AHA FIT Newsletter

By Stephen Broughton, MD

Eight minutes and 46 seconds. That is how long I knelt on the ground surrounded by my colleagues in front of our hospital. We joined in protest with physicians and healthcare providers at locations across the country gathered in support of justice for George Floyd, a 46-year old black man who died face down in the street with a knee forcefully pressed upon his neck by a police officer for that same 8 minutes and 46 seconds. A bystander had recorded his arrest and death as it happened on Memorial Day, and later posted the video on social media. Most notable from the video, were Floyd’s clearly audible repeated plea, “I can’t breathe,” the fact that the knee was never removed from Floyd’s neck even after he became unresponsive, and that no other officers stepped in to attempt to stop what was happening.

Floyd joins Breonna Taylor and Ahmaud Arbery who were chronicled in recent national news stories of black people whose deaths resulted from unprovoked interactions with law enforcement, or civilians allegedly “acting to uphold the law” in their neighborhood. All 3 of these events occurred within the brief time span of 4 months, however, those three are merely the most recently publicized. There have been many others, and although charges were established in some of these cases, rarely have there been convictions. The recording of George Floyd’s death in sequence with so many other events just like it, and the absence of change in policies to prevent such deaths, has finally pushed our country to its breaking point.

As healthcare providers, we know that there are access and management inequities among the black populations compared to other racial groups. Black communities have higher mortality rates from cardiovascular disease, asthma, cancer, and pregnancy. Recent data has also suggested that blacks are being disproportionately affected by COVID-19. This all ties into many other factors that have been shown to affect overall health status, including access to healthcare, educational level, health literacy, household income, and other determinants of socioeconomic status. Furthermore, black people have been made to be among the most vulnerable populations in the country if additional variables are included such as systematic oppression from mass incarceration, hiring bias in employment, access to loans and fiscal resources, and neighborhood housing system redlining, just to name a few.

We can only imagine how being black can increase stress levels due to this myriad of factors involving personal health, safety, and wellbeing. This pervasive stress has not only affected black parents and spouses; it is also a concern for myself, a 30-something black male cardiology fellow, who also might fit the general physical profile of someone deemed a “person of interest” by the police. Regardless of race, ethnicity, or character, I should not have to fear for my life when I interact with law enforcement, a threat that the majority of my non-black peers do not have to face. We should all be able to have faith in individuals whose motto is “To Protect and Serve”. We should all be able trust that everyone will live to see a fair trial in our judicial system for presumed crimes. The current state of the country proves that this has not been happening as it should.

This is a time where we as a medical community not only need to be there for the black patients whom we treat, but also our friends, colleagues, and the communities we serve. We have very strong voices as health professionals, and it is our duty to use them. Just as we vocalized frustration with the availability of PPE supplies during this COVID-19 pandemic, we must not go silent now. Our silence is a failure to acknowledge what’s going on, and is as equally detrimental. We are now fighting another pandemic in racism and social injustice, that is not new to those who have experienced it. This pandemic has also been claiming innocent lives, but our responses have been slow and action as citizens essentially absent.

My colleagues, coworkers, and I realized something as we knelt and grieved together that day. We see clearly that our country continues to be plagued by racial and systemic oppression, and these acts being committed by certain individuals as an abuse of power, can no longer go unchecked. The system is broken, and we have to strive collaboratively to change it soon, or risk failing as a country. Reach out to your friends, colleagues, and coworkers who are grieving. Start with listening to their thoughts and experiences. Engage in conversation to help seek understanding. If feeling uninformed, educate yourself on these issues. We want to be heard, we want change, and we want black lives to matter, just as much as everyone else’s. We are all in this together, and there is no better time to unify than now. I challenge us all to do just that and lead the way.

-- These views are of the authors and not necessarily represented by the organization. --

For those of you looking to jumpstart or continue a successful academic career, please consider applying for an AHA grant. Here, we interviewed a few fellows who were awarded AHA grants during training, providing words of advice on components for a successful application and more. View a list of available AHA grants.

Past AHA Post-Doctoral Training Fellowship Winners

Endorsed by all UPMC General Cardiology Fellows in Training

The harsh realities of racial inequality and discrimination that permeate American life have been thrust to center stage in recent months. It has become increasingly clear that the field of medicine is not immune to these injustices. The publication of an article in the Journal of the American Heart Association by Dr. Norman Wang has gained attention because it questioned whether achieving racial and ethnic diversity within medical training programs is a worthwhile goal. We, as Cardiology Fellows, wholeheartedly reject such views.

We are inspired by the physicians who recognized the article’s falsehoods and brought its issues to the forefront. We assume that many readers also disagreed with the author’s viewpoints but did not feel comfortable, or find the issue significant enough, to speak out against it. The power structure embedded in medical training inherently presents barriers to questioning discriminatory ideas that are presented as facts.

Many trainees, especially those of color, confront obstacles of unequal resources and opportunity long before applying to medical school. Subjective judgments about performance throughout training are frequently affected by biases. The negative impacts of both conscious and unconscious biases have practical consequences of maintaining existing power structures therefore impeding the necessary progress towards diversifying our physician workforce. There is a large body of evidence demonstrating that these biases hamper our ability to serve as physicians and leaders in medicine. Recent events should prompt the medical field to reevaluate the depths of inequities and the systemic nature of this problem. They implore us as a field to ask the fundamental question - how do we transform the hurt of yesterday and today into a more equitable tomorrow?

We are a diverse group of informed individuals, educated physicians and trainees of different colors, races, ethnicities, religions and orientations. Diversity and inclusion are part of our culture and we voice our resolve to lead a better tomorrow.

Based on our experiences as a diverse group of Cardiology Fellows, we suggest trainees, faculty, and institutions take the following steps to reimagine the status quo:

1. Recognize the value in recruiting a diverse residency or fellowship training class. Create an inclusive culture where it is clear that institutional leadership is committed to supporting trainees of all backgrounds, religions, walks of life, and orientation.
2. Place individuals who are both accessible and committed to an equitable mission at every level of leadership. Our chief fellows, for instance, are figures who represent ideals beyond academic success. Advocates at all levels are needed within the hierarchy of medicine.
3. Provide trainees with positive and accepting spaces to discuss their experiences without fear of retribution. Trainees need to be heard, and programs need to be cognizant of additional barriers created for trainees due to power dynamics.
4. Learn about co-fellows’ or trainees’ backgrounds and life experiences. Take time to appreciate what can be learned from each other to help develop effective and empathetic clinicians.
5. Create a culture of accountability where physicians are responsible, as advocates, for our patients and our colleagues. A culture and environment wherein individuals can feel empowered to advocate for a more accountable workplace for both patients and healthcare workers without fear of retribution.
6. Incorporate discussions of diversity in medicine into organized educational sessions. Dedicating time and space to this topic during a Journal Club or Grand Rounds not only provides valuable education but demonstrates the priority of this mission.

While the publication of this article by Dr. Norman Wang was painful for many, it also provides an incredible opportunity for us to recommit to the goals of diversity and inclusion. We owe it to our patients to train a physician workforce that reflects the diverse country we live in. Diversity among our trainees leads to a wider breadth of ideas, a better reflection of the population we serve, and a more holistic approach to the art of medicine. Contrarian voices to this broader vision should lead us to invigorate our efforts to support current trainees, and further explore ways to expand and enrich the pipeline. We remain hopeful that institutions around the country, including our own, will continue to work in expanding access to the medical field for those of all backgrounds.

As we look at our own institution, as well as to other training programs around the country, we see the future of medicine. We are dedicated to a shared vision of what medicine can and should look like; to listening to, learning from, and empowering one another.

-- These views are of the authors and not necessarily represented by the organization. --

Nupoor Narula, MD, RPVI
Fellow, Cardiovascular Disease
NYP/Weill Cornell Medicine
President, AHA Cardiovascular Fellows Society of Greater New York

The American Heart Association (AHA) is an incredible resource for fellows-in- training (FIT), as we parse out our interests in the various avenues of cardiovascular medicine, pursue these aspirations, and navigate one of the most important transitions in our careers thus far, namely that from fellow to independent practitioner. During our fellowship, we have come to realize that support and mentorship from faculty and colleagues alike can have a profound influence on our career trajectory. The ability to connect with mentors and colleagues at the annual American Heart Association Scientific Sessions has extended and become more widely accessible through presence of affiliated state-level Societies. In our case, we’ve had the opportunity to conduct events through the AHA Cardiovascular Fellows Society of Greater New York. Founded by Dr. Valentin Fuster 30 years ago, the goal of the society is to build a sense of community amongst cardiology fellows, provide access to high impact educational programs, and encourage community service and outreach within our New York area.

Each year, the Society’s first educational event is Career Night, where we bring together early-, mid-, and senior-level colleagues in all cardiovascular medicine subspecialties so that FIT have a forum to ask job-associated questions and network with established Cardiology members and mentors in the greater New York area. This year, Career Night was preceded by a panel discussion with senior cardiology attendings, with a focus on “Creativity in Cardiology” and unique clinical, investigative, global health, leadership, and editorial paths which can be pursued within the field. Our second and third events during the year are Controversy Dinners, in which a case with a complex diagnostic or management dilemma is presented by a cardiology fellow and moderated by a Fellows Society Board Member. During this time, a group of experts debate and discuss the case in the presence of more than 100 FIT from different institutions. As an example, our first topic this year, chosen with Dr. Fuster’s guidance, focused on understanding the role, evaluation, and management of coronary microvascular disease. Through initiatives and gatherings such as these balanced throughout the year, the Society provides excellent educational and networking opportunities, and facilitates ongoing involvement in our local community and the AHA at large.

By Pina Patel, MD

The International Stroke Conference (ISC) 2020, held in February this year in Los Angeles, yielded some very exciting presentations in the realm of education, research, clinical trials & late breaking science. Below are key highlights from the conference.

Clinical trials recap

1. ISC celebrates milestone anniversaries for tPA and Endovascular Trials
   1. The 25th anniversary of the landmark NINDS alteplase (tPA) trial marks a breakthrough in the treatment of acute ischemic stroke. In 1995, the NINDS trial proved the efficacy and reasonable safety of tPA. Per pilot study analysis, the dose 0.9 mg/kg demonstrated the best efficacy, therefore, was chosen for the NINDS trial up to 3 hours from symptoms onset, which showed that patients in the treatment arm were 30% more likely to have minimal or no disability at 3 months with reasonable safety (symptomatic ICH 6.4%) for intra-cerebral. This trial changed the way we treat acute ischemic stroke and outcomes for patients. Today, tPA is the mainstay therapy for acute thrombolysis in eligible patients suffering from disabling stroke symptoms.
   2. The 5th anniversary of the endovascular trials marks the important contribution of neuro-intervention in the effective treatment of acute ischemic stroke due to large vessel occlusion. In 2015, four trials were published in NEJM which showed improved functional independence and decreased disability if patients were treated within about 7.3 hours from acute ischemic stroke onset. Since then, these trials were expanded and EVT remains one of the most effective treatments for acute ischemic stroke due to large vessel occlusion.
2. EXTEND IA TNK Part 2 recommends optimal dosing for Tenecteplase. The original EXTEND-IA TNK trial demonstrated that tenecteplase at 0.25 mg/kg improved reperfusion and clinical outcomes compared with alteplase. Given various reported doses used for treatment, Part 2 of this trial sought to clarify the optimal dosage of tenecteplase prior to endovascular thrombectomy (EVT) in patients with large vessel occlusion ischemic stroke. This randomized clinical trial including 300 adults demonstrated that both groups (0.25mg/kg vs 0.4mg/kg dose) achieved the same rate of reperfusion prior to EVT (19.3%) and that there was no difference in functional outcomes. Their findings suggest that the higher dose of tenecteplase does not confer an advantage over the lower dose, and therefore the investigators recommend 0.25 mg/kg be the standard dose for tenecteplase.
3. B-PROUD demonstrates that mobile stroke units (MSUs) improve clinical outcomes A Berlin research group presented premier evidence that MSUs not only accelerate care delivery for acute ischemic stroke, but also improve patients’ functional outcomes as well. This investigation is the first reported randomized trial showing improved outcomes for patients receiving prehospital treatment on an MSU compared with those receiving conventional care from EMS and emergency departments. The findings of improved functional outcomes may have been a result of quicker and more frequent use of tPA on the MSU from stroke onset, but also from providing earlier neurological assessment with continuous monitoring and management of complications in the prehospital setting.
4. Surgeons successfully treat brain aneurysms using a robot. Canadian researchers used a robot to treat brain aneurysms for the first time and their experience was presented as late breaking science. The group showed that using a robot to treat brain aneurysms is feasible and could allow for improved precision when placing stents, coils and other devices. The robotic system could eventually allow remote surgery, enabling surgeons to treat strokes from afar.
5. Wearable brain stimulation could safely improve motor function after stroke. According to preliminary late breaking science, a new, non-invasive wearable magnetic brain device that stimulates the brain to rewire itself is safe and could improve motor function in stroke patients. In the initial, randomized, double-blind, sham-controlled clinical trial of 30 chronic ischemic stroke survivors, the device transcranial, rotating, permanent magnet stimulator, or TRPMS, produced significant increases in physiological brain activity in areas near the injured brain, as measured by functional MRI. The researchers from Houston Methodist Hospital believe the study results are a signal of possible improved clinical motor function after magnetic brain stimulation for patients after stroke, which will need to be confirmed in a larger, multicenter trial.

Stroke Central

This year, the Stroke Central Programming included many educational and interactive sessions including tips on giving a scientific presentation and getting your article published, how to build upon your CV and negotiating your first job, creating a successful work-life balance in academic neurology and ways to network and engage with the Stroke community. A session on Stroke &; Women highlighted some of the presentations at ISC related to sex differences in stroke risk factors and stroke deaths, representation of women in acute stroke trials and women working in science and medicine.

We are pleased to announce that the 17th global Cardiovascular Clinical Trials Forum (CVCT) will be hosted virtually this year on December 3–7 2020.

The CVCT Forum strongly advocates for the evolution and growth of Young Investigators, giving the opportunity to network and to make connections with senior principal investigators. We passionately believe that what we offer for Young Investigators is exceptional.

Why? With the ratio of faculty/attendee at its highest as 1:3, young fellows have unprecedented networking opportunities with a unique mix of methodologists, designers of clinical trials, investigators, regulatory authorities, partner learned societies, patients, patient associations, cardiologists, epidemiologists, statisticians, major journal editors, scientific press, industry R&D & CRO’s and key decision makers for cardiovascular trials.

What else does the CVCT offer for young fellows?

• A scientifically rich program: delivered by the highest caliber faculty, that offers a genuine sharing experience
• Career Escalator: meet a mentor and discuss your career path
• Abstract contest: win a travel grant to attend the next CVCT forum!
• Papers & Publications: first author opportunities alongside senior faculty members as co-authors
• Industry training: fellowship programs
• Industry Internships: join a pharma study team

For more information please visit the official CVCT forum website: www.globalcvctforum.com
To register visit www.globalcvctforum.com/register and click 'Register'

The CVCT forum & AHA FIT will soon announce its collaboration to offer young fellows MORE!