August 25th, 2010
Is There a Generation Gap in Cardiology?
Larry Husten, PHD, Harlan M. Krumholz, MD, SM, L. David Hillis, MD and Andrew M. Kates, MD
A brief posting in the Wall Street Journal Health Blog on the clash of generations in the medical workplace recently caught our attention. The Blog summarizes a commentary by Sharon Phelan in Obstetrics & Gynecology, which posits that “different attitudes about work and life held by members of different generations can create tensions and clashes in the workplace.” (Think “Marcus Welby, MD” vs. “Scrubs.”) Older physicians are more likely to place their careers first, while younger physicians are more likely to place family first.
Here’s what Phelan told the Health Blog: “’The risk is that the more senior folks think the newer folks don’t care and that they’re not professional, and look down on them. Meantime some of the younger folks have lost respect for the older folks — they think they’re incredibly misdirected in their emphasis [on work above all else].”
Here are some of our thoughts on the matter. We invite you to share yours as well.
Larry Husten: I wonder if my perspective as an outsider might help: Isn’t it possible that it’s not so much a generational difference per se but a difference in the overall relationship to the healthcare system? Older physicians were much more likely, with good reason, to feel more independent and less burdened by external controls, while younger physicians are much more likely to feel like employees. If you own the store, you’re more likely to stay open late for a good customer. But if you’re just being paid an hourly wage, you’re less likely to make the sacrifice.
L. David Hillis: A good thought. Nowadays, the older physicians certainly no longer own the store, yet many continue to center their lives around their work. They feel a strong personal professional commitment to their patients that trumps all other things in their lives.
Larry Husten: Nothing personal, but maybe you just can’t teach an old dog new tricks…
Andy Kates: I think the main explanation is that the “younger” generation (I think I am part of that) witnessed our parents (especially fathers and my father-in-law) miss out on the key events in their children’s lives and do not want to act the same way.
Harlan Krumholz: I think the generational shift is more profound and speaks to identity — as well as expectation. It is in medicine but also pervades our society and culture. And it is more about what is generationally normative than anything else. Each generation sets its own rules and feels, in a sense, that it is correcting the problems of past generations. And maybe it does. But I found the recent New York Times article about Velcro parents interesting — and wondered what the right involvement is in children’s key events (Andy’s phrase). And that is my generation.
Readers are invited to contribute to the discussion in the comments section.
August 24th, 2010
Questions About IABP During High-Risk PCI
Larry Husten, PHD
CardioExchange welcomes Simon Redwood and Divaka Perera to discuss their randomized trial of routine intra-aortic balloon pump (IABP) insertion during high-risk PCI for the reduction of major adverse cardiac and cardiovascular events (MACCE) in patients with severe LV dysfunction and extensive coronary disease. Their study, which appears in the Journal of the American Medical Association, showed that, among 301 patients with LVEF < 30% and Jeopardy Score > 8/12, elective IABP did not reduce the incidence of MACCE. An intriguing observation was the difference in all-cause mortality at 6 months of 7.4% in the control group compared with 4.6% in the IABP group. IABP treatment was also associated with fewer major procedural complications but more bleeding complications.
Do you think that this study is sufficient to recommend that the routine use of IABP for patients undergoing high-risk PCI be abandoned? Should it be a Class III recommendation (that is, should not be used) in the next guidelines?
Simon Redwood: The take-home message certainly isn’t that the IABP has no role in the cath lab. What we have shown is that it doesn’t need to be used routinely in these patients (i.e., extensive coronary disease and poor LV function) undergoing elective angioplasty. However, there will still be some patients with very poor LV function and complex disease who will benefit from their use prophylactically — we only scored extent of coronary disease, not complexity. The SYNTAX score can classify complexity but was not available when we designed this trial.
All previous recommendations regarding IABP use have been based on registries. This is the first prospective randomized trial, and we hope will certainly help to revise the current guidelines. With a trial of this size we couldn’t perform multiple sub-analyses, but it appears that the patients requiring bailout IABP use were towards one end of the spectrum of our cohort (i.e., more extensive disease).
Finally, the investigators involved in this trial were all “high-volume” PCI operators with extensive experience in dealing with such “high-risk” patients. Although very speculative, if the trial had been done in low-volume centers by low-volume operators, the results may have been different!
As far as we know, this is the largest cohort of “ischaemic cardiomyopathy” patients undergoing PCI reported and, overall, the mortality is excellent, so we see it as a very positive trial for PCI!
Just to put that in perspective, only about 2% of the patients in SYNTAX had a EF of less than 30%!
Divaka Perera: I would echo Simon’s comments. I think the trial does definitively address the question of routine IABP insertion in patients with poor LV function and extensive coronary disease. What it doesn’t do is to allow us to clearly identify (prospectively) the important minority (nearly 1 in 8 in this study) who are going to need rescue IABP support during the case. Post-hoc analysis suggests that these were patients with virtually the whole myocardium subtended by diseased coronary arteries but the study was not powered to allow full multivariate analysis of this subgroup. As such, we would recommend a standby approach for such high-risk cases.
What do you think of the 6-month mortality difference between the groups? Although the difference is not significant, it is consistent with a large effect.
Simon Redwood: The 6-month mortality difference, although not significant, is certainly interesting and has prompted us to continue to follow these patients longer term to see if any “real” differences emerge. Again, highly speculative, it could be possible that there were small differences in LV function associated with the IABP that may translate to a difference in long-term outcome beyond 6 months. Note that our trial was not designed to be powered to look at this, but nevertheless, we will continue to follow the patients.
What will you say to those who point to the differences in the procedural complications?
Simon Redwood: The differences in procedural complications were largely hemodynamic issues, particularly hypotension, which highlights the importance of a standby approach in these patients and prompt IABP insertion at the earliest hint of emerging problems. I was quoted years ago as saying,” If you think of a balloon pump for more than a few seconds you should probably put one in.” Perhaps that could now be modified to include “…during the case!”
August 24th, 2010
Study Suggests Prognostic Power of Dyspnea in Acute Heart Failure
Larry Husten, PHD
Results of a study with the hormone relaxin suggest that a lack of ongoing dyspnea relief may be an important predictor of outcome. Marco Metra and fellow investigators in the Pre-RELAX-AHF study randomized 232 patients with acute heart failure to placebo or one of 4 doses of relaxin. Only 25% of all patients in the study achieved early dyspnea relief, and patients who lacked persistent dyspnea relief and who had worsening heart failure had a longer length of initial hospital stay and a worse outcome at 60 days. The findings, conclude the authors in their report in the European Journal of Heart Failure, suggest that “beyond being the main measure” of acute heart failure symptoms, dyspnea endpoints “are also related to prognosis and hence may be regarded as important and meaningful targets of therapy.”
August 23rd, 2010
AHA Science Advisory Calls for More Research on CVD in Asian-Americans
Larry Husten, PHD
In a “Call to Action” contained in a new scientific statement, the American Heart Association says that more research is needed on cardiovascular disease in Asian-Americans.
“Available research shows that subgroups of Asian-Americans are at increased risk of complications and death from cardiovascular disease; however, Asian-Americans are often studied as a group, which masks the differences within this heterogeneous population,” according to Latha Palaniappan, chair of the AHA committee that wrote the advisory, in an AHA press release. The statement is published in Circulation.
Among the many details included in the statement, the report notes that Asian Indians and Filipinos are at increased risk for coronary disease, while Japanese- and Chinese-Americans are at lower risk for coronary disease but at higher risk for stroke.
August 20th, 2010
Door to Balloon (D2B) Time: The Wrong Performance Measure?
Richard A. Lange, MD, MBA
The authors of a recently published study evaluated the association between system delay (i.e., time from the patient’s first contact with the health care system to initiation of reperfusion) and outcome in STEMI patients transported by EMS and treated with primary PCI. Some patients were triaged directly to a PCI center, whereas others were transported to their local hospitals before transfer to a PCI center.
Compared with patients triaged directly to a PCI center, those transferred to a PCI center had a shorter D2B time (29 vs. 39 min, P<0.001) but a longer total health system delay (240 min vs. 172 min; P<0.001). Importantly, this delay substantially influenced long-term (3.4-year) mortality, which was 15% of those with a treatment delay of 0-60 minutes, 23% with a delay of 61-120 minutes, 28% with a delay of 121-180 minutes, and 31% with a delay of 181-360 minutes (P<0.001).
Apparently, transfer to another facility for primary PCI might not constitute optimal care of the AMI patient. Given regional variations in treatment delay, how do you decide how to treat these patients?
August 20th, 2010
A “Good” Heart…
John Mandrola, MD, FACC
John Mandrola, an electrophysiologist and avid cyclist, usually writes about cycling in the Wednesday posts to his blog, Dr. John. Here he examines how antagonism relates to carotid thickness.
This Wednesday, it will be easy to combine cycling and medicine.
When I saw this study that linked antagonistic personality traits and cardiovascular risk, it was simply impossible to ignore, especially on a Wednesday. Low hanging fruit, no doubt.
It was an NIH sponsored study that looked at the effects of antagonistic traits, low agreeableness specifically, on heart health. Yes, you read it right, agreeableness. To quantify agreeableness, these researchers used a personality questionnaire that evaluated six traits: trust, straightforwardness, altruism, compliance, modesty, and my favorite, tender-mindedness.
Your hypothesis is probably right: people who were distrustful, cynical, manipulative, self-centered, and quick to express anger fared worse. Don’t worry cyclists, these are not your traits. Ha! Wink.
Please do not dismiss this as just another mundane study proclaiming the risks of an angry personality. The specifics of the findings and their implications hit really hard.
The researchers studied 5600 patients from Sardinia, Italy. They used carotid artery thickness as a surrogate measure of vascular health. (Obviously, a thicker vessel wall is worse. Also, on average, men have thicker-walled carotid arteries than women.) There were four striking findings:
- Low agreeableness scores were associated with thicker-walled arteries and an increased likelihood of progressive thickening over a three-year span.
- The effects of poor agreeableness scores were more pronounced in women. So much so that the artery thickness of women with really low agreeableness scores was the same as in men. In other words, being a highly disagreeable woman may transform the favorable female artery to resemble the less desirable state in men. (I am not making this up.)
- Straightforwardness and compliance were the specific traits that correlated most with artery wall thickness.
- The wake-up-and-pay-attention take-home message is that the increased CV risk of antagonistic traits is similar in magnitude to the risks of high cholesterol, high blood pressure, and even smoking. Statistically speaking, being disagreeable was as bad as being a smoker, or having high blood pressure or high cholesterol.
There are caveats here. This is a population-based study, not a randomized, prospective trial. Also, it evaluated a select population in one area of Italy. Finally, this study used a surrogate endpoint for heart disease, rather than hard endpoints, such as heart attack and stroke.
Nonetheless, I predict that in the future, the health of the “spiritual” heart will be scientifically linked with the health of the “biologic” heart. And this link will likely be where the “rubber meets the road,” where the platelets hit the vessel wall, the endothelium. At least when it comes to inflammation and heart health, Gramps may have been wrong when he frequently said, “nice guys finish last.”
Eat well, sleep well, move a lot, and now, be agreeable, straightforward, and even tender-minded, should be the advice of doctors to patients who wish to minimize their cardiac risk profile.
Cyclists, you have no need to worry, I can vouch for your tender-mindedness.
JMM
August 19th, 2010
Responding to the Nay-Saying Patient
Andrew M. Kates, MD
We (both faculty and fellows) have all had patients request that fellows or residents not be involved in their care, as Dr. Wes Fisher so nicely describes in his recent post.
But how can we respond to the patient’s request? And, how far do we take it? Should the patient have the prerogative to insist on this — but only for surgeries or other invasive procedures? What about an in-office evaluation? Or reading an echocardiogram? What parameters are appropriate and what approaches have you found to be successful — or not — in communicating with the patient who is reluctant to allow the involvement of a fellow?
We are interested in hearing from both fellows and attendings about this issue. Respond at the end of Wes’s post.
August 18th, 2010
Nay Fellow Way?
Westby G Fisher, MD
CardioExchange welcomes this guest post, reprinted with permission, from Dr. Westby Fisher, an electrophysiologist practicing at NorthShore University HealthSystem, Evanston, IL and a Clinical Associate Professor of Medicine at University of Chicago’s Pritzker School of Medicine. This piece originally appeared on his blog, Dr. Wes.
It was to be a routine pacemaker.
The parties assembled. The room prepped. IV started. Chest scrubbed. Antibiotics given. His nervous eyes raised when he saw me before the procedure, relieved at the sight of at least one familiar face.
August 17th, 2010
Going Beyond Door-to-Balloon by Starting Earlier
Larry Husten, PHD
Efforts to speed delivery of PCI to STEMI patients have focused on shortening the door-to-balloon time. Now a group of Danish researchers propose that efforts to improve care must include assessment of treatment from the time of the patient’s first contact with the emergency medical system. Analyzing historical data from 6209 MI patients who received primary PCI, they found a strong relationship between system delay and long-term mortality:
- 0-60 minute delay: 15.4% mortality
- 61-120 minutes: 23.3% mortality
- 121-180 minutes: 28.1% mortality
- 181-360 minutes: 30.8% mortality
In their report in JAMA, the researchers conclude that “increased focus on the total health care system delay may optimize triage of patients with STEMI and may be the key to further improving survival of these patients.”
August 16th, 2010
A Treat for Chocolate Lovers from Sweden
Larry Husten, PHD
In a report that will surely provide comfort to millions, a study of 31,823 Swedish women found that over 9 years of follow-up, women who regularly consumed moderate amounts of chocolate had a lower risk for developing heart failure than those who ate no chocolate at all. However, no protective effect was observed in women who consumed chocolate one or more times per day. In their paper in Circulation: Heart Failure, Elizabeth Mostofsky and colleagues note that the high-quality chocolate consumed in Sweden contained higher cocoa concentrations, which has been linked to beneficial cardiovascular effects, than chocolate consumed in the United States.
“You can’t ignore that chocolate is a relatively calorie-dense food and large amounts of habitual consumption is going to raise your risks for weight gain,” said the paper’s senior author, Murray Mittleman, in an AHA press release. “But if you’re going to have a treat, dark chocolate is probably a good choice, as long as it’s in moderation.”
“Those tempted to use these data as their rationale for eating large amounts of chocolate or engaging in more frequent chocolate consumption are not interpreting this study appropriately,” said Linda Van Horn, the immediate past chair of the American Heart Association Nutrition Committee, in the AHA press release. “This is not an ‘eat all you want’ take-home message, rather it’s that eating a little dark chocolate can be healthful, as long as other adverse behaviors do not occur, such as weight gain or excessive intake of non-nutrient dense ‘empty’ calories.”
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