Circulation February 7, 2017 Issue

 


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 Centre and
Duke-National University of Singapore.


                                               
Today is special, special, special because here with me is the
editor of special populations and that is Dr. Sharon Reimold from
UT Southwestern, who is the editor handling the special issue for
Go Red For Women.


                                               
Welcome, Sharon.


Dr Sharon
Reimold:         Thank
you, Carolyn. I'm happy to be here.


Dr Carolyn
Lam:               
This is so cool. Just us ladies chatting about issues that we
need to be talking about.


                                               
Now first of all, this is the first time that Circulation is
doing a focus issue for Go Red for Women. Could you tell us a
little bit more about that?


Dr Sharon
Reimold:         Sure.
The Go Red for Issue campaign has been around for many years. The
editorial staff realized that we really hadn't had an entire
issue devoted to cardiovascular issues in women. We decided
several months ago to try to make this a reality and asked for
submissions of articles and we’re delighted to see the interest
that our cardiologists across the country had, as well as across
the world, in submitting their research for consideration in this
issue.


Dr Carolyn
Lam:               
I know. There are seven original papers. There are review papers.
There are research letters. It's an amazing issue.


Dr Sharon
Reimold:         We had
hoped to focus on a lot of different areas in which heart care in
women is influenced. We're really quite delighted that we had
papers on pregnancy, papers related to strategies to get women
involved in trials. We were able to look at novel risk factors in
women, and also, have an excellent review about arrhythmias in
women versus men that I think everyone will want to take in.


Dr Carolyn
Lam:               
Yeah. Congratulations once again right off, but let's jump
straight into this set of twin papers that deal with post MI
outcomes and sex differences. There've been quite a number of
publications on this. What makes these two papers special?


Dr Sharon
Reimold:         I think
these papers are special because they're trying to think more
deeply into why women tend to get re-hospitalized after a heart
attack more often and what are the reasons that they're getting
readmitted.


                                               
For instance, it seems that women, as we know, may get a variety
of different symptoms that are their equivalent or anginal
equivalent after they've been in the hospital and also before
they were in the hospital. I, personally, suspect that when
somebody comes to the hospital with chest discomfort and they've
recently had a heart attack, then often times, they get
readmitted and re-hospitalized.


                                               
These papers are starting to look at mechanisms, why this
happens. I think this will be the bridge to the point where we
figure out what can we about this, to hopefully, make men and
women more equal in this regard.


Dr Carolyn
Lam:               
That's so true and well put. I also found very, very interesting
and important that paper that really highlighted the importance
of coronary flow reserve and microvascular ischemia, not just
obstructive disease. Can you say a few words about that paper?


Dr Sharon
Reimold:         Sure.
It's been known for a long time that if you perform
catheterizations on men versus women with similar presentation
... Women may not have as much obstructive disease. This
particular manuscript explores coronary flow reserve and
identifies this as being part of the difference between men and
women in that regard. That, obviously, could have important
implications for the clinical care of these patients.


Dr Carolyn
Lam:               
I like that. All these papers really took what we may have known
a bit before, but took them to a deeper level and in a very novel
way. So important. You mentioned some of the novel aspects that
were also explored in the issue, the pregnancy related factors,
in fact, novel risk factors that we should be taking note of in
women. Do you want to comment on a few highlights?


Dr Sharon
Reimold:         The
relationship of pregnancy complications to long term, both
maternal and offspring health has been around for a while, but
really, we don't know very much about it. We, certainly, have
known previously that women with preeclampsia, or those who have
significant hypertension, or diabetes in pregnancy may have later
problems when they are in middle age or older.


                                               
What we are learning from some of these new entries into the
research domain is that women who have premature labor and
delivery are also at risk for having complications, and this sort
of fits in the middle. It's not just preeclampsia, or
hypertension, or diabetes. It's that you delivered earlier. Then
moreover, we have a couple of research focused letters that
describe arrhythmias in pregnancy and what happens to those women
during pregnancy. I think we all have seen young women come in
and have symptoms, but we really don't know what their outcome
has been because any single physician probably just sees a few of
them. This highlights arrhythmias as a issue in that population.


                                               
We also looked at other articles that focused on other risk
factors for heart disease, ranging from breast arterial
calcification to traditional biomarkers that we may be drawing in
hospital, BMP, troponin, and such. There's a nice manuscript that
focuses on hormone changes in women and how they're associated
with development of cardiovascular disease. So a fairly broad
look at a variety of different risk factors that we don't think
about when we're simply asking, "How old are you? What's your
blood pressure? What's your diet? Do you have diabetes, and do
you have lipid disorders?"


                                               
What I would hope that we would get out of this is to open all of
our minds and our approaches to patients to think about asking
about their pregnancies, did they have any complications,
figuring out if they have any hormonal issues, and then being
free to consider whether or not the woman that you have in front
of you actually has obstructive disease or perhaps has issues
with abnormal flow reserve.


Dr Carolyn
Lam:               
Exactly. I would, actually, add to that, also, looking at our
commonly used cardio metabolic biomarkers with the lens of
realizing that there are important sex differences in all these
biomarkers. That was a very nice paper, corresponding author, Dr.
James de Lemos. All these papers are just so practical.


                                               
I'm actually going to switch tracks now, Sharon, because I really
want to talk about this final paper. All I need to do is read the
title of the editorial and it’ll be self-evident. "Women are less
likely than men to be full professors in cardiology. Why does
this happen and how can we fix it?" I love that you invited this
editorial. Could you tell us a bit about the paper that sparked
this editorial and your thoughts on this?


Dr Sharon
Reimold:         Yes. The
original article has as its first author, Dr. David Blumenthal.
It's an article that's one of a series of manuscripts that looked
at academic cardiologists and looked at faculty rank where they
were able to gather data on sex differences, clinical
productivity, research funding, publications, et cetera. They
have looked at other disciplines other than cardiology, but this
particular manuscript focuses on cardiologists. What it
demonstrates is that we are getting, perhaps, a little bit more
women in at the assistant professor level, but there’s still a
significant lag at the full professor level.


                                               
In fact, in many centers if you query development offices,
there's probably at least a seven year lag between women and men
in terms of making it through the whole spectrum. While perhaps,
this is not new conceptually, I think it does quantitate it for
us and it highlights the concept that this is an issue now,
similarly to what it was 25 years ago when I was a cardiology
fellow.


                                               
The interesting compliment to this is the editorial by Dr. Karns
and Dr. Bairey Merz which tries to go into why does this happen
and how can we fix it. They took a very academic approach to
their editorial in terms of looking at data and then talk about
implicit bias and how even a very small degree of implicit bias
will cause men to be promoted, perhaps more in a faster manner
than in women, and also bring up some things we don't even think
about. One of the best ones was the concept that you advertise
for a new position as a cardiologist. If you advertise for
someone and you list the skills you want and what you want to
build, then that's a more gender neutral way to approach a job.
If you advertise for a dynamic, outgoing, I don’t know, vigorous
sort of person, and there are ads out there that read like that,
you are, inadvertently, advertising for a man, most of the time.


Dr Carolyn
Lam:               
Male characteristics.


Dr Sharon
Reimold:         Yeah.
They talk about that. Then they obviously end up with how can we
fix it? I think that's a real challenge.


                                               
There are some data within the field of literature for
development that suggest that mentoring and coaching are
important, but that they don't necessarily push people up the
ladder very rapidly. There are some places, for instance, our
University of Texas system now that is very interested in the
concept of sponsorship. That someone sponsors another individual,
could be male or female, to get involved and pushes them ahead,
not pulls them, so that they have opportunities for faster career
development and success. In any event, I think this compliment of
paper and editorial really highlights an issue that, while not
necessarily affecting female patients, certainly affects
cardiology as a destination career.


Dr Carolyn
Lam:               
I agree. I think part of the how to fix it is simply by being
aware and acknowledge the issue. That is exactly what we’re doing
in these papers. I love that they are academically written. Like
you said, you read a lot about these gender biases in the popular
press, but it's so refreshing to see it addressed in an
editorial, in a beautiful paper, in circulation.


                                               
Sharon, congratulations on just this excellent, excellent issue.
Is there anything else you may want to highlight about the issue?


Dr Sharon
Reimold:         I think
that's the major thing. I think we moved a long way from the
beginning of Go Red For Women as a campaign where we really
wanted patients to be aware that hypertension or elevated
cholesterol levels were an important issue. I think now is a time
where we move forward. We’ll learn more about differences between
men and women and we figure out how we can treat or account for
these differences as we strive to make health care for all and
cardiovascular care for all improve over time.


Dr Carolyn
Lam:               
Thanks Sharon. Everyone of you listening to this, go pick up this
issue. I'm sure we've peaked your interest.


                                               
Thank you for listening to Circulation On The Run. Don't forget
to tune in next week.