Notes from Rounds: Day One at AHA 2019

Adam Sturts, MSIV

In an effort to diversify on-site coverage at the American Heart Association (AHA) 2019 Scientific Sessions in Philadelphia this week, MD Magazine® enlisted the aid of an aspiring medical student to provide observations and key takeaways from the sessions he attended throughout the meeting.

Neurology and Cardiology

Adam Sturts, MSIV, a fourth year medical student with a cardiology focus at Rowan University School of Osteopathic Medicine, is also a type 1 diabetic. His unique perspectives in both training rotations and direct patient care management drew him to learn more how the relay of conference information and data applies to patient benefits.Below is Sturts' journal of notes on the "Main Events" sessions he attended at AHA on Saturday, November 16. Medical students, care providers, and experts interested in contributing to MD Mag coverage can contact us here.Having recently completed an inpatient stroke rotation at Penn State Hershey Medical Center, the first session I was drawn to was the "Hand in Hand: Healthy Heart, Healthy Brain" session. The interrelationship and similarities between the heart and the brain are complex and interesting.

For example, both fill in diastole and both are affected by vascular disease. Ahmed Tawakol, MD, of Massachusetts General Hospital, discussed emotional stress and cardiovascular disease.

I found this topic especially interesting, because it is something that we all experience. The attributable CVD risk is similar to other common risk factors such as smoking, dyslipidemia, hypertension, and diabetes. Tawakol first highlighted the proposed model linking stress to CVD based on animal models in which increased levels of stress, led to increased sympathetic activity, increased bone marrow activation, proliferation, and release of inflammatory monocytes which may enter arterial wall in the heart.

Tawakol explored this model in humans using FDG PET/CT imaging and other imaging modalities to visualize these monocytes as well as activity in the amygdala, which contributes to the stimulation of the stress response. Fluorodeoxyglucose PET CT and PET MR were used to quantify activity in the amygdala, bone marrow, and arteries in a population of 293 patients followed for 5 years. Of the 293 patients, 22 had CVD.

Patients that did not have CV events had lower amygdala activity. Higher amygdala activity, bone marrow activity, and arterial inflammation corresponded with a higher rate of CVD events, as per varied analysis. Each standard deviation increase in activity in the amygdala resulted in 60% to 70% increases in the risk of CV events.

Tawakol also discussed the association between socioeconomic (income, crime) and environmental stressors (noise) and their association with CV risk. Tawakol found people living in the lowest income areas had higher amygdala activity and arterial inflammation. Conversely, people living in lower crime areas had lower amygdala activity. Through mediation analysis, he found an association between socioeconomic status and MACE through amygdala, bone marrow activity, and arterial inflammation.

Tawakol even proposed that patients with high atherosclerotic risk and high stress should be considered for screening for stress.

This discussion brought my attention to stress—an easily overlooked potentially modifiable risk factor for CVD. Although large trials are still needed to prove causation and determine the efficacy of the intervention, these findings propose a link. Indicating control of stress levels could improve cardiovascular health.

Afterward, there was a light-hearted discussion that cardiologists might have highly active amygdalas secondary to the stress involved with the profession. Clinicians and trainees should take the time to assess our own stress using tools like the perceived stress scale and to find ways to reduce our own stress levels, whether it be through CBT, exercise, yoga, mindfulness or blowing off some steam with friends after a challenging shift in the hospital.

Diabetes Management

Between fourth-year clinical rotations, internal medicine residency interviews, and trying to navigate the management of diabetes in the setting of cardiovascular disease, my amygdala activity might be very high. Fortunately, Subodh Verma, MD, helped to clarify my source of confusion in his discussion of SGLT2 inhibitors and GLP1 agonists. -ASIn the afternoon, I attended the “Managing Diabetes in Heart Failure: Finding the Sweet Spot” discussion. GLP1 agonists and SGLT2 inhibitors have shown profound benefits in recent cardiovascular outcome trials. It is essential to consider the presence of atherosclerotic cardiovascular disease, heart failure, and kidney disease when considering these drugs for patients. During his discussion, Verma provided “report cards” on each of these drugs to highlight relative strengths and weaknesses in the treatment of these often concomitant conditions.

The GLP1 agonists have shown strength in reducing MACE among patients with existing ASCVD and even in patients with ASCVD risk factors alone. For this reason, they might be a better option for patients with strong atherosclerotic risk factors and diabetes. In addition, they have the benefit of weight loss and stronger a1c reduction than SGLT2 inhibitors.

In contrast, the SGLT2 inhibitors have demonstrated profound benefits in terms of primary and secondary prevention of heart failure, CV death and a multitude of primary and secondary prevention renal outcomes. Dapagliflozin recently demonstrated mortality benefit in the DAPA-HF trial among a population of patients with heart failure reduced ejection fraction with and without diabetes. These results have the potential to alter current guideline-directed medical therapy for heart failure. CREDENCE recently demonstrated the benefit of canagliflozin in people with advanced kidney disease, indicating that these drugs are effective in improving cardiovascular and renal outcomes across a wide range of eGFR.

Although contrasting the benefits of these drugs during his discussion, it was noted that both drugs can be used simultaneously to target different pathophysiological mechanisms of disease. Verma closed his talk by referencing European Society of Cardiology recommendations that in drug naïve patients with type two diabetes, vascular disease or risk factors, you should consider using an SGLT2 or a GLP1 ahead of metformin.

Despite all of these tremendous benefits, it is always important to note the potential side effects of these drugs. SGLT2s may contribute to ketoacidosis, especially in times of illness and/or dehydration. GLP1 are not without their own gastrointestinal side effects.

These drugs are really changing the way I think about managing diabetes, cardiovascular disease, and kidney disease. Understanding the interconnections between these pathologies and the pharmaceutical options available for treatment is essential in providing optimal glycemic, cardiac and renal outcomes based on the patient’s specific phenotype.

Our discussion regarding these therapies was timely as Biykem Bozkurt, MD, brought up some astounding facts regarding the prevalence of diabetes and its relationship to heart failure. Diabetes prevalence is increasing across all ages and projected to increase by 55% across the next 2 decades. Diabetes doubles the risk of heart failure in men and quadruples the risk in women. Each percent increase in Hga1c results in an 8% increase in the incidence of heart failure. She also pointed out that heart failure is actually a risk factor for developing diabetes.

Butler brought up some interesting points regarding medication prescribing confusion in his discussion, “Whose Responsibility is it to Prescribe Glycemic Agents.” Sometimes the clear benefits of these drugs are overlooked secondary to the confusion between prescribing physicians, particularly cardiologists, endocrinologists, and primary care physicians.

As a medical student, I have witnessed this confusion firsthand, and I have had many conversations throughout my rotations with endocrinologists, neurologists, cardiologists and primary doctors regarding this confusion. It is essential to engage in cross-specialty conversation to ensure that patients are receiving optimal care. Fortunately, Robert Eckel, MD, discussed an initiative to help alleviate this barrier to optimal care.

Lastly, Eckel spoke on behalf of a movement that he is part of, between the AHA and ADA, to spearhead this confusion among other issues including stroke and cardiovascular disease. Everyone should take a look at or reach out to “Know Diabetes by Heart” initiative which hopes to awareness and understanding of the link between diabetes and cardiovascular disease.

The initiative, which is supported by a conglomerate of organizations, seeks to “comprehensively combat the national public health impact of type 2 diabetes and cardiovascular disease by raising awareness and understanding of the link between diabetes and cardiovascular disease, positively empowering people to better manage their risk for cardiovascular disease, heart attacks and strokes, and supporting health care providers in educating their patients living with type 2 diabetes on cardiovascular risk and increasing their patients’ engagement in prevention of cardiovascular deaths, heart attacks and strokes." -AS