Fellows-in-Training Podcast

Dr. Carolyn
Lam:              
Welcome to Circulation on the Run, your weekly podcast summary
and backstage pass to the journal and its editors. I'm Dr.
Carolyn Lam, Associate Editor from the National Heart Center and
Duke National University of Singapore, and I'm just so thrilled
to be joined by a co-host today and that's Dr. Amit Khera. He's
the Editor of Digital Strategies for Circulation from UT
Southwestern. Welcome, Amit.


Dr. Amit
Khera:                
Hi, Carolyn. Thank you for letting me participate today and we're
excited about this Fit featured podcast.


Dr. Carolyn
Lam:              
We have a very special episode today. First of all, because we
don't have a print issue that follows this week and so, there's
no usual summaries, but we do have special guests and these are
the Fellows-in-Training.


                                               
Now, we sent out a call online to all the fellows to tell us a
bit about themselves as well as which articles in Circulation
stood out to them, and we had an overwhelming response from all
over the world, of which these two fellows really stood out.


                                               
So, join me in welcoming Dr. Punag Divanji from United States and
Dr. Mayooran Namasivayam from Australia. Welcome.


Dr. Punag
Divanji:           
Hi, thank you so much for having us.


Dr. Mayooran Namasivayam:      Thank you
very much.


Dr. Carolyn
Lam:              
So, Punag, could you start us off by telling us a little bit
about yourself, your training, your dreams, and why you chose
that particular paper from this month's Circulation that spoke to
you?


Dr. Punag
Divanji:           
I'm currently a second year Cardiology Fellow, completing my
General Fellowship and beginning a research year at the
University of California in San Francisco. I will be pursuing
research in women's health and subsequently pursuing an
Interventional Cardiology Fellowship. Subsequently, this,
hopefully, will lead to a career in academic Interventional
Cardiology.


Dr. Carolyn
Lam:              
Now, we asked you to pick an article from Circulation. I really
wonder which was your pick?


Dr. Punag
Divanji:           
I think one of the most important ones that spoke to me recently
was the CVD-REAL Study, the comparative effectiveness of
cardiovascular outcomes in new users of SGLT2 inhibitors. The
CVD-REAL Study from Dr. Kosiborod of the Saint Luke's Mid America
Heart Institute and an international group of colleagues was the
first multinational retrospective observational study to compare
CVD outcomes in patients with type 2 diabetes, who were
prescribed sodium-glucose co-transporter 2 inhibitors or SGLT2
inhibitors. The primary objective of this study was to compare
the risk of hospitalization for heart failure in patients with
established type 2 diabetes that were newly initiated on SGLT2
inhibitors.


                                               
Patients who were newly initiated on an SGLT2 inhibitor had a 39%
lower risk of hospitalization for heart failure compared with
those newly initiated on other glucose lowering drugs. There was
significant geographic variation in the use of SGLT2 inhibitors,
with the predominance of canagliflozin in the United States,
dapagliflozin in European countries, and no more than 7%
penetration of empagliflozin in any of these six countries.


                                               
Despite this, there was no signs of significant heterogeneity
across the countries, suggesting the cardiovascular benefits
observed may be class related. In addition, the reduced risk of
hospitalization for heart failure was stable across sensitivity
analyses, including sequential occlusion of other
glucose-lowering drugs like insulin, metformin, or even the GLP-1
receptor agonists, the only other class of drug with benefits in
CVOTs.


Dr. Carolyn
Lam:              
Punag, give us an idea why this paper stand out to you. I mean,
we had the EMPA-REG Outcome Trial, and I'd love to know how much
you use this medication in your practice, and did it change after
this?


Dr. Punag
Divanji:           
This is, I think, a profoundly important study for a number of
reasons. Type 2 diabetes carries a significant burden of
cardiovascular risk. It's associated with complications like
heart failure, myocardial infarction, and all caused death, of
course. We have for many years been treating cardiovascular
disease in diabetes with an aim towards reduction in hemoglobin
A1c. However, we know that reduction in hemoglobin A1c has not
necessarily resulted in improvement in cardiovascular outcomes.
The EMPA-REG Outcome Study and the recent CANVAS Study seem to
suggest that these medications may have a benefit, these SGLT2
inhibitors may have a benefit in cardiovascular outcomes.


                                               
In practicing clinical cardiology, we often refer our patients
with diabetes to endocrinologists or to their Primary Care
physicians to initiate diabetes medications, and aren't directly
involved in that decision making. The result of trials like these
though, seems to indicate that medications that can have a
cardiovascular outcome in this high-risk patient population, may
indeed benefit from the input of cardiologists.


                                               
With the high penetrance of medications like insulin and
metformin in this population, there may indeed be room for
initiation of SGLT2 inhibitors, and if it is indeed a class
effect, as this seems to indicate, there is considerable room for
addition of this medication into our  [inaudible 00:05:13].
And potentially a pretty significant benefit, in terms of
cardiovascular outcomes.


Dr. Carolyn
Lam:              
I agree. I took that with me as well, especially because, you
know, it's as the name says, CVD-REAL was supposed to be a real
world setting, and it included diabetic patients, like you nicely
emphasized that didn't have established cardiovascular disease,
so maybe addressing a wider population than that was seen in
EMPA-REG Outcomes. Thank you so much, Punag.


                                               
Could I turn to you now, Mayooran? So, all the way from
Australia, could you tell us a little bit about yourself and your
training?


Dr. Mayooran Namasivayam:      I'm in my
third year of Cardiology Fellowship at St. Vincent's Hospital in
Sydney, Australia. I'm also involved with post-graduate research
doing my PhD through the University of New South Wales and the
Victor Chang Cardiac Research Institute doing clinical work here
at St. Vincent's. And my particular areas of interest are cardiac
imaging and heart failure, and I'll be looking to do an advance
Fellowship in imaging and/or heart failure in the near future.


Dr. Carolyn
Lam:              
Brilliant! So, which paper did you pick over the last month?
Which spoke to you?


Dr. Mayooran Namasivayam:      I picked
two papers. But the first one I was going to discuss was the
paper by Nickenig and colleagues, which looked at trans-catheter
treatment of severe tricuspid regurgitation using edge-to-edge
MitraClip technique, which I found very interesting. So this was
an observational feasibility study, which primarily looked at
safety outcomes at 30 days, but also the technical feasibility of
performing this procedure for tricuspid regurgitation therapy.
Essentially the authors demonstrated that there was a reduction
in tricuspid regurgitation severity or TR grade in 91% of their
cohort. There are also improvement in soft surrogate endpoints
such as New York Heart Association class and six-minute walk test
distance, and importantly there were no intraprocedural major
adverse events; however, there were three in-hospital deaths.


                                               
I found the study particularly interesting because it's a very
emerging technology using the MitraClip in the tricuspid position
and to date, this is the largest study on this subject. It
recruited patients from 10 centers. I think, interestingly, the
22 patients in that cohort, had both mitral and tricuspid valve
disease treated with the MitraClip technique. I think it really
bodes well for the future of transcatheter valve interventions
and I think shows that this is A, technically possible, but in
the early stages at least safe and possibly efficacious, but
certainly we would need longer term data to confirm that this is
making a difference for people and that it is safer in the long
term. I think it raised a lot of important issues going forward
using transcatheter interventions in the tricuspid position.


Dr. Carolyn
Lam:              
You said that you're interested in heart failure and training in
heart failure. Do you see that a lot, because I certainly do?


Dr. Mayooran Namasivayam:      Yes, we
see it quite a lot at our center. Our center is a [inaudible
00:08:10] transplant center and so a lot of our patients with
cardiomyopathy have quite bad tricuspid regurgitation. Many of
them in the setting of left heart failure, some in the setting of
pulmonary hypertension, and then some in our post transplant
population we see some tricuspid regurgitation as well.


                                               
I think we're following on from the surgical literature, which
shows that if you have some degree of mitral regurgitation that
requires surgical intervention and there's at least moderate
tricuspid regurgitation, then correction of that may be of some
benefit. If we follow that on using transcatheter methodology,
then certainly this may be an option going forward for patients
that have transcatheter mitral valve repairs or replacements. One
of the benefits of using a transcatheter method is you're not
limited to the one opportunity you have with cardiopulmonary
bypass where a decision's made to seek either both mitral and
tricuspid together or potentially do it as staged procedure if we
were to use the transcatheter approach.


                                               
So, yeah, we certainly see severe tricuspid regurgitation a lot
and I think options such as this really do give us therapeutic
opportunities for our patients who may not have the surgical
robustness to have a general anesthetic and a big tricuspid valve
replacement or repair surgically. I think the other key
population where this may be relevant is tricuspid valve
intervention in the post transplant setting where re-operation in
the setting of immunosuppression may be problematic and fraught
with adverse events. I think it's quite promising going forward
and I'd love to see more data on this in the near future.


Dr. Carolyn
Lam:              
Indeed, and it's just so nice to hear about how the articles in
our journal have, well, if I may say, inspired both of you.


                                               
Amit, I know that we want to get our fellows talking a little bit
more about Circulation On The Run. Can I hand it over to you now?


Dr. Amit
Khera:                
Sure, absolutely, and thank you Carolyn for handing the baton.


                                               
I first want to give my full disclosure. I'm a Fellowship Program
Director and of all the hats I wear, I find that to be one of the
most important ones. You know, at Circulation, we certainly
appreciate that Fellows-in-Training are the future of
cardiovascular medicine and cardiovascular science. We are
actively looking for ways to better engage the
Fellows-in-Training and to make sure we're meeting their needs
and enhancing their career trajectory. So, I appreciate both of
you being on the call today and for this inaugural Fit podcast
series, and this will not be the last of this series. So, we look
forward to doing more.


                                               
Maybe I will ask each of you individually, and I'll start with
you Mayooran, can you tell me a little bit about how you consume
the medical literature. I appreciate that it's generational and
back in the day, everybody would get their print copy in the mail
and now there's many different ways to consume it. Tell me a
little bit about how you go through the medical literature and
your way around that.


Dr. Mayooran Namasivayam:      I tend to
do a regular periodic browsing of the online journals. I tend to
have a few journals, one of which is Circulation that I read sort
of on a weekly or at most, fortnightly basis. Just to dig out the
key articles of interest and the major updates. At our hospital
the fellows have a weekly journal club meeting, which I actually
chair. It's quite refreshing to get everyone's different opinions
in their own areas of interest from the fellows to discuss topics
of interest from various journals.


                                               
So, for me personally, it's a combination of browsing online
journals with combining a more formal setting as our journal
club. But from a research perspective, I use things like the RSS
feeds and Journal Alerts, so journal articles that come up in key
topics of research interest for myself. With regards to clinical
practice, I tend to browse. Speaking to colleagues of mine, they
use various things like social media or apps which will highlight
major developments or summarize key articles. I think
increasingly, that will be the way forward. But that's the way I
go about it.


Dr. Amit
Khera:                
What I really like what you said were a few things. Obviously
there's an overwhelming amount of literature and by using tools
like RSS feeds and table of contents, you can sort of keep up. I
like that you're complementing that at your institution with this
deep dive of journal club; this thing that many institutions
including ours do, where you're really vetting articles in detail
and hearing different perspectives. So, a nice blend of ways to
consume it.


                                               
Punag, I'm going to ask you a little bit about social media. When
I looked, turns out CVD REAL, the one that you chose, had an
altmetric score of 487, so we think of impact factor, but
altmetric's a whole other way to look at impact of our articles.


                                               
I'm curious about your thoughts on social media and the place of
social media with disseminating scientific literature. I know
many fellows are actively involved on Facebook and Twitter and
other pathways. Tell us a little bit about your thoughts on that.


Dr. Punag
Divanji:           
You know, very similar to the practice described in Australia,
it's very similar to what we do here. We have weekly journal
clubs, we discuss these articles with the faculty and really try
to integrate it into our practice. A big part of that at, I
think, many institutions across the country is the use of social
media.


                                               
It is particularly robust, I think, in the cardiovascular field,
especially at national or international meetings wherein late
breaking clinical data is rapidly disseminated. The outcomes and
a few important trials that will impact clinical practice are
rapidly disseminated, such that we are able to, I think, quite
quickly access information, but beyond that, learn for example,
the description is such that medical literature is doubling every
two to three years. It's difficult to keep pace with that, but
when thought leaders in the field present data that they find
most interesting, most useful, or most relevant to patient care
on a platform like social media, it's, I think, a wonderful way
for Fellows-in-Training to quickly aggregate high quality data.
It's something that I rely on heavily.


Dr. Amit
Khera:                
I think that's a great point, and where things have changed now
is not only can you get information quickly through social media,
but as you pointed out, the ability to interact with luminaries
in the field to get their opinion on it and even engage in a
conversation. That certainly wasn't available several years back
and I think it's a great advance for Fellows-in-Training.


                                               
I'm going to stick with you for a second and hear your thoughts a
little bit on how Circulation may better engage
Fellows-in-Training or meet their needs.


                                               
How can Circulation or other journals for that matter help in the
pathway for Fellows-in-Training?


Dr. Punag
Divanji:           
I think the concerns of Fellows-in-Training are unique in
comparison to those already in practice. We are at a point in our
careers where we're trying to learn the basic important
groundwork of cardiology, but at the same time, given the rapid
evolution of data, it's imperative that we have the ability to
learn new things on top of that foundation.


                                               
Engaging fellows in that way, I think, involves a strategy that
looks at a couple of different things. One is obviously social
media, which is, let's be honest one of the core ways that
trainees interact, and let's be honest, one of the most common
things you see a trainee doing is looking at their phone.


Dr. Amit
Khera:                
And faculty.


Dr. Punag
Divanji:           
And faculty for that matter, fair enough. But if you're able to
provide information via Twitter or via this Circulation app and
be able to alert someone of a new update in the field or a new
guideline document or a way to better risk stratify patients that
come in with myocardial infarction, this type of rapidly
accessible data I think plays well to the [ethos 00:15:32] of the
fellow wherein we like to be able to do things quickly and
effectively, but also expand our knowledge in the most efficient
way possible.


Dr. Amit
Khera:                
That's very insightful. So, if I hear you correctly, it's sort of
continuing to make sure that we disseminate information quickly
and rapidly to Fellows-in-Training in a way that is easy for them
to consume.


                                               
This brings to the point about when we look at our metrics, the
podcast and other digital media strategies we have really hit
broadly in an international audience, which we're very excited
about.


                                               
Certainly, Mayooran, I'm going to ask you as well your views on
how can Circulation or other journals for that matter help engage
Fellows-in-Training or enhance their training and career
trajectories?


Dr. Mayooran Namasivayam:      I guess
today is a wonderful opportunity for fellows to participate in
Circulation's online activities and engage with fellows from
around the world, so this is one such example. I think echoing
some of the thoughts of Dr. Divanji, as a fellow, you're doing
many things and you're wearing many hats. You're learning new
procedures, you're learning core cardiology, you're involved in
research, you're doing on-call activities and clinical duties,
and sort of amassing the latest evidence and putting that
together and working out how that's going to change your practice
now and in the future is important, but is not always easy to do.


                                               
I think features such as Circulation's podcast, which summarize
key developments sort of state-of-the-art review articles,
guideline summaries, which come out in Circulation, and even the
simple things like the summaries that come out on the print
journals which say what is new and what are the clinical
implications, which allow us to read that in a minute or two, and
then read on if we're so interested, but at least get a summary
or a snapshot of a major article. I think those features are
really key in sort of summarizing key developments in a short and
accessible way. I think as been discussed already, engaging with
the newer media, social media, online media in the way that other
publishing modalities such as newspapers are sort of engaging
with their audience I think, is certainly important in the future
to an increasingly time-poor audience.


Dr. Amit
Khera:                
Well, glad to hear that these features are resonating well with
you both and it's certainly helping you in terms of accessing and
understanding the relevance of these articles in your daily
practice.


                                               
The final question, I'll finish with you and then come back to
Punag, is, as Carolyn says every week, this is your backstage
pass to the editorial process, so a way to look behind the
curtain or Oz if you will on how journals work and we certainly
strive for transparency at Circulation.


                                               
So, I'm going to maybe ask you if you have any questions for us
on how the journal works or any questions regarding the editorial
process?


Dr. Mayooran Namasivayam:      I guess
one of the things that I was wondering was you must, particularly
at Circulation, just be inundated with a huge array of papers,
which I'm sure all are of excellent quality.


                                               
When you're looking at a paper quickly to make a decision about
whether it's something you'd pursue further or look into, what
gives you that instinct that you know this is probably a good
paper? Is it the abstract? Is it the cover letter? Is it the
title? What gives you that first impression that we should really
look into this a bit further?


Dr. Amit
Khera:                
Well that's a fantastic question. I'll answer and I'll see if
Carolyn wants to add anything as an associate editor as well.


                                               
First you have to realize that yes, there's enormous volume of
papers, but the most important thing is to assemble an expert
team. I think Dr. Hill, our editor-in-chief, Joe Hill has
certainly done that. He's established an international group of
associate editors that are well-accomplished across the breadth
of cardiovascular spectrum, so your interest is in heart failure,
you have a couple of imaging type articles, Punag has talked
about women's cardiovascular health and also diabetes and
cardiovascular disease. We have editors that really have
expertise on each of these areas.


                                               
The first level is our editorial, editor-in-chief, and deputy
editors, et cetera who'll take the first pass at which articles
seem to be well done and would meet priority for Circulation.
Then distribute them to editors that are content experts, that
really understand those areas well. I take that responsibility
very seriously when I get a paper. I know I've been on the other
end of that. It's a tremendous amount of work. All the authors
have contributed, patients have contributed their data. So, we
take that responsibility incredibly seriously.


                                               
We try to be thoughtful, that if it's a paper that really will
not meet priority, we should turn it around quickly and let the
authors know that so that they can then move onto another journal
and not waste time. The flip is, if something seems that in our
field, in our expertise would meet priority to our readers and
could advance the field, we send it out for expert review, then
have a very thoughtful discussion, even in advance online,
through a web portal and then as a group with all of our editors
across the world, to really think critically about each paper,
it's merits and ways to strengthen it. We always try to do that,
which is to not only say yes or no on a paper, but what can we
tell an author to make a paper better, because we want the very
best products coming out on Circulation.


                                               
I hope that gives you an idea of how we think about it. It's sort
of a tiered approach, starting with our editor-in-chief and
deputy editors and then down to associate editors. Again, we try
to turn it around, how would we want our papers treated if we
were submitting to a journal?


                                               
Carolyn, do you have anything to add to that.


Dr. Carolyn
Lam:              
Yeah.


                                               
So, Mayooran, that's great question. I think I can guess where
it's coming from, sort of if one were to submit a paper to
Circulation, is there any particular part that you would want to
focus on, because that's the part that immediately catches our
attention, right? I think that's what you're asking.


                                               
Well, I would say without a doubt it's the science. So, you
talked about the cover letter, you talked about abstract and
things, the most important bar that the paper has to cross is
validity. Then, right next to that would be novelty. So, for us,
you know, once we can see that the science is well done and the
results look robust, that has to be there before anything even
happens beyond. Then, that's when the process kicks in like Amit
said. Then we look at it from our specialty points of view and
make sure that it's something novel and something that would be
of interest to our Circulation audience.


                                               
Does that answer your question?


Dr. Mayooran Namasivayam:      It does.
It does, thank you both very much. Thank you.


Dr. Amit
Khera:                
All right, I'm going to now pitch the same question to you,
Punag.


                                               
What are your thoughts? What sort of questions you have for us
behind the curtain of Oz and the editorial process?


Dr. Punag
Divanji:           
You know it's quite interesting, one of the most compelling
components of the Circulation on the Run podcast is at the end
when Dr. Lam has a wonderful discussion with the associate editor
that was responsible for the article and the authors and gives us
an idea not only of what drove their process of scientific
discovery, but also what drove the editors to really believe in
that article to warrant publication; to say that this is
something that our readers need to see. I think that really quite
remarkable to gain that point of view.


                                               
My question is, you seemed to strike this balance between basic
translation and clinical research when publishing each week.
There are often a variety of topics that come from all three
fields. Each week in the publication, there seems to be this
balance between basic translational and clinical research wherein
the readers really are able to gain perspective into the entire
field of cardiology from articles that range from clinical
outcomes from blood sugar management to the [pathophysiology
00:22:57] of takotsubo syndrome.


                                               
How do you, as editors, strike that balance in each issue? How do
you decide which articles are going to be published in concert
with others?


Dr. Amit
Khera:                
That's a great question. Sort of looking at the spectrum of types
of articles and types of science and how do you decide sort of
what goes together. Kind of like a meal, you know, what
components go together.


Dr. Carolyn
Lam:              
I'd like to call it wine paring.


Dr. Amit
Khera:                
Wine pairing. I like that. So, if it's a roast, what sort of red
wine and so forth. I think that's an excellent question.


                                               
I think first, we do strive for balance and that, as you know,
Dr. Hill has a ... his lab is a basic science lab, and
Circulation has always been a journal which does the hightest
quality science including both basic science and clinical and
translational research. I also say we have other offerings as you
know, which are thought pieces on my mind, and perspective
pieces. So we really try to have the full spectrum. As we talk
about, there are many people that enjoy their vegetables, the
hard core original research articles, but a lot of people also
like the deserts and the appetizers, these other types of
articles that I mentioned.


                                               
I think it's trying to find that right balance. We always like to
have a balance of all of those together, because we appreciate
there's a spectrum of readers and at the same time, we also
appreciate that I'm more of a clinical researcher, I can gain
insight and value from reading basic science research and
similarly the basic scientist could gain value from the types of
clinical articles we try to place in Circulation.


                                               
So I think maybe as was mentioned, a little bit of a menu and a
wine pairing we include this whole spectrum of different types of
offerings, but I think the one bar is they all have to be
articles that have some clinical implications, be it clinical,
translational, or basic science, even the epidemiologic studies
research that I do, they all have to, in the end, have some sort
of clinical importance or relevance. I think that's the benchmark
for all of the articles.


                                               
Carolyn, do you want to add anything?


Dr. Carolyn
Lam:              
No, I think you got it all. In fact, Amit, I'm going to turn it
back to you for the last question.


                                               
As Editor of Digital Strategies for Circulation, tell us, what's
in store?


Dr. Amit
Khera:                
Well, you know, it's been a great first year and I think many
would say one of the highlights has been the podcast for sure. I
think we've developed a platform of social media engagement, of
learning how to work though our digital strategies platforms and
setting a high bar for our podcast.


                                               
Now it's time to go to level two, or next level. How do we
enhance what we're offering? How do we get creative about new
types of podcasts, like this one we're doing today? How do we
think about more interactive social media engagement? How do we
further enhance the way we distribute science across the world?
So, we have a big appetite and big ambition, but I think that is
what we should be doing when we have such good science and making
sure we disseminate it broadly.


                                               
So, I think you'll see building on the platform we've already
established, and apropos to today, I hope we really bring the
Fits along with us on this ride to further expand our offering of
our science.


Dr. Carolyn
Lam:              
Thank you so much for joining us on this special episode. Don't
forget to tune in next week.