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Circulation on the Run

Jun 26, 2017

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.