The European Medicines Agency 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 concluded that ”although dual blockade of the renin-angiotensin More…

This post was authored by Payal Kohli, MD, fellow-in-training at the University of California San Francisco.

Despite a growth in female physicians, there are as few female cardiologists as ever. Statistics from ACC membership as well as nationwide censuses has shown that the percentage of women in cardiology has unchangingly remained within the 10-15 percent range over the last several years, dashing our hopes that this number may be slowly creeping upwards.

So what seems to be the problem? Why are women continuing to go into fields like pediatrics and dermatology, while turning their backs on exciting fields like cardiology and surgery?  And, there are fewer women cardiologists going into academics than men. Don’t we need more estrogen to balance out all that testosterone?

There is the obvious challenge that female cardiologists face: achieving a work-life balance that remains compatible with societal (and sometimes marital) expectations.  It is quite impossible to be doing stat echoes on call and taking STEMI call while being seven months pregnant (although I do have some amazing colleagues who somehow manage to pull it off), who also get home in time to put dinner on the table every evening. And the ever-growing length of cardiology fellowship, compared with other disciplines even within internal medicine, is not helping matters.  Granted, a fellowship doesn’t last forever, but it still continues to pose a significant stumbling block for many female medical residents who, if they are contemplating child-bearing, often have to wait until they are no longer on call every other night before even thinking about becoming pregnant.

There is also the less obvious barrier, which I think is much more paramount for many women – the lack of strong female role models.  At every major crossroad in our lives, we look to our mentors to help guide us and get a sneak preview into our own future.  If our specialty has only a small percentage of females, then who do we turn to for this type of guidance?

Now, don’t get me wrong, I have been privileged to have some amazing male mentors in my life, but there continues to be professional and personal challenges that are unique to women, which I cannot fully comprehend from interacting with my male mentors. The old saying goes, men are from Mars and women are from Venus!

As I stand at the crossroads of academic medicine and private practice, I feel much less confident making a decision, with the majority of my uncertainty coming from the lack of women within my field who I can look to see how it’s done.  Unfortunately, I haven’t had the opportunity to work some of the amazing women in our field, like JoAnne Foody, MD, FACC, or Roxanna Mehran, MD, FACC, who have somehow overcome all barriers and demonstrated that we as women, can actually have it all – family, career, academic cardiology and even fashion (in case you hadn’t noticed, they are both very sharp dressers).  They do give me hope that it is possible.

The question becomes, what are we doing to try to fix it?  Personally, I have decided to take a more active role as a preceptor for young medical students and residents, encouraging more of them to become cardiologists.  I have also joined the ACC’s Women in Cardiology Council and hope to promote awareness and networking opportunities amongst female trainees. But else what do you think we can do to increase the number of women in cardiology and increase the opportunities for women to interact with other women?

*A version of this article also ran in the May issue of CardioSource WorldNews.

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. 28% of the More…

Look at this sample question from the American College of Cardiology self-assessment. Tell me whether you see the problem. (It came in a mass advertisement-email, so I don’t think it is a secret.)

Sample Question

A 75-year-old woman is referred to you with a murmur. She has had the murmur for many years and has been followed by her primary care doctor. Recently she has noted increasing symptoms of shortness of breath with exertion, but no angina or presyncope. A stress nuclear study is normal.

She is otherwise healthy except for mild hypertension. Her BP today is normal at 120/20 and she is in normal sinus rhythm. Her only medications are antihypertensive meds. On examination her murmur appears to be that of aortic stenosis. She has no clinical signs of congestive heart failure. You order an echocardiogram that reveals the following:

Echocardiographic report: Calcific aortic stenosis with preserved LV ejection fraction. Left ventricular hypertrophy is present and the LV chamber dimensions are normal. Mild mitral annular calcification is noted. Peak instantaneous aortic valve gradient is estimated at 56 mmHg with mean aortic gradient estimated at 30 mmHg. Aortic valve area by the continuity equation is 0.7 cm2.

You should now consider which of the following?

a. Surgical intervention with surgical valve replacement
b. Percutaneous intervention with a transcutaneous aortic valve
c. Balloon aortic valvuloplasty
d. Continued medical management for now

A hint: Look at the wording of the answers. I kept looking for the choice I would have made–choice ‘e.’ Nowhere in the possible answers was an option to present multiple different paths to the patient and let her choose the one that fits best with her goals.

We will have to foray into valvular heart disease for a minute. This 75 year-old women has a stenotic (partially blocked) aortic valve, which is the valve that let’s blood out of the heart to the body. The valve area of 0.7 tells us that the degree of blockage is severe. (Think pinhole.) The three major symptoms of AS are shortness of breath, chest pain and syncope (fainting). And the best evidence suggests that patients with symptomatic AS live longer and feel better with valve replacement surgery. So, given how the question is written, letter ‘a’ correct.

My problem with the wording is that we are not given a choice to discuss different paths and align care with the patient’s goals. In this case, it is true that valve replacement surgery offers the best chance for a longer life and improved breathing. But open-heart surgery is significant. It means cutting the chest and heart open; it means exposing the patient to a 5-day hospital stay, with pain, less of autonomy and possible other complications. I like to tell patients considered for procedures that their disease may limit them today, but they walked in to my office under their own power. They are alive. There is always the risk that surgery or a procedures could render them worse. Risk from intervention may be low, but it is not zero.

The point is that patients vary in their level of risk aversion and goals for treatment. In this valve case, there is another path that the patient can choose: she might prefer to live with the disease and continue to reassess symptoms. Yes, living with the disease exposes the patient to the risk of death, but what if we presented the actual statistics and let the patient decide? Maybe this 75 year-old woman has different views of death than we do? Maybe her symptoms aren’t that bad, or perhaps she fears being in a nursing home more than death?

Don’t misunderstand, I want my patients to live long and well. In this case, if I were seeing the patient I would be clear that the path of surgery offers the best chance for a longer and fuller life, but the tradeoff in getting to that better place means accepting the (low-but-real) risks of surgery. I would also say that no one needs to have her chest cracked open. The path of no treatment is an option.

The practice of medicine, especially in this era of aggressive therapy, will be better when the correct answer to the question above is

‘e’: Aortic valve replacement offers the patient improved survival and better quality of life, but the best practice is to discuss the evidence, present multiple paths and align care with the patient’s goals.

We must get past the paternalism. In the span of my career, Cardiologists have always been leaders. Why shouldn’t we lead the way in shared-decision making and rationale use of our amazing tools?

Vanquishing the word “need” would be a god start.

JMM