Circulation Fellows-in-Training January 2018

Dr Carolyn
Lam:               
(Music playing)...Welcome to Circulation on the Run, your weekly
podcast summary and backstage pass to the Journal and his editors
I'm Dr. Carolyn Lam associate editor from the National Heart
Center and Duke National University of Singapore. Today is one of
my favorite podcasts as always because it is the fellows in
training podcast.


                                               
This is where the center stage and we’re so pleased to have two
brilliant fellows with us today. Dr. Tom Ford from University of
Glasgow and Dr. Kevin Shah from UCLA and of course joining us
today as well is our editor for digital strategies, Dr. Amit
Khera. Hi everyone.


Dr Kevin
Shah:                  
Hi Carolyn.


Dr Carolyn
Lam:               
Hey Kevin. Since you're there in wonderful bright and sunny
California and going to talk about one of my favorite topics
HFpEF. Could you please tell yourself and then please tell us
also about the paper you chose?


Dr Kevin
Shah:                  
I am a third-year general cardiology fellow at UCLA. I have a
career interest in advanced heart failure and transplant
cardiology. I'm going to be doing a one-year fellowship in that
next year at Cedars Sinai in Los Angeles.


                                               
The article that I picked to discuss was the Reduced LAP Heart
Failure I Trial and it was specifically testing a novel device in
a small cohort of patients to see if the creation of intraatrial
septal connection in patients with HFpEF can improve their
filling pressures as well as their symptoms with exercise.


Dr Carolyn
Lam:               
Yeah so Kevin what about this paper stood out to you?


Dr Kevin
Shah:                  
The two biggest things that were impressive to me and that really
stood out were 1) this concept that keeps coming up more
frequently in contemporary research, which is the idea of using a
sham trial. Specifically, in this study they did perform a
one-to-one randomized trial. With one of the arms, if they did
not receive the actual device, they underwent a complete sham
undertaking including headphones in music and blind folding the
patient who were not sure if they received the device or not.


                                               
I think it's an important concept because it does speak to the
placebo aspect of procedures. It tries to really control for that
when a patient doesn't know if they received a novel device, and
we can still test them and see how they feel after-the-fact. I
think that's an important strategy in modern trials.


Dr Carolyn
Lam:               
Kevin, that is such a good point and really quite novel too. So
we've discussed this paper before but not quite the aspect that
you point out and I couldn't agree more. The REDUCED LAP follows
its pilot study results, which was open label single arm right
published in the Lancet. So this is a very reassuring results
since knowledge sham controlled.


                                               
I suppose the lesson comes from other device trials that were
sham controlled and then gave maybe slightly different results),
right when we're talking about the renal innervation trials
before. But you said that there were two points that stood out to
you so what was the second?


Dr Kevin
Shah:                  
The other will also be endpoints and what they chose to target.
It was a small trial but I think it's important in a disease
state such as HFpEF to select specific endpoint that really
reflect the physiology and pathophysiology and the authors should
be commended. I think for selecting primary and secondary
endpoint that will primarily focus on hemodynamics as well as
symptomatic relief.


                                               
I know that they are working toward their stage 3 trial and I
think in the vein selection of these type of endpoint. Probably
more so than endpoints such as mortality are going to favor this
disease state in terms of trying to carve out some sort of
therapy that actually make patients feel better.


Dr Carolyn
Lam:               
Great great points. For me to just knowing that a hemodynamic
endpoint makes sense, because if we look at the Champion Trial
and look at the HFpEF  subgroup of the champion trial it
also seems to show that if people just treated patients with
HFpEF  according to a hemodynamic guide and in the champion
trial that was the pulmonary artery pressure reading. That
actually appeared to keep patients out of hospital. And I have to
agree with you that sometimes we forget that has HFpEF  is
about pulmonary congestion and that the end of the day it is a
hemodynamic disease. It is heart failure in other words.


                                               
Kevin one last thing what do you think about using this sort of
strategy in HFREF?


Dr Kevin
Shah:                  
That's a good question I can't say I know at least this device
has been studied in this trial like you mentioned in one prior
trial that was not randomized. I'm sure it's been at least
investigated. I can't say I've seen any literature on it. I like
to think that it would make some sense from a physiological
standpoint, but I don't know if anyone is actually gone to the
task of seeing how the device performs in HFREF.


Dr Carolyn
Lam:               
As I said I think at the end of the day I think they're all part
of the same heart failure family. And left atrial hyper tension
is kind of the final common pathway. So I agree with you that
maybe it's worth considering in HFREF too, but then on the other
hand of course and have friends HFREF you've got all this great
medical therapy. Well Kevin I really, really appreciate your
selection. May I now switch over to Tom? Tom would you like to
tell us a little bit about yourself ,and which paper you chose.


Dr Tom
Ford:                     
Sure thing my name is Tom Ford. I'm very interested in
interventional cardiology, and my career path has been a bit
unusual because I did my basic cardiology training in Sydney. And
then from there I got a great opportunity to pursue a research
degree, a PhD, which I’m currently halfway through. That's what
Prof. Colin Berry and Prof. Keith Oldroyd here in Glasgow and
that’s a British Heart Foundation Fellowship so it's a great
opportunity. I went out for recent WOSCOPS Trial from posthoc
analysis. In this is a really interesting study a lot of the
readers and listeners will be familiar with the original
publication. It was actually published 22 years ago. Published in
the New England Journal of Medicine.


                                               
The WOSCOPS was a landmark trial that looked at statins for
primary prevention. And this is the present analysis that looked
at just over 2500 Mills with LDL-cholesterol above hundred and
190 mg/dL. So for those of you listeners in the UK 4.5 mmol per
liter so quite the high LDL. They looked at these gentlemen
without pre-existing vascular disease. There's guideline
recommendation for this group but not much evidence. And what
they showed was over a five-year period of follow-up that there
was a reduction in cardiovascular death and all cause mortality
with this treatment. That wasn't just for the period of the trial
because of the study design we were able to get a legacy effect
which was noted over 20 years of follow-up. So in summary a trial
will show the benefits of  statins and primary prevention
mortality benefit for people without very high LDL to start with.


Dr Carolyn
Lam:               
Carolyn awesome Tom. I love that she began saying that your into
interventional cardiology but you chose an article about medical
therapy and the importance of it, the statins. I fully agree with
you. Amit did you have some for Tom?


Dr Amit
Khera:                 
Sure. First I want to commend you both I don't think you did this
on purpose but Carolyn's heart failure HFpEF  expert. I'm
sure she loved the other trial and I'm a preventative
cardiologists. So we certainly love you choices this week. Tom,
thanks for the summary. It's an important article and one that we
did highlight on the previous podcasts. You know there's so many
things to talk about but certainly remind you that we have great
data sets around that can answer unique questions that maybe are
unanswerable today and I think this is an example of that.


                                               
Can you speak to this ideal of pulling an old 22-year-old child
as you mentioned and how that provides insights and kind of as a
PhD student ways to think about ways to be creative and research?


Dr Tom
Ford:                     
One of the reasons I chose this child because it's close to my
heart looking at a population in the west of Scotland. Sadly over
here we've got too high prevalence of cardiovascular morbidity
and mortality. So what this trial speaks to is the benefits of a
really carefully planned procedure. I mean these were outstanding
researchers that thought ahead of their time, and as a result of
their analysis. Over two decades later they are still multiple
publications and there's kind of open approach where there's
different research groups that have used this data set for number
of different outputs.


                                               
I think a real outstanding example of what can be done with
well-planned study.


Dr Amit
Khera:                 
Sounds like were in agreement about how to use a fruitful
database and continue to learn from it as time goes on. The thing
about this as you pointed out is the LDL above 190 component and
what the authors say this is sort of the first clinical trial
evidence for treatment. In your view, does this change practices
or guidelines? Was this already what we were doing? Does this
support what we were already doing, or how does this impact
clinical care and guidelines currently?


Dr Tom
Ford:                     
I think it's a good point. People will say we were doing this
anyways. I think now it's going to be helpful and practical
inside the clinic. If you can say to a patient well actually look
I know we’re asking you to take this tablet you've not actually
had an event but, ultimately we know the natural history of
people in your position may well be unfortunately that they’re
high-risk, and that there is actually a mortality benefit to be
had from these tablets that you don't necessarily want to take
but definitely the benefit’s there.


Dr Amit
Khera:                 
The neat part as you pointed out also was dual components when
they're looking at the on treatments during the trial. We see an
improvement in events. What the WOSCOPS investigators have done
so creatively over the years is this idea of a legacy affect.


                                               
The long-term impact in preventive cardiology – certainly a space
for where were going was just looking beyond the short-term.
There's obviously problems there too because that was not pre
specified people were necessarily on assigned therapies. Tell me
when you look at this long-term legacy effect what does that mean
to you? How does that add be it the way you counsel patients or
how you think about this treatment in patients with high LDL?


Dr Tom
Ford:                     
The effect of the statin assumes that all the patients are
actually taking the drug. I think there has to be an analysis of
these patients in this trial and obviously not everyone was
compliant. So I think we can maybe extraopolate that for the that
there might be in even bigger effect for those patients that were
actually taking the drug. And I think if you were to take it for
five year period. Obviously we don't know what happens after
that. What we do know is the solid mortality data.


                                               
What it speaks to me is that if you take the drug and you are at
high risk to begin with then potentially it's plaque
stabilization, the pleiotrophic effects of statins that we know
are beneficial and the hard endpoints are definitely reduced.
That persists over 20 years of follow-up. So I think that’s
really a great victory for preventive cardiology as you said.


Dr Amit
Khera:                 
That's a great point about biasing towards the know when you have
people crossing over and that this may be conservative of what
was seeing in the long term. I think that's a really important
point. One last question for you. The West of Scotland trial -
generations have changed and back then obviously part of it was
trial design but LDLs on average were higher. The median or mean
in the group was around 192.


                                               
If you look when they look above or below that 190. The people
below were 178 or so - still pretty high LDL. So it does beg the
question you know we have this paradigm of LDL above 190 should
be treated regardless. You wonder if that should be 160 or
whether the number should be lower. What are your thoughts about
that?


Dr Tom
Ford:                     
I agree with you. I think it's always a challenge to kinda pass
off dichotomous endpoints when you’ve got continuous variable
like LDL. It's just a continuum of risk and divided using the
figure 190 in the study. In fact the patients with LDL less than
190 they couldn't show statistically significant reductions in
all cause mortality. But I think it's again personalization of
meds and we may have to discuss the risk with individual patient.


                                               
Ultimately we do have to have a firm conclusion. I think in this
study the data is quite clear that 190 does seem to be quite
robust as the predictor who's gonna get the most benefit.


Dr Amit
Khera:                 
Listen I think protection article that you pointed out was close
to home and you certainly discuss it very well and provided lots
of important insights. And again I think it was an excellent
choice and one that was really highlighted in the media as well.
I think there was a broad allure to this article. If we make
change gears now little bit we've heard about the science part
know we want to talk about what it means to be a fellow in
training.


                                               
I just want to say on behalf Circulation also speak for myself.
It's so important for us to involve fellows in training into our
activities and you're one of our major targets in terms of impact
and goals for the journal. We're so delighted to do this twice a
year and were always thinking about other ways we can get FITs
involved. I mentioned just a couple of things the American Heart
Association has of fellows in training program where people can
sign up for free and get online access to the journal.


                                               
So I hope all fellows are taking part in that. We're starting a
new initiative called FAVES where just like you both submitted
articles of interest of the fellows can do the same. On Fridays
we’ll post those on social media so these are a few ways that
were getting FITS more involved and we really hope to continue
that. Let me start by maybe asking Kevin to have a chat with you
as much.


                                               
Kevin in terms of journals there's some me now we're getting
inundated with information. I think that's a good thing. How do
you consume the medical literature? There's old print journals;
there's the online journal; there's a table of contents your
social media tell us a little bit about how you consume the
medical literature.


Dr Kevin
Shah:                  
I agree. We’re kinda getting to a space where now the amount of
information that's coming out is tremendous. I think that finding
a strategy to help filter out what appeals to your clinical and
research interest is becoming more challenging. For me I'll say
print journals are slowly kind of falling off. I don't subscribe
to too many of them but they still do come to my doorstep. The
main way that I would say I'm getting access to or at least
becoming aware of articles that are kinda relevant to where I am
in my training and what I'm doing is the social media. Some
primarily at least for me is Twitter.


                                               
I'll say it's a helpful tool and that I can follow a group of
individuals that have a similar professional interest as me and
you can almost always rely on the fact that somebody will post an
article that becomes relevant to a common interest. So between
sharing on social media I think that's the primary way that I'm
really catching my eyes to a major journal articles.


                                               
Aside from that I still subscribe by email to a couple larger
journals and see their weekly or biweekly updates about what's
being published. And the last at least in my institution our
division chief Dr. Gregg Fonarow; he goes out of his way to send
to the fellows and faculty new articles that are kind of
pertinent to clinical practice. Which is very helpful for us.


Dr Amit
Khera:                 
That's so helpful and you know everyone has their own way of
consuming the literature but I certainly appreciate your interest
in social media. You know there are some luddites out there that
think of it literally as just social and it really has a
professional bent to it. Well rapidly you can figure out the most
cutting-edge important articles in your field so I certainly
appreciate your comments. Tom let me ask you now, at your stage
of training. You've had an interesting training path as you said
you sort of started as an interventional cardiologist and now you
are doing a PhD. There so many different articles in Circulation.
We have original research, state-of-the-art reviews. We have
these opinion pieces and on my minds and different ones. Tell us
a little bit about what articles appeal to you and which other
novel formats maybe you'd be interested in seeing.


Dr Tom
Ford:                     
I think that the original research articles are great if it's in
your chosen field. Obviously this is where we're going to a great
deal of detail on specific topics but outside of that I think
that the review articles are great form if it's something that’s
a common clinical topic to kinda brush up on. Your On My Mind
section I think is great because it gives you an opportunity to
hear from key opinion leaders in the field. I think it was Morton
Kern discussing invasive coronary physiological assessment.


                                               
So I think there’s different types of articles that can be quite
helpful.  To start with the original research ones. I’ll
skim through the contents. I'll tend not to read the details if
it's not in my chosen field.


Dr Amit
Khera:                 
Yeah great point. Obviously they are topical depending on what
your main interest area and we always say reading around your
field to get a broader perspective in cardiovascular medicine. I
think you hit on the point about on my mind ones. We really want
people be able to free associate and original article are
sometimes more stiff and linear. So we really like those pieces
as well. Carolyn we’ll give you second set ask a question or two
to for today.


Dr Carolyn
Lam:               
Actually Amit I just wanted to comment. Isn't it so encouraging
to hear the variety of approaches and you know Circulation has
enough that we’re meeting various different needs. I really
wanted to take the opportunity to thank you as editor of digital
strategies for just doing so many of these initiatives for
Circulation. I think it’s just incredibly important for the
Journal to keep up with the times in that sense. Amit, may I be
cheeky ask you how do you consume the literature?


Dr Amit
Khera:                 
Carefully. You know the neat part in being on the editorial board
of Circulation and one of the associate editors we get to see so
many amazing papers that come through and I think obviously I get
to see, essentially and also my digital strategies role I
essentially see every paper that comes through that we end up
publishing.


                                               
Obviously I get wide exposure to Circulation but obviously beyond
that I get all the e-Table of Contents for almost every major
cardiovascular Journal. Certainly looking at social media and I
tend to find hotspots interventions and other areas and podcasts
– let’s not forget podcasts. So there's some great podcasts out
there. I know of one.


Dr Carolyn
Lam:               
Oh I love it. All right but just one last question for both Tom
and Kevin from me. I honestly would love to know what do you
think we could do better or what would you like to see more from
Circulation?


Dr Kevin
Shah:                  
I guess the question I have for Circulation is there any role or
have fellows ever gotten involved in the review process for
articles?


Dr Amit
Khera:                 
Listen that's really important because you learn a lot from doing
that and obviously in institutions similar to ours where if you
asked to review a paper you have a fellow contribute. I think you
might be asking something sort of more formal and systematic with
Circulation. I will say that one of our Circulation journals I
believe it's Circ Heart Failure or  Quality and Outcomes
I'll check. It has a formal program where fellows essentially can
be assistant editors if you will.


                                               
We have our cardiology fellows here at UT Southwestern involved
in that process. And I think part of that process is just an IT
issue of how to maintain confidentiality of our papers for our
authors but yet still let fellows contribute meaningfully. And
also timing because you know papers have cycles where you decide
if he should go out for review but it'll come back and you never
know when that happens you have to make the next level decision.


                                               
Then it goes potentially to a meeting and so being able to make
sure that fellows can participate at every level, cause that's
where the value comes in. We are certainly interested in learning
from what our other Circulation of family journals is doing in
that space and definitely an area that we've thought about some
fellows contribute but need to do more.


Dr Carolyn
Lam:               
And Tom how about you?


Dr Tom
Ford:                     
Just picking up on your point on what the sister journals are
doing you know I see the Outcomes Journal is looking at more
visual abstracts and video abstracts. You know I think it's
really important that we increase the efficiency of learning.
What's your take on that?


Dr Carolyn
Lam:               
That is the greatest suggestion. I like first of all your phrase
of increasing the efficiency of learning. Amit, I'm going to turf
it to you again.


Dr Amit
Khera:                 
I'll tell you what's amazing you know when I started this role a
bit ago. Both of you are obviously contributing to research and
everyone on this call is and I think we forget that in the social
media space we don't have a lot of data. Some things sound good
or feel good. At Circulation my predecessor Carolyn Fox did a
randomized trial called intention to tweet if you haven't read
it. And there's a follow-up to that that was published. And
essentially by randomizing articles to social media or not there
was no increase in the views if you will of the article.


                                               
There's always limitations to every study but the point is, as
you think about novel offerings, something we struggle or
something we’ve seen as an opportunity, what works we tried a few
things we tried certain videos and we look at what's the uptake
and interestingly some things we thought that would be widely of
interest really weren’t. Then other avenues we’ve tried have
been.  


                                               
I love what you said, and as Carolyn also felt, the idea of
efficiency of learning. I think we need to do frankly in the
social media and journal spaces is to continue not just to
innovate but to study and figure out what works and what doesn't
to help different learners.


Dr Carolyn
Lam:               
(Music playing)....Thank you very much audience for listening
today as well. You've been listening to Circulation on the Run.
Don't forget to tune in again next week.