the world. Visit their website (thechipnetwork.org) and become a member to access free high-quality educational material, upcoming news and events, and the fantastic monthly Journal Watch, keeping you up to date with congenital scientific releases. Visit their website (https://thechipnetwork.org/) for more information. Heart UniversityHeart University aims to be “the go-to online resource” for e-learning in CHD and paediatric-acquired heart disease. It is a carefully curated open access library of educational material for all providers of care to children and adults with CHD or children with acquired heart disease, whether a trainee or a practicing provider. The site provides free content to a global audience in two broad domains: 1. A comprehensive curriculum of training modules and associated testing for trainees. 2. A curated library of conference and grand rounds recordings for continuing medical education. Learn more at www.heartuniversity.org/ CardioNerds Adult Congenital Heart Disease Production Team Amit Goyal, MD Daniel Ambinder, MD

CardioNerds (Amit Goyal and Daniel Ambinder), ACHD series co-chairs Dr. Dan Clark and Dr. Josh Saef, and ACHD FIT lead Dr. J.D. Serfas (Duke University) and Cardiology Fellow Dr. Victoria Thomas (Vanderbilt University) join ACHD experts Dr. Jamil Aboulhosn (Professor of Medicine at UCLA and the director of the Ahmanson/UCLA Adult Congenital Heart Disease Center) and Dr. Joanna Ghobrial, Medical and Interventional Director of the Adult Congenital Heart Disease Center at Cleveland Clinic. They discuss common ACHD pathologies that benefit from interventional procedures such as transcatheter pulmonic valve replacement (TPVR) and share new advancements in transcatheter approaches to correct sinus venosus defects. They end with a brief discussion on how to become an adult cardiology interventionalist that performs ACHD interventions. Episode notes were drafted by Dr. Victoria Thomas. Audio editing by CardioNerds Academy Intern, student doctor Akiva Rosenzveig.  Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. The CardioNerds Adult Congenital Heart Disease (ACHD) series provides a comprehensive curriculum to dive deep into the labyrinthine world of congenital heart disease with the aim of empowering every CardioNerd to help improve the lives of people living with congenital heart disease. This series is multi-institutional collaborative project made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Josh Saef, Dr. Agnes Koczo, and Dr. Dan Clark. The CardioNerds Adult Congenital Heart Disease Series is developed in collaboration with the Adult Congenital Heart Association, The CHiP Network, and Heart University. See more Disclosures: None CardioNerds Adult Congenital Heart Disease PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls – ACHD: Interventional Cardiology The ductus arteriosus, which is formed from the distal portion of the left sixth arch, is key to fetal circulation because it allows blood to bypass Transcatheter pulmonic valve replacement (TPVR) is a treatment for many ACHD patients that can spare them repeat sternotomies. This is important as many ACHD patients hava already undergone multiple surgeries in their childhood.   Before any ACHD cardiology intervention, appropriate imaging (TEE, TTE, Cardiac MRI, Cardiac CTA, and/or 3D printing) is imperative to understanding the relevant anatomy and hemodynamics to guide procedural indication and planning.    As with other structural interventions, consider a SENTINEL device (cerebral embolic protection system) to provide embolic protection in procedures that could lead to debris/embolic dislodgement when appropriate. Sinus venosus defects can be repaired via a transcatheter approach with a covered stent in the superior vena cava (SVC).   Consider using 3D printing or 3D digital imaging when preparing for complex ACHD interventions.    Notes- ACHD: Interventional Cardiology 1. When considering a patient for TPVR there are 3 types of landing zones for pulmonic valves in ACHD patients:    Pulmonary conduits or homografts. These are typically seen in patients with TOF or prior Ross or Rastelli procedure. These may be calcified and stenotic and so pre-dilatation is often needed before valve replacement.   Bioprosthetic Valves. (Valve in Valve TPVR) Native outflow tract 2. What are some of the more severe complications to consider when talking to an ACHD patient about a TPVR?   Coronary artery compression Conduit rupture Vessel injury (including the pulmonary bed) Valve embolization Endocarditis 3. What are some of the hemodynamic measurements one would want to pay attention to in a patient with a Fontan heart?    You will see higher CVPs in patients with a Fontan palliation. The CVP will typically be higher than your wedge pressure, as the circuit relies on passive transpulmonary blood flow.    Evaluating the wedge pressure is crucial. Elevation may indicate arrythmias and or ventricular dysfunction.     4. When considering closing a fenestration of a Fontan circuit, what are the measurements that one would want to consider?  You would want to temporarily occlude the fenestration with a balloon on a wedge catheter for 10-15 minutes roughly to observe the patient’s Fontan pressure/CVP, wedge pressure, arterial saturation, PA saturation, and systemic blood pressure.    You may want to reconsider occlusion if there is a significant drop in systemic pressures or cardiac output; or significantly increased Fontan pressure/CVP.    5. What are the technical considerations to consider when occluding a fenestration in a Fontan circuit?   You want to make sure there is no thrombus in the fenestration or Fontan circuit.    Consider using the SENTINEL cerebral protection system/device (a device that can provide embolic protection from dislodged debris or emboli). However, this device is typically unable to be used in ACHD who have undergone a BTT shunt due to stenosis.     6. How does a transcatheter intervention help a sinus venosus defect?  Placement of the covered stent in the SVC with a dilated portion into the right atrium creates the closure of the sinus venosus defect. The covered stent also helps with rerouting the anomalous pulmonary vein(s) posteriorly to drain into the left atrium.   To learn more about PAPVR, enjoy Episode #106. Case Report: A Hole in the HFpEF Diagnosis. 7. What are some of the concerns to consider when closing a sinus venosus defect via a transcatheter approach?  Plan for increased left atrial pressures and pulmonary venous pressures in older patients. This is due to your left heart using the sinus venosus defect as a pop-off mechanism before closure, especially in elderly patients with a small left ventricle or diastolic dysfunction. Once the sinus venosus defect is closed/fixed, the blood is no longer able to shunt over to the right atrium and so more blood returns to the (potentially low compliance) left system. You also must watch for pulmonary vein compression when placing your covered stent in the SVC.  You also need to consider the length of your covered stent, as the superior portion of the stent needs to be well-anchored above the entry point of the anomalous pulmonary vein to prevent embolization.   To counteract this, Dr. Aboulhosn suggests that before placing a covered stent in the SVC to fix the sinus venosus defect consider placing a catheter in the left atrium via the transeptal approach. This will then allow a wire to be placed from the left atrium into the most superior pulmonary veins for protection if there is any stenosis/compression after placing the covered stent in the SVC. The transeptal puncture will then serve as a small defect to allow for some mild left-to-right shunting and decompress the left atrium. The transeptal puncture typically endothelializes over time.   References Stout KK, Daniels CJ, Aboulhosn JA, et al. 2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. Apr 2 2019;139(14):e698-e800. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000603  European Society of G, Association for European Paediatric C, German Society for Gender M, et al. ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). European heart journal. Dec 2011;32(24):3147-3197. https://academic.oup.com/eurheartj/article/39/34/3165/5078465  Hansen, J. H., Duong, P., Jivanji, S. G., Jones, M., Kabir, S., Butera, G., … & Rosenthal, E. (2020). Transcatheter correction of superior sinus venosus atrial septal defects as an alternative to surgical treatment. Journal of the American College of Cardiology, 75(11), 1266-1278. https://doi.org/10.1016/j.jacc.2019.12.070  Aboulhosn, J. A., Hijazi, Z. M., Kavinsky, C. J., McElhinney, D. B., Asgar, A. W., Benson, L. N., … & Levi, D. S. (2020). SCAI position statement on adult congenital cardiac interventional training, competencies and organizational recommendations. Catheterization and cardiovascular interventions: official journal of the Society for Cardiac Angiography & Interventions, 96(3), 643-650. https://doi.org/10.1002/ccd.28885  Meet Our Collaborators! Adult Congenital Heart AssociationFounded in 1998, the Adult Congenital Heart Association is an organization begun by and dedicated to supporting individuals and families living with congenital heart disease and advancing the care and treatment available to our community. Our mission is to empower the congenital heart disease community by advancing access to resources and specialized care that improve patient-centered outcomes. Visit their website (https://www.achaheart.org/) for information on their patient advocacy efforts, educational material, and membership for patients and providers CHiP Network The CHiP network is a non-profit organization aiming to connect congenital heart professionals around the world. Visit their website (thechipnetwork.org) and become a member to access free high-quality educational material, upcoming news and events, and the fantastic monthly Journal Watch, keeping you up to date with congenital scientific releases. Visit their website (https://thechipnetwork.org/) for more information. Heart UniversityHeart University aims to be “the go-to online resource” for e-learning in CHD and paediatric-acquired heart disease. It is a carefully curated open access library of educational material for all providers of care to children and adults with CHD or children with acquired heart disease, whether a trainee or a practicing provider. The site provides free content to a global audience in two broad domains: 1. A comprehensive curriculum of training modules and associated testing for trainees. 2. A curated library of conference and grand rounds recordings for continuing medical education. Learn more at www.heartuniversity.org/ CardioNerds Adult Congenital Heart Disease Production Team Amit Goyal, MD Daniel Ambinder, MD

The following question refers to Section 6.1 of the 2021 ESC CV Prevention Guidelines. The question is asked by Dr. Christian Faaborg-Andersen, answered first by Houston Methodist medicine resident Dr. Najah Khan, and then by expert faculty Dr. Eugenia Gianos. Dr. Gianos specializes in preventive cardiology, lipidology, cardiovascular imaging, and women’s heart disease; she is the director of Women s Heart Health at Lenox Hill Hospital and director of Cardiovascular Prevention for Northwell Health. 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 #23 An asymptomatic 55-year-old man with no past medical history presents to clinic after having a cardiac CT as part of an executive physical. His coronary artery calcium (CAC) score was 200 and the coronary CTA demonstrated isolated 70% stenosis of the left circumflex coronary artery. He is asymptomatic and able to jog 2 miles daily without limitation. He was recently started on aspirin 81 mg daily and atorvastatin 40 mg daily by his primary care provider. His LDL is 50 mg/dL, HbA1c is 6.0%. His BP is 108/70. What would you recommend? A Stop aspirin 81 mg daily as he has not had an ASCVD event or revascularization B Cardiac catheterization and stent placement in the left circumflex C Increase atorvastatin to 80 mg daily D Stress test E No change in management Answer #23 Answer choices A Stop aspirin 81 mg daily as he has not had an ASCVD event or revascularization B Cardiac catheterization and stent placement in the left circumflex C Increase atorvastatin to 80 mg daily D Stress test E No change in management Explanation The correct answer is E – no change in management. Though the patient has not had an ASCVD event or revascularization, low-dose aspirin may be considered with definite evidence of CAD on imaging (Class IIb, LOE C). He is asymptomatic and does not have high risk anatomy on CT (i.e., proximal LAD, left main disease, multivessel disease), so percutaneous coronary intervention or stress testing are not indicated. His LDL is well controlled, so increasing atorvastatin would not be appropriate at this time. Main Takeaway Aspirin 75-100 md daily may be considered in the absence of MI or revascularization when there is definitive evidence of CAD on imaging (Class IIb, LOE C). Guideline Loc. Section 6.1 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!

The following question refers to Section 5.1 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by Keck School of Medicine USC medical student & CardioNerds Intern Hirsh Elhence, answered first by Greater Baltimore Medical Center medicine resident / Johns Hopkins MPH student and CardioNerds Academy House Chief Dr. Alaa Diab, and then by expert faculty Dr. Biykem Bozkurt. Dr. Bozkurt is the Mary and Gordon Cain Chair, Professor of Medicine, Director of the Winters Center for Heart Failure Research, and an advanced heart failure and transplant cardiologist at Baylor College of Medicine in Houston, TX. She is former President of HFSA, former senior associate editor for Circulation, and current Editor-In-Chief of JACC Heart Failure. Dr. Bozkurt was the Vice Chair of the writing committee for the 2022 Heart Failure Guidelines. 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 #17 A 63-year-old man with CAD s/p CABG 3 years prior, type 2 diabetes mellitus, hypertension, obesity, and tobacco use disorder presents for routine follow-up. His heart rate is 65 bpm and blood pressure is 125/70 mmHg. On physical exam, he is breathing comfortably with clear lungs, with normal jugular venous pulsations, a regular rate and rhythm without murmurs or gallops, and no peripheral edema. Medications include aspirin 81mg daily, atorvastatin 80mg daily, lisinopril 20mg daily, and metformin 1000mg BID. His latest hemoglobin A1C is 7.5% and recent NT-proBNP was normal. His latest transthoracic echocardiogram showed normal biventricular size and function. Which of the following would be a good addition to optimize his medical therapy? A DPP-4 inhibitor B Dihydropyridine calcium channel blocker C SGLT2 inhibitor D Furosemide Answer #17 Explanation The correct answer is C: SGLT2 inhibitor. This patient is at risk for HF (Stage A) given absence of signs or symptoms of heart failure but presence of coronary artery disease and several risk factors including diabetes, hypertension, obesity, and tobacco smoking. At this stage, the focus should be on risk factor modification and prevention of disease onset. Healthy lifestyle habits such as maintaining regular physical activity; normal weight, blood pressure, and blood glucose levels; healthy dietary patterns, and not smoking have been associated with a lower lifetime risk of developing HF. Multiple RCTs in patients with type 2 diabetes who have established CVD or are at high risk for CVD, have shown that SGLT2i prevent HF hospitalizations compared with placebo. The benefit for reducing HF hospitalizations in these trials predominantly reflects primary prevention of symptomatic HF, because only approximately 10% to 14% of participants in these trials had HF at baseline. As such, in patients with type 2 diabetes and either established CVD or at high cardiovascular risk, SGLT2i should be used to prevent hospitalizations for HF (Class 1, LOE A). The mechanisms for the improvement in HF events from SGLT2i have not been clearly elucidated but seem to be independent of glucose lowering. Proposed mechanisms include reductions in plasma volume, cardiac preload and afterload, alterations in cardiac metabolism, reduced arterial stiffness, and interaction with the Na+/H+ exchanger. SGLT2i are generally well tolerated, but these agents have not been evaluated in those with severe renal impairment (estimated glomerular filtration rate [eGFR] <25 mL/min/1.73 m2). Main Takeaway It is important to identify patients who are at risk for HF (Stage A) and focus on risk factor optimization to prevent disease onset and progression. Guideline Loc. Section 5.1 Decipher the Guidelines: 2022 Heart Failure Guidelines Page 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 4.6 of the 2021 ESC CV Prevention Guidelines. The question is asked by Student Dr. Shivani Reddy, answered first by Johns Hopkins Cardiology Fellow Dr. Rick Ferraro, and then by expert faculty Dr. Eileen Handberg. Dr. Handberg is an Adult Nurse Practitioner, Professor of Medicine, and Director of the Cardiovascular Clinical Trials Program in the Division of Cardiovascular Medicine at the University of Florida. She has served as Chair of the Cardiovascular Team Section and the Board of Trustees with the ACC and is the President for the PCNA. 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. Question #22 Mr. HC is a 50-year-old man presenting for a routine clinic visit. He is not sure the last time he had a lipid panel drawn, and would like one today, but ate lunch just prior to your appointment – a delicious plate of 50% fruits and vegetables, 25% lean meats, and 25% whole grains as you had previously recommended. True or False: Mr. HC should return another day to obtain a fasting lipid panel. TRUE FALSE Answer #22 Answer choices TRUE FALSE Explanation  This statement is False. A non-fasting lipid panel is appropriate for risk stratification and lipid evaluation in most patients per the ESC guidelines. While no level of evidence in provided in the ESC guidelines, this recommendation is consistent with AHA/ACC cholesterol guidelines, which have also largely moved away from fasting lipid panels for most patients and give a Class 1 (LOE B) recommendation to obtaining a fasting or nonfasting plasma lipid profile for ASCVD estimation and baseline LDL-C in adults 20 years of age or older. The ESC recommendation is based upon large trials showing that results of fasting and non-fasting panels are largely similar. This is similar to the AHA/ACC guidelines, which note non-fasting and fasting LDL-C change minimal over time following a normal meal, while HDL-C and tryiglycerides appear to have similar prognostic significance with cardiovascular outcomes in fasting or nonfasting states. A fasting lipid panel should be considered in those with hypertriglyceridemia, metabolic syndrome, and diabetes mellitus, as consumption of food or drink can have direct and immediate effects on TG and blood glucose values. Main Takeaway A non-fasting lipid panel is appropriate for the majority of patients undergoing lipid evaluation and cardiovascular risk stratification.  Guideline Loc. Section 4.6.1 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 Sections 11.3 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by Western Michigan University medical student and CardioNerds Intern Shivani Reddy, answered first by Johns Hopkins Osler internal medicine resident and CardioNerds Academy Fellow Dr. Justin Brilliant, and then by expert faculty Dr. Harriette Van Spall. Dr. Van Spall is Associate Professor of Medicine, cardiologist, and Director of E-Health at McMaster University. Dr Van Spall is a Canadian Institutes of Health Research-funded clinical trialist and researcher with a focus on heart failure, health services, and health disparities. 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 #16 Ms. Augustin is a 33 y/o G1P1 woman from Haiti who seeks counseling regarding family planning as she and her husband dream of a second child.  Her 1st pregnancy 12 months ago was complicated by pre-eclampsia and peripartum cardiomyopathy (LVEF 35%). Thankfully she delivered a healthy baby via C-section. She has no other past medical history and is currently on losartan 25 mg daily and metoprolol succinate 200 mg daily.  She has been asymptomatic. Which of the following statements is recommended to medically optimize Ms. Augustin prior to her 2nd pregnancy? A No medical optimization or preconception planning is needed as her 1st pregnancy resulted in a healthy infant. B Discontinue losartan and metoprolol with no other needed pregnancy planning  C Change her medication regimen, consider repeat TTE, and provide patient-centered counseling regarding risk of a future pregnancy D Continue losartan and metoprolol and advise against repeat pregnancy  Answer #16 Explanation The correct answer is C – change her medication regimen, consider repeat TTE, and provide patient-centered counseling regarding risk of a future pregnancy. Heart failure may complicate pregnancy either secondary to an existing pre-pregnancy cardiomyopathy or as a result of peripartum cardiomyopathy. In women with history of heart failure or cardiomyopathy, including previous peripartum cardiomyopathy, patient-centered counseling regarding contraception and the risks of cardiovascular deterioration during pregnancy should be provided (Class I, LOE C-LD) Peripartum cardiomyopathy (PPCM) is defined as systolic dysfunction, typically LVEF < 45%, often with LV dilation, occurring in late pregnancy or early postpartum with no other identifiable etiology. PPCM occurs worldwide, with the highest incidences in Haiti, Nigeria, and South Africa. Other clinical risk factors include maternal age > 30 years, African ancestry, multiparity, multigestation, preeclampsia/eclampsia, anemia, diabetes, obesity, and prolonged tocolysis.   The pathogenesis of peripartum cardiomyopathy is complex and it is likely a multifactorial process.  The combination of hemodynamic changes of pregnancy, inflammation of the myocardium, hormonal changes, genetic factors, and an autoimmune response have all been proposed as possible mechanisms and these may certainly be interrelated. While pregnancy is generally well-tolerated in women with cardiomyopathy and NYHA class I status pre-pregnancy, clinical deterioration can occur and so counseling and shared decision-making are important. In fact, the ROPAC study of pregnancy outcomes for women with structural heart disease showed that women with pre-pregnancy or previous peripartum CM had the highest mortality rate at 2.4%. Subsequent pregnancies for women with previous peripartum cardiomyopathy have been associated with further decreases in LV function, maternal death, and adverse fetal outcomes. LVEF < 50% prior to a subsequent pregnancy is the strongest prognostic determinant. Different strategies are needed to optimize the cardiovascular health of women with a prior history of PPCM before embarking on a subsequent pregnancy including pre-conception counseling regarding risk of subsequent pregnancies, pharmacologic strategies, and a multi-disciplinary approach to expectant management. Pre-conception counseling: can utilize cardiovascular risk tools including ZAHARA I and CARPREG II scores (which predict outcomes during pregnancy in women with prior heart disease) and obtain a baseline TTE prior to conception to inform shared decision making.   Pharmacologic strategies: in women with HF or cardiomyopathy who are pregnant or currently planning for pregnancy, ACEi, ARB, ARNi, MRA, SGLT2i, ivabradine, and vericiguat should not be administered because of significant risks of fetal harm (Class 3: Harm, LOE C-LD). Beta blockers (preferably metoprolol), hydralazine, and nitrates are considered acceptable during pregnancy, when guided by multidisciplinary shared decision-making regarding benefits and potential risks.  Diuretic dosing should be discussed (if applicable) to minimize the risk of placental hypoperfusion. A repeat TTE should be performed 3 months following changes in heart failure medicine regimen. Of note, postpartum women who breastfeed can start an ACEi (enalapril or captopril are preferred), and metoprolol remains the preferred beta blocker. Multidisciplinary care may include consultations with genetics, gynecology, and maternal-fetal medicine teams, as appropriate to the outcome of shared decision making. During pregnancy, for women with decompensated HF or evidence of hemodynamic instability antepartum, delivery planning will include obstetrics and maternal-fetal medicine, cardiac anesthesia, cardiology, and neonatology teams. Therefore, answer choice C is correct because pre-conception counseling is essential to guide pertinent discussions on risk stratification prior to subsequent pregnancies. Additionally, her medications need to be modified by discontinuing her ARB prior to conception. Choice A is incorrect because she is high risk for worsening cardiomyopathy and repeat preeclampsia in her next pregnancy. Choice B is incorrect because shared decision making and risk stratification prior to 2nd pregnancy are essential. Choice D is incorrect because, although she is at high risk for complications including worsening cardiomyopathy, preeclampsia/eclampsia, and neonatal demise, repeat pregnancy is not absolutely contraindicated and should be an informed decision after appropriate education within the construct of a multidisciplinary team. See Heart Failure and Pregnancy Infographic created by Dr. Alaa Diab, CardioNerds Academy Chief. Main Takeaway In summary, when a patient with history of peripartum cardiomyopathy is planning on a repeat pregnancy, patient-centered counseling regarding risks and management strategies should be provided with guidance from a multidisciplinary team and medications should be adjusted to balance GDMT for heart failure against risks to fetal development.  Guideline Loc. Section 11.3, Table 30 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!

The CardioNerds Academy welcomes Dr. Melanie Sulistio to give the 2nd Annual Sanjay V. Desai Lecture in Medical Education to mark the graduation of the 2022 CardioNerds Academy Class. Join us as Dr. Sulistio and CardioNerds Academy Program Director Dr. Tommy Das discuss the humanity deficiency in medicine, and how the practice of compassionate assumption can lead us to be better physicians for our patients, our colleagues, our learners, and ourselves. Credit to rising CardioNerds Academy chiefs Dr. Rawan Amir, Dr. Kate Wilcox, Dr. Alaa Diab, and Dr. Gurleen Kaur for their terrific acting in this episode. Audio editing by CardioNerds academy intern, Pace Wetstein. Dr. Sanjay V Desai serves as the Chief Academic Officer, The American Medical Association and is the former Program Director of the Osler Medical Residency at The Johns Hopkins Hospital. Dr. Melanie Sulistio is an Associate Professor of Medicine in the Division of Cardiology at the University of Texas Southwestern. Additionally, she is an Associate Dean for Student Affairs and Distinguished Teaching Professor at the University of Texas Southwestern Medical School and co-chairs the ACC Internal Medicine Residency Program. She has a passion for medical education and promoting humanity in medicine, and is actively involved in the work of teaching communication skills that encompass meaningful care, discussions with patients, and difficult conversations with colleagues. Relevant disclosures: None Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. CardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!

CardioNerds join Dr. Samid Muhammad Farooqui, Dr. Hiba Hammad, and Dr. Syed Talal Hussain, from the University of Oklahoma Pulmonary and Critical Care Medicine Fellowship Program, in Oklahoma City. The fellows will take us in a fascinating discussion of a case of rapidly progressing dyspnea and pulmonary hypertension in a patient with metastatic breast cancer. They will then reveal an interesting etiology of pulmonary hypertension, where the secret was on the wedge! University of Oklahoma faculty and expert in pulmonary hypertension and right ventricular physiology, Dr. Roberto J. Bernardo provides the E-CPR for this episode. Audio editing by CardioNerds Academy Intern, Dr. Christian Faaborg-Andersen. A septuagenarian female, with a past medical history of metastatic breast adenocarcinoma, presented to the hospital with worsening dyspnea over a period of 3 weeks. She was found to be in rapidly progressive hypoxic respiratory failure with unremarkable chest x-ray, CTA chest, and V/Q scan. Transthoracic echocardiogram revealed elevated RVSP and a subsequent right heart catheterization showed pre-capillary pulmonary hypertension with a low cardiac index. She was treated for rapidly progressive RV dysfunction with inotropic support and inhaled pulmonary vasodilators until she decided to pursue comfort measures. Wedge cytology came back positive for malignant cells, confirming a diagnosis of Pulmonary Tumoral Thrombotic Microangiopathy (PTTM). CardioNerds is collaborating with Radcliffe Cardiology and US Cardiology Review journal (USC) for a ‘call for cases’, with the intention to co-publish high impact cardiovascular case reports, subject to double-blind peer review. Case Reports that are accepted in USC journal and published as the version of record (VOR), will also be indexed in Scopus and the Directory of Open Access Journals (DOAJ). “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. 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! Case Media – When Tumors Take Your Breath Away – University of Oklahoma College of Medicine Pearls – When Tumors Take Your Breath Away – University of Oklahoma College of Medicine Pulmonary arterial hypertension (PAH) is a progressive disorder of the pulmonary vasculature, characterized by progressive obliteration and remodeling of the pulmonary circulation, resulting in increased pulmonary vascular resistance and increased right ventricular (RV) wall stress, abnormal right ventricular mechanics, and eventually RV dysfunction and death. Pulmonary hypertension (PH) is divided into pre-capillary and post-capillary profiles, where pre-capillary PH is hemodynamically characterized by a mean pulmonary artery pressure (mPAP) > 20 mmHg, pulmonary artery wedge pressure (PAWP) ≤ 15 mmHg and a pulmonary vascular resistance (PVR) ≥ 3 Woods Units (WU), and post-capillary PH is defined as mPAP > 20 mmHg, PAWP ≥ 15 mmHg, and PVR can be either < 3 WU (isolated post-capillary PH) or ≥ 3 WU (combined pre- and post-capillary PH). Pulmonary arterial hypertension (PAH) falls under the pre-capillary PH profile. Dyspnea on exertion is the most common manifestation of PH, and the most common initial complain. Other symptoms and physical findings such as venous congestion, peripheral edema, signs of RV dysfunction or syncope present later in the disease course. As such, PH has to be considered in the differential diagnosis of dyspnea, especially in cases of undifferentiated or unexplained dyspnea. PAH is a chronic but progressive condition, where symptoms progress over the course of months to years. Subacute or rapidly progressive forms of PH (symptoms rapidly worsening over the course of weeks) should warrant consideration for alternative etiologies (i.e., pulmonary embolism or a different cardiopulmonary disorder as the main driver of symptoms), or unique rapidly progressive phenotypes of PAH such as pulmonary tumor thrombotic microangiopathy (PTTM). PH in the setting of malignancy warrants special consideration, where the pulmonary vascular disorder could be related to venous thromboembolic disease, external compression of the pulmonary vasculature (if the tumor directly compresses mediastinal structures), related to chemotherapeutic agents (such as tyrosine kinase inhibitors) or thoracic radiotherapy (ie. fibrosing mediastinitis), or related to tumor emboli per se, such as in PTTM. PTTM is a unique manifestation of PH in the setting of malignancy, known to be rapidly progressive, associated with poor RV adaptation, and almost universally fatal. The confirmatory testing of PTTM is by pathology (autopsy), although as in our case, sometimes tumor cells can be identified during cytology of pulmonary artery wedge samples. Show Notes – When Tumors Take Your Breath Away – University of Oklahoma College of Medicine 1. How do you approach dyspnea? Dyspnea is a subjective sensation of uncomfortable breathing. It can be caused by pathologies in cardiac, pulmonary, neuromuscular systems as well as in systemic illnesses. Dyspnea is also a manifestation of psychogenic disorders. Presentation of dyspnea can be divided into acute and chronic forms and the etiology can be identified by a thorough evaluation. A detailed history and physical exam can help identify the organ system involved. Certain physical signs can be suggestive of the culprit organ system e.g., lower extremity edema in congestive heart failure, increased antero-posterior diameter of the chest in obstructive lung disease, etc. Imaging modalities can be very helpful in determining the cause of dyspnea. Chest radiographs, CT scans of the chest, and echocardiograms can help identify the etiology of dyspnea. Additionally, other testing like pulmonary functions tests can be used too. 2. What are the different Pulmonary Hypertension groups? Pulmonary Hypertension (PH) is divided into 5 main groups in the WHO classification, as follows: Group I Pulmonary Arterial Hypertension (PAH)   Idiopathic, heritable, drugs, congenital heart disease, liver disease, connective tissue disease, toxins, anorexigens among other causes Group II PH due to Left Heart Disease Left sided heart failure, valvular pathology Group III PH due to Lung Disease COPD, Interstitial Lung Disease, Sleep Apnea Group IV PH due to Chronic Thromboembolic Disease Pulmonary emboli Group V PH due to Other Causes Sarcoidosis, ESRD, Sickle Cell Anemia, Chronic Hemolytic Anemia, Certain Metabolic Disorders 3. How do you approach a patient with Pulmonary Hypertension? The goal is to discover an identifiable etiology for proper classification of pulmonary hypertension according to the WHO groups, in order to guide prognostication and management. A thorough history and physical exam is the first step in the diagnosis of pulmonary hypertension. Exertional dyspnea is the most common presenting symptom. Due to the nonspecific symptoms, there is often a delay in the diagnosis. Other symptoms include chest pain, fatigue, edema. In severe cases, patients may have syncopal episodes. Physical Exam findings concerning for pulmonary hypertension include signs of volume overload (i.e., edema, elevated JVP). Cardiac auscultation may reveal a loud P2 component. Laboratory workup includes basic assessment of hematology along with testing for HIV and serological markers of connective tissue diseases. Biomarkers of cardiovascular system like BNP are important in identification and prognostication of pulmonary hypertension. Radiological studies like chest radiographs, CT scans of the chest and ventilation/perfusion scans of the lung are used to identify pulmonary pathologies and the presence of thromboembolic disease respectively. Echocardiographic assessments are important for diagnosis and assessment of pulmonary hypertension. It allows for the assessment of the left side as well as a detailed analysis of the right side which has diagnostic and prognostic value. Finally, the gold standard for diagnosis is a right heart catheterization, which allows for accurate measurements of the pressure in the different chambers of the heart and allows for the phenotyping of pulmonary hypertension. 4. What are the considerations for Pulmonary Hypertension etiologies in patient with malignancy? How is Pulmonary Tumoral Thrombotic Microangiopathy diagnosed? Pulmonary hypertension in a patient with malignancy requires special attention. Apart from the common reasons for pulmonary hypertension, use of chemotherapeutic agents has been associated with the development of pulmonary arterial hypertension, particularly with Tyrosine Kinase Inhibitors. Pulmonary Veno-Occlusive Disease (PVOD) can be precipitated by the use of many chemotherapeutic agents especially alkylating agents. Detrimental effects of chemotherapeutic agents on myocytes can cause Group II pulmonary hypertension. Chemotherapy and radiation therapy induced lung damage can also cause Group III pulmonary hypertension.  Large tumors may directly compress mediastinal structures causing elevated pulmonary pressures due to external compression.  In patients with adenocarcinoma, tumoral thrombotic microangiopathy can result in sub-acute pulmonary hypertension known as Pulmonary Tumoral Thrombotic Microangiopathy (PTTM). PTTM results in rapid clinical deterioration and hence requires a high suspicion of index. It is mostly diagnosed postmortem, but can be diagnosed by performing wedge cytology. 5. What is the prognosis of PTTM and how is it treated? PTTM carries a grave prognosis. It causes accelerated occlusion of pulmonary arteries resulting in acute to subacute pulmonary hypertension and ensuing RV dysfunction and failure. The mainstay of treatment relies on pulmonary vasodilation and slowing the growth of malignant cells. Pulmonary vasodilators, especially endothelin receptor antagonists, have been reported to be used. Imatinib, a tyrosine kinase inhibitor, has been reported to be used with some improvement in survival.  References – Vonk Noordegraaf A, Chin KM, Haddad F, et al. Pathophysiology of the right ventricle and of the pulmonary circulation in pulmonary hypertension: an update. Eur Respir J. Jan 2019;53(1):1801900. doi:10.1183/13993003.01900-2018. Link: Bernardo RJ, Haddad F, Couture EJ, et al. Mechanics of right ventricular dysfunction in pulmonary arterial hypertension and heart failure with preserved ejection fraction. Cardiovasc Diagn Ther. Oct 2020;10(5):1580-1603. doi:10.21037/cdt-20-479. Simonneau G, Montani D, Celermajer DS, et al. Haemodynamic definitions and updated clinical classification of pulmonary hypertension. The European respiratory journal. 2019;53(1):1801913-1801913. doi:10.1183/13993003.01913-2018. Dumitrescu D, Sitbon O, Weatherald J, Howard LS. Exertional dyspnoea in pulmonary arterial hypertension. Eur Respir Rev. Sep 30 2017;26(145)doi:10.1183/16000617.0039-2017. Buser M, Felizeter-Kessler M, Lenggenhager D, Maeder MT. Rapidly progressive pulmonary hypertension in a patient with pulmonary tumor thrombotic microangiopathy. Am J Respir Crit Care Med. Mar 15 2015;191(6):711-2. doi:10.1164/rccm.201501-0004IM. Price LC, Wells AU, Wort SJ. Pulmonary tumour thrombotic microangiopathy. Lippincott Williams and Wilkins; 2016. p. 421-428. Price LC, Seckl MJ, Dorfmüller P, Wort SJ. Tumoral pulmonary hypertension. European Respiratory Review. 2019;28(151)doi:10.1183/16000617.0065-2018. Shah AT, Bernardo RJ, Berry GJ, Kudelko K, Wakelee HA. Two Cases of Pulmonary Tumor Thrombotic Microangiopathy Associated with ROS1-Rearranged Non-Small-Cell Lung Cancer. Clin Lung Cancer. Mar 2021;22(2):e153-e156. doi:10.1016/j.cllc.2020.09.020. Godbole RH, Saggar R, Kamangar N. Pulmonary tumor thrombotic microangiopathy: a systematic review. Pulm Circ. Apr-Jun 2019;9(2):2045894019851000. doi:10.1177/2045894019851000

The following question refers to Section 4.4 of the 2021 ESC CV Prevention Guidelines. The question is asked by Dr. Maryam Barkhordarian, answered first by medicine resident Dr. Ahmed Ghoneem, 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. Question #21 Ms. J is a 57-year-old woman with a past medical history of myocardial infarction resulting in ischemic cardiomyopathy, heart failure with reduced ejection fraction, and major depressive disorder who presents today for follow-up. She reports feeling extremely overwhelmed lately due to multiple life stressors. She is on appropriate cardiovascular GDMT agents and is not prescribed any medications for her mood disorder. True or false: in addition to psychotherapy for stress management, it is appropriate to consider Ms. J for anti-depressant SSRI pharmacotherapy at this time to improve cardiovascular outcomes. A True B False Answer #21 Explanation The correct answer is FALSE. An ESC class 3 recommendation states that SSRIs, SNRIs, and tricyclic antidepressants are not recommended in patients with heart failure and major depression; this is based on data suggesting potential lack of SSRI efficacy for reducing depression or cardiovascular events, as well as safety data indicating an association between SSRI use and increased risk of CV events and all-cause as well as cardiovascular mortality among HF patients. Mental health disorders are associated with worse outcomes in patients with ASCVD and appropriate treatment effectively reduces stress symptoms and improves quality of life. Nonpharmacologic modalities of treatment (exercise therapy, psychotherapy, collaborative care) should be considered before pharmacotherapy to improve cardiovascular outcomes in patients with heart failure. Of note, the ESC suggests SSRI treatment be considered for patients with coronary heart disease (without HF) and moderate-to-severe major depression based on data that SSRI treatment is associated with lower rates of CHD readmission (RR 0.63), all-cause mortality (RR 0.56), and the composite endpoint of all-cause mortality/MI/PCI (HR 0.69) vs. no treatment. This is a class 2a recommendation. ESC also gives a class 2a recommendation to consider referral to psychotherapeutic stress management for individuals with stress and ASCVD to improve CV outcomes and reduce stress symptoms. The ACC/AHA guidelines do not provide focused recommendations regarding mental health considerations in patients with elevated cardiovascular risk. Main Takeaway It is important to consider mental health treatment in patients with ASCVD as mental disorders are associated with increased CVD risk and poor patient prognosis, and data support that mental health interventions can improve overall and CVD outcomes, as well as improve quality of life. Guideline Loc. Section 4.4 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!