May 23rd, 2013
Small Study Suggests Statins May Blunt Benefits of Exercise
Larry Husten, PHD
A small study is raising big questions about whether statins may blunt the beneficial effects of exercise. The study has been published online in the Journal of the American College of Cardiology and is the subject of a New York Times blog.
Some 37 previously sedentary, overweight or obese adults with at least two other risk factors underwent 12 weeks of aerobic exercising training; 19 were randomized to also receive a statin (simvastatin 40 mg/day). At the end of the study, cardiorespiratory fitness, as measured by maximal oxygen uptake, had increased significantly by 10% in the control group but only by 1.5% in the simvastatin group. The control group also had a significant 13% increase in skeletal muscle citrate synthase activity, a measure of mitochondrial activity in muscles, compared with a 4.5% decrease in the simvastatin group. The authors, led by John Thyfault at the University of Missouri, say their results “suggest that simvastatin may mitigate improvements in fitness in response to exercise training by impairing increases in skeletal muscle mitochondrial content and function.”
The authors conclude: “Given the strong independent cardio-protective effects of increasing cardiorespiratory fitness or lowering LDL, the benefits and risks of each should be carefully considered when choosing treatment modalities.”
The study raises troubling questions about the interactions of statins and exercise, but its small size, along with other limitations, may hinder its immediate impact. In an accompanying editorial, Paul Thompson and Beth Parker take note of several of these limitations. For one, because the control group did not take a placebo pill, participants were not blinded to their treatment. They cite evidence that people on statins are likely to overestimate the skeletal muscle side effects of statins.
They also note that the researchers did not report whether the two groups achieved similar levels of exercise intensity:
We have observed a reduction in spontaneous physical activity levels in individuals over age 55 years treated with atorvastatin. Knowing whether or not the statin-treated subjects exercise-trained less intensely…would indicate if statins reduced the training stimulus itself or if they reduced the physiological response to a similar training stimulus.
Thompson and Parker also cite a recent analysis published in the Lancet that found that both statins and increased physical fitness were independently associated with low mortality but that “the combination of statin treatment and increased fitness resulted in substantially lower mortality risk than either alone.” This suggests that the short-term changes in surrogate endpoints seen in the JACC study, even if found to be true, may not result in important long-term differences in health.
Robert Eckel, speaking on behalf of the American Heart Association, raised several other questions about the study. “The bottom line,” he said, is that the simvastatin 40 mg regimen used in the study “may impact on your training,” but that the results would need to be validated for lower doses of simvastatin and for other statins. In addition, he said, the results of a study in a population that does not have established cardiovascular disease should not be extrapolated to people with established disease, in whom the benefits of statins have been conclusively demonstrated.
May 23rd, 2013
When Are Dual-Chamber ICDs Necessary for Primary Prevention?
Pam Peterson, MD, MSPH, Frederick Masoudi, MD, MSPH and Nihar Desai, MD, MPH
Pamela Peterson and Frederick Masoudi discuss findings from their research group’s registry study, published in JAMA, suggesting that primary-prevention patients without a pacing indication derive no more clinical benefit from dual-chamber ICDs than from single-chamber devices in the year after implantation. CardioExchange’s Nihar Desai conducted the interview.
THE STUDY
The researchers retrospectively analyzed data from about 32,000 patients in the National Cardiovascular Data Registry who had received an implantable cardioverter-defibrillator (ICD) for primary prevention but did not have a pacing indication: 38% had a single-chamber device, and 62% had a dual-chamber device. One year after implantation, the two groups did not differ significantly in their rates of death, all-cause hospitalization, or hospitalization for heart failure. Complications were significantly more common with dual-chamber than with single-chamber devices. (For CardioExchange’s complete news coverage of the study, click here.)
THE AUTHORS RESPOND
Desai: Why were you interested comparing outcomes with single- versus dual-chamber devices?
Peterson and Masoudi: Several observations prompted our study. First, up to two thirds of patients with left ventricular systolic dysfunction who receive an ICD for primary prevention and do not have a pacing indication receive dual-chamber devices. Second, marked geographic variation exists in the use of dual-chamber ICDs, unrelated to patient characteristics. Third, little evidence supports the use of dual-chamber ICDs for primary prevention, and current practice guidelines are not explicit about which type of device should be used.
Desai: What implications do your findings have for providers and payors and, perhaps, for the possibility of developing a performance metric?
Peterson and Masoudi: Dual-chamber ICDs, despite their greater complexity and cost, did not improve mortality or hospitalization rates and, in fact, were associated with higher rates of complications than single-chamber devices. Those findings do not support the routine use of dual-chamber devices for primary prevention in patients who have no pacing indication. Admittedly, we don’t yet know whether dual-chamber devices limit the need for device revision and for ICD therapies. Without that evidence yet in hand, it is difficult to justify the widespread use of dual-chamber devices in patients without clear indications for pacing. Given the substantial variation in their use and the lack of evidence of benefit, this appears to be an excellent opportunity for a performance metric.
Desai: How do you envision national registries and clinical trials complementing each other to answer clinically relevant questions?
Peterson and Masoudi: Clinical trials elucidate the efficacy of a therapy in ideal populations. Registries complement clinical trials by providing information about real-world practice patterns. In particular, registries reveal who is receiving specific therapies for what indications — and what the patients’ outcomes are. In addition, some clinical questions will never be addressed by a clinical trial, and registries may be the only source of data to answer them.
Share your observations about dual-chamber ICD use in clinical practice. Does this new study change your perceptions?
May 22nd, 2013
Subdural Hematoma and Possible ACS After Syncope
Indu Poornima, MD and James Fang, MD
A 54-year-old man with no history of coronary artery disease was walking his dog when he experienced an unwitnessed episode of syncope. He spontaneously regained consciousness within a few minutes. Bystanders took him to the ER, where he underwent noncontrast CT of the head that showed a subdural hematoma with a questionable, small subarachnoid bleed. A 12-lead electrocardiogram showed anterior T-wave inversions, and his troponin T level was positive at 0.4 µg/liter. The patient was admitted to the cardiac intensive care unit.
A 2-dimensional echocardiogram revealed distal anteroseptal and apical wall-motion abnormalities and a left-ventricular ejection fraction of 40%. Because of the intracranial bleed, he was conservatively managed with a beta-blocker, aspirin, and a statin. He remained hemodynamically stable for the next 48 hours without arrhythmias. A repeat CT of the head showed no progression in the subdural hematoma, and no evidence of intracranial bleeding.
Questions:
1. What would be your next step in managing this patient: cardiac catheterization, coronary CT angiography, evaluation for an implantable cardioverter-defibrillator, or some other alternative?
2. Why would you choose that management approach?
Response:
May 29, 2013
This patient’s story begins with syncope that has yet to be explained. Despite the apparent lack of history of CAD, the documented cardiac dysfunction raises the possibility of cardiac syncope. The syncope may have been secondary to ischemia-mediated ventricular tachycardia (VT) or ventricular fibrillation (VF), given the ECG changes, anteroseptal and apical wall-motion abnormalities, and positive troponin. The larger the ischemic territory, the more likely that ischemia may result in VT/VF.
The case author also leads one to consider that the syncope may have been an arrhythmic manifestation of a previously unrecognized cardiomyopathy (e.g., reduced LV ejection fraction). However, syncope is an unusual first manifestation of asymptomatic LV dysfunction, particularly if recent in onset.
Alternatively, the unexplained syncope may have led to a traumatic subdural hematoma and then secondary LV dysfunction, as may occur in the context of an acute stroke syndrome or significant stress (e.g., Takotsubo cardiomyopathy). In this case, the “syncope” may have resulted from a mechanical, unwitnessed fall while the patient was walking his dog. A subdural hematoma rarely manifests as syncope and, therefore, is unlikely to have been the initial clinical event.
I favor coronary angiography (which can be done safely without heparin) to evaluate the patient’s coronary anatomy, as long as his neurologic status is stable. It’s critical to ascertain explanations for the LV dysfunction and the syncope. Coronary CT could be considered as an alternative if there is significant concern about performing coronary angiography in the presence of a subdural hematoma. A cardiac MRI can be useful to look for evidence of scar (e.g., chronic cardiomyopathy) or a Takotsubo-like problem (JAMA 2011; 306:277). Evaluation for an ICD should be deferred until the nature of the heart disease is better delineated.
Follow-Up:
June 5, 2013
The patient underwent cardiac MRI on day 3, and the report indicated >75% delayed hyperenhancement in the distal anteroseptum and apical septal regions, with evidence of microvascular obstruction suggestive of scar, as well as akinesis of the distal septal walls and apical walls. LV ejection fraction was estimated at 52%. Given the evidence of scar and the recent subdural bleed, coronary angiography was deferred. CT angiography was performed. The report read as follows:
Small, calcified nonobstructive plaque in the proximal portion. There is a significant stenosis of the mid-portion with mixed plaque and thrombus as well. This most likely
represents plaque rupture with a subtotal occlusion, given the poor filling of the LAD distal to this lesion.
The patient remained asymptomatic and hemodynamically stable without arrhythmias during his hospital course. His cardiologist and the electrophysiologist debated about whether to offer an ICD for secondary prevention in the setting of significant scar and presentation with syncope. The patient eventually underwent ICD implantation and was discharged home on standard post-MI therapy.
Three months after discharge, he reported symptoms of shortness of breath and was referred for exercise myocardial perfusion SPECT. He exercised for 11 minutes on the Bruce protocol without chest pain, ECG changes, or arrhythmias. His perfusion images showed a medium-size area of moderate-to-severe reversible ischemia in the apex and distal anterior and anteroseptal regions, with a preserved LV ejection fraction of 57%. The resting perfusion scan suggested viable myocardium in all territories. The patient was continued on medical therapy.
Further Questions:
- Was the ICD implantation indicated? If so, why? If not, why not?
- Should an EP study have been done?
- How do you explain the discrepancy between the MRI and the nuclear perfusion results?
- Would you consider coronary angiography and revascularization at this time?
Response 2:
June 13, 2013
- An ICD is not indicated without further investigation. The stress-test results, angina equivalent, and coronary CT findings point to untreated ischemia.
- Once the ischemia (which may be driving the presumed ventricular arrhythmia) is treated, I would consider an EP study to assess inducibility of ventricular tachycardia, given the scar.
- MRI and nuclear findings are complementary and not necessarily at odds, as the two modalities assess different aspects of myocardial structure and function. The transmural extent of hyperenhancement is not described.
- Despite the patient’s good exercise capacity, his original presentation with syncope suggests that ischemia of the anterior wall putatively caused a ventricular arrhythmia. An ICD arguably doesn’t treat the problem but rather the “symptom.” Strong consideration should be given to revascularization, particularly in light of the dramatic initial presentation. However, I would favor medical management of his CAD if the original presentation was not syncope.
May 21st, 2013
Athletes with ICDs Don’t Need to Quit Sports
Larry Husten, PHD
Although the American College of Cardiology and the European Society of Cardiology now advise people with ICDs not to participate in vigorous sports, a new study offers strong support for people with ICDs who want to take part in sports.
Now findings from the ICD Sports Safety Registry, published in Circulation, provide vital new information about this important topic. The registry, which was performed with the assistance of patient advocacy groups, included 372 ICD patients between 10 and 60 years of age who participated in sports more vigorous than golf or bowling. The most common reasons for having an ICD among people in the registry were long-QT syndrome in 73 people, hypertrophic cardiomyopathy in 63, and arrhythmogenic right ventricular cardiomyopathy in 55. Of the subjects, 60 were college age or younger who took part in competitive sports.
The main finding of the study was reassuring: not one participant died, needed to be resuscitated, or suffered a severe arrhythmia-related injury while playing sports during the average of two and one-half years that patients were followed in the study. In addition:
- 77 people had 121 shocks during the course of the study,
- 40 people had at least 1 inappropriate shock,
- 36 people had shocks during competition or practice,
- 29 people had shocks during other physical activity, and
- 23 people had shocks during rest.
The study authors discussed the complex effect of ICDs on quality-of-life in this group:
Healthy college athletes have higher physical, emotional, and social functioning and quality-of-life scores than nonathletes, yet athletes sidelined with an injury score lower in all of these domains than both active athletes and nonathletes. Many adolescents with ICDs and their physicians report restriction from sports and the resultant feeling of not being normal as one of the most important negative aspects of their device.”
Limiting sports participation might also have a paradoxical impact on survival. The authors observed that although exercise can trigger lethal arrhythmias in the short term, “the better conditioned the individual, the less likely overall he or she is to die suddenly.” But it is not known whether this holds true for younger people with arrhythmogenic conditions.
The authors concluded that “a blanket recommendation against competitive sports for all patients with ICDs is not warranted. There are risks and benefits of sports participation. However, neither do these data suggest that all sports are safe for all patients.”
The registry was funded by the ICD manufacturers Boston Scientific, Medtronic, and St. Jude Medical.
May 21st, 2013
European Medicines Agency Starts Review of Combined Use of Drugs that Block the Renin-Angiotensin System
Larry Husten, PHD
The European Medicines Agency (EMA) said last week that it was initiating a review of the combined use of agents that block the renin-angiotensin system (RAS). The three classes of RAS-blocking drugs (ACE inhibitors, ARBs, and direct renin inhibitors) are used to treat hypertension and congestive heart failure.
The EMA said that the review was being performed to address concerns that combined RAS-blocking drugs could increase the risk for hyperkalemia, hypotension, and kidney failure when compared with a single agent. A recent meta-analysis of 33 clinical studies published in the British Medical Journal (BMJ) concluded that “although dual blockade of the renin-angiotensin system may have seemingly beneficial effects on certain surrogate endpoints, it failed to reduce mortality and was associated with an excessive risk of adverse events… The risk to benefit ratio argues against the use of dual therapy.”
Franz Messerli, senior author of the BMJ meta-analysis, applauded the EMA action and said that “as usual the FDA is dragging its feet.”
The FDA said that it had completed a review of the subject and had “recently updated the labels of nearly all agents affecting the RAS to describe the risks associated with dual inhibition including hypotension, renal dysfunction, and hyperkalemia.” However, Messerli was critical of the updated label, which states:
Dual blockade of the RAS with angiotensin receptor blockers, ACE inhibitors, or aliskiren is associated with increased risks of hypotension, hyperkalemia, and changes in renal function (including acute renal failure) compared to monotherapy. Closely monitor blood pressure, renal function, and electrolytes in patients on Diovan and other agents that affect the RAS.”
Messerli responded that this “means you still may use dual RAS provided you ‘closely monitor’ the above. To my way of thinking this is not acceptable. Since we have no outcome data showing benefit for dual RAS blockade, this is not simply a question of closely monitoring.”
Messerli said he supported the 2009 Canadian hypertension guidelines, which specifically warned against the dual use of ACE inhibitors and ARBs. U.S. and European guidelines have not taken a similar strong stand.
May 20th, 2013
Similar Cardiovascular Risk Observed with COPD Drugs
Larry Husten, PHD
A large observational study has found no difference in the increased risk for cardiovascular disease between the two main classes of drugs used in the first-line treatment of chronic obstructive pulmonary disease (COPD). LABAs (long-acting inhaled beta-agonists) and LAMAs (long-acting muscarinic antagonists) have a variety of beneficial effects in COPD patients, but evidence has been building that these agents may produce a small but significant increase in cardiovascular risk.
In a new study published online in JAMA Internal Medicine, Andrea Gershon and colleagues analyzed data from nearly 200,000 elderly COPD patients from Ontario, Canada. Of these, 28% of the group had a cardiovascular event. When compared to matched controls not taking either of the drugs, new users of the two drugs were more likely to experience a cardiovascular event (odds ratio for LABAs: 1.31, CI 1.12-1.52; OR for LAMAs: 1.14, CI 1.01-1.28). The difference between LABAs and LAMAs was not significant. The elevated risk for both class of drugs was highest in the first few weeks after the start of treatment.
The results, write the authors, “support the need for close monitoring of all patients with COPD who require long-acting bronchodilators regardless of drug class.”
In an accompanying commentary, Prescott Woodruff writes that the study provides an accurate portrait of the real-world use of these drugs. The study, he notes, “captures early ‘sentinel’ events that might otherwise lead to participant exclusion in a clinical trial.” However, the study does not provide information about the relative safety of a newer formulation of one LAMA, the Respimat Soft Mist Inhaler (Boehringer Ingelheim), which delivers a smaller dose of tiotropium in a fine cloud but may result in higher plasma levels. The safety of the Respimat system is now being studied in a large trial. In addition, the Ontario study did not study any difference in effect that might exist between LAMAs and LAMAs when used in combination with inhaled corticosteroids.
May 20th, 2013
Selections from Richard Lehman’s Literature Review: May 20th
Richard Lehman, BM, BCh, MRCGP
CardioExchange is pleased to reprint selections from Dr. Richard Lehman’s weekly journal review blog at BMJ.com. Selected summaries are relevant to our audience, but we encourage members to engage with the entire blog.
BMJ 18 May 2013 Vol 346
Comparative Safety and Effectiveness of Sitagliptin in Patients with Type 2 Diabetes: You’ll be tired by now of me banging on about the need for long term proof of safety and a reduction in patient important adverse events before awarding a licence for sugar lowering drugs in type 2 diabetes. Sitagliptin is one of a group of drugs (DPP 4 inhibitors) which is coming under close scrutiny for possible harms to the pancreas; following short-term trials, it was licensed in 2006 under the brand name of Januvia. Here is a survey of a large US provider database looking at outcomes over 2.5 years. They detect no increase in acute pancreatitis and a neutral effect on all cause hospital admission and mortality. But that is not the end of the matter, as the editorial explains. It’s a well-conducted study, but in a drug that may be taken for decades, insufficient to allay all concerns.
JAMA Intern Med 13 May 2013 Vol 173
Use of Glucocorticoids and Risk of VTE (pg. 743): People who are given corticosteroids often have conditions that increase the risk of venous thromboembolism (VTE), so how can you tell if the corticosteroids themselves cause VTE, or whether it’s all confounding by indication, to use the EBM jargon? It’s something the authors of this Denmark-wide case-control study have considered carefully. Filling in a prescription for steroids in Denmark is associated with a doubling in the risk of VTE. Confronting the confounding issue, they respond, “we consider a biological mechanism likely because the association followed a clear temporal gradient, persisted after adjustment for indicators of severity of underlying disease, and existed also for noninflammatory conditions.”
Forced Smoking Abstinence – Not Enough for Smoking Cessation (pg. 789): Lock ‘em up and stop them having any cigs: that’ll cure them. But in fact the fascist method of smoking cessation is almost uniformly unsuccessful. Prisoners released from American jails where they were forced to give up smoking are back smoking regularly at 3 months in 98% of cases, male and female. Those offered the WISE intervention, described in this study, sustained a quit rate of 12% at 3 months. It’s a sad, mad world.
May 17th, 2013
Instagram for Heart Attacks: iPhone App Speeds ECG Transmission to Hospital
Larry Husten, PHD
In the crucial early stages of a possible myocardial infarction (MI), EMTs on the scene now rely on slow and unreliable proprietary technology to transmit vital ECG data to physicians at a hospital for evaluation. But a new iPhone app using standard cell phone networks may help speed the process and, ultimately, cut delays in treatment for MI patients.
In a presentation earlier today at the American Heart Association’s Quality of Care and Outcomes Research Scientific Sessions 2013 meeting in Baltimore, faculty and students at the University of Virginia discussed an iPhone app they designed to overcome some of the limitations of the current system. The iPhone app takes a photo of the ECG, reduces its size, and transmits the image over a standard cell phone network to a secure server. The image can then be viewed at the receiving hospital by physicians qualified to read an ECG.
The researchers tested the app more than 1,500 times over different cell phone networks. The app was consistently faster than the traditional method, transmitting images in 4-6 seconds, compared to 38-114 seconds for an actual-size email image and 17-48 seconds for a large email image. “The app was significantly faster, exhibited substantially less standard deviation, and had less than a 0.5% failure rate at 120 seconds, compared to failure rates of 3%, 71.2%, and 15.5% for full-sized photos on the three networks,” the authors reported. They are now testing the app in rural areas with limited cell-phone access.
“Simple cellular technology can save lives,” said David R. Burt, lead author of the study, in a press release from the AHA. “This system may make pre-hospital ECG transmission a more inexpensive and reliable option. That can translate to faster treatment and saved lives.”
May 16th, 2013
Salt Report from IOM Sparks Much Heat, Only a Little Light
Larry Husten, PHD
An Institute of Medicine report on salt earlier this week sparked a lot of controversy. The report concludes that there’s no evidence to support current efforts to lower salt consumption to less than 2300 mg/day. Unfortunately, the press coverage offered little insight into the science behind the issue. On the Knight Science Journalism Tracker blog, Faye Flam deftly uncovers the almost-universal shallow coverage in the media.
The one exception, the one story worth reading that “dug into the science,” according to Flam, is Gina Kolata’s story in the New York Times:
She tells us that the current guidelines are based only on indirect evidence which shows that salt intake has a small effect on blood pressure, and in turn blood pressure can influence risk of heart disease and stroke. From that, she wrote, “researchers created models showing how many lives could be saved if people ate less salt.” This does not fill one with confidence in the current guidelines, especially when considering the possibility that one can get too little salt.
In total contrast, Flam points to an “inappropriately flippant” story in the New York Daily News that told readers to “Go ahead, order a side of fries.”
Most of the news reports “consisted of he-said, she-said dueling experts,” writes Flam. In opposition to the IOM report, many quoted statements from the American Heart Association and the Center for Science in the Public Interest defending lower salt goals. But, she wrote, “the frustrating thing about most of the stories was that the Heart Association and CSPI sources never gave specifics on this alleged evidence.”
Flam cites serious deficiencies in stories that appeared in HealthDay, the NBC News website, AP, Bloomberg, and, of course, the Daily News story “that was mostly pictures of fries and chips, with some encouragement that these foods might not be so bad after all.”
The Times story quotes cardiologists Michael Alderman and Elliott Antman on opposing sides of the issue. Alderman, a hypertension expert who has long been skeptical of drastic sodium-lowering goals, told Kolata that “as sodium levels plunge, triglyceride levels increase, insulin resistance increases, and the activity of the sympathetic nervous system increases. Each of these factors can increase the risk of heart disease.” The IOM report, he said, “is earth-shattering. They have changed the paradigm of this issue. Until now it was all about blood pressure. Now they say it is more complicated.”
By contrast, Elliott Antman, speaking on behalf of the AHA position, told Kolata that the AHA “remained concerned about the large amount of sodium in processed foods, which makes it almost impossible for most Americans to cut back. People should aim for 1500 milligrams of sodium a day.” The AHA’s advice “is based on epidemiological data and studies that assessed the effects of sodium consumption on blood pressure,” he said.
May 14th, 2013
Presenting at HRS — Benefits Before the Session, During, and Afterwards
Amit Mehrotra, MD, MBA
Several Cardiology Fellows who are attending the Heart Rhythm Society meeting in Denver this week are blogging for CardioExchange. The Fellows include Luis Garcia, Sandeep Goyal, and Amit Mehrotra. You can view the previous post
Now that I have recovered from a hectic work and travel schedule, I can reflect on the short time I spent at HRS. I arrived Thursday afternoon and left Friday evening. At Thursday afternoon’s poster session, I visited my good friend and colleague, Michael Broman. I have heard his presentation numerous times on FOG-2, a transcription cofactor that he believes may be associated with the development of atrial fibrillation. This time, it was nice to see others from outside the University of Chicago take interest in his work and to see my friend showcase some of his hard work.
After the poster session, we met up with our section chief, Dr. Martin Burke, who helped me practice the oral presentation I was to give Friday on my research into decision modeling to guide the management of recalled ICD leads.
What worked best about the preparation was the number of times I presented the work to my colleagues and attending physicians. We reviewed it at least three times, and with each presentation, revisions were made. For example, I initially spent a great deal of time explaining the process of Markov analysis rather than my specific work and its application to recalled leads. I quickly changed this and spent more time explaining my model. At the next review, I was asked to spend a little more time explaining my graphs. I added a few slides to clarify the graphical representation of our findings. The result of this iterative review process, I believe, was a much clearer and more concise presentation than I would have presented de novo. I highly recommend that anyone presenting at a conference do the same.
It was a great feeling to have our section’s strong support regarding the presentation of our work. The prep session was followed by a cocktail at a local bar, a nice reminder of the social aspect of these meetings, which plays as strong a role in why I attend as the educational component.
That evening, we attended a Medtronic dinner. The relationship between industry and physicians is particularly strong within electrophysiology. While this relationship carries the potential pitfall of undue influence from those with a vested interest in maximizing profit rather than necessarily optimizing patient care, I have seen its potential benefits in research funding and strong educational conferences. Whatever the case, after an evening of excellent food and drink, I was simply enjoying the time with my colleagues and attending physicians outside the work setting.
The following morning, I caught up with my co-fellows and made the final preparations for my presentation. The seminar was well attended, and I was excited to see other groups performing similar analyses. It is rare to meet someone who has experience in Markov analysis or Monte Carlo simulation plus an interest in electrophysiology. The questions I was asked were limited and fairly straightforward, mostly regarding the example Markov analysis I showed.
More intriguing than the questions asked was the request for collaborative work. I was approached after the presentation and asked to coordinate efforts with a group of physicians working at Duke University. I am looking forward to this opportunity and am interested to learn of additional ideas regarding decision modeling in electrophysiology.
I was particularly excited when another seminar attendee came to the microphone and quoted one of our previously published studies. I guess this is why we hold conferences — to share in the value of such research and promote enthusiasm to continue with new endeavors. I know I am more more motivated even after a brief 24 hours at this year’s conference, and I look forward to attending others in the future.
NEJM Journal Watch — Recent Cardiology Articles- Does Use of Drug-Coated Devices Improve Outcomes in Chronic Limb-Threatening Ischemia?
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- Postpartum Blood Pressure Control in Hypertensive Disorders of Pregnancy: Is Lower Better?
- Beta-Blocker Use After Takotsubo Syndrome
- CTA-Guided Care in Stable Angina: Long-Term Results