Editorials
Trends in Heart Failure Outcomes From a Large, Geographically Diverse Cohort During the COVID-19 Pandemic
The evolving coronavirus disease 2019 (COVID-19) pandemic has presented extraordinary challenges to the health of populations globally. As our understanding of the virus continues to grow at a rapid pace, it has become increasingly clear that the clinical manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection range widely and are in large part dictated by age, underlying comorbidities, and vaccination status. Robust epidemiologic data during the past years have underscored that individuals with chronic health conditions including cardiovascular disease, diabetes mellitus, immunosuppression, tobacco use, and obesity carry a significantly greater risk of falling critically ill with SARS-CoV-2.Explaining Unexplained Hypoglycemia Due To Insulin Analogs
Hypoglycemia is a potentially life-threatening condition that requires urgent medical attention. Most hypoglycemia in patients with diabetes is related to medication use, and recent studies have indicated the contributions of insulin analogs in cases of hypoglycemia.1,2 Even in patients without diabetes, it is important to exclude insulin administration as a cause of hypoglycemia, yet detection of insulin analogs is not straightforward. The small structural changes that result in favorable pharmacokinetics of insulin analogs also affect the detection of analog insulin by immunoassays, culminating in varying results from different commercially available assays.The Imposter Syndrome in Physicians
Imposter syndrome (IS), also known as imposter phenomenon or imposterism, is defined as feelings of uncertainty, inadequacy, and being undeserving of one’s achievements despite evidence to the contrary. Imposter syndrome has 5 subtypes1:Racial Disparities and Excess Cardiovascular Mortality Before and During the COVID-19 Pandemic: Time for a Solution
Health disparities are a complex and multifactorial construct involving lack of access to health care, differential treatment modalities, and different outcomes for the same disease based on racial or socioeconomic class. Disparity in health care has garnered an increasing amount of attention from health care providers and health policy experts.1 Several studies have elucidated the effect of health care disparity between different socioeconomic and ethnic groups on cardiovascular (CV) outcomes as well as relating to the ongoing SARS-CoV-2 infection (COVID-19) pandemic.Ambulatory Remote Patient Monitoring Beyond COVID-19: Engagement and Sustainment Considerations
Care delivery innovations in response to the COVID-19 pandemic, particularly digital health solutions, have been wide ranging and impactful. The spectrum of such innovations includes, for example, technology-based screening tools, electronic health record–based protocols, rapid provider onboarding and education, clinical decision support and diagnostics, large-scale data collection with real-time dashboards for tracking and surveillance to monitor outcomes and hospital capacity, and rapid adoption and expansion of telehealth services and remote monitoring to improve safe access to health care and to optimize resource utilization.Making a Case for the Anti-inflammatory Effects of ACE Inhibitors and Angiotensin II Receptor Blockers: Evidence From Randomized Controlled Trials
In this issue of Mayo Clinic Proceedings, Awad and colleagues1 present a meta-analysis of randomized controlled trials evaluating the effects of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) as anti-inflammatory agents. Their findings support the beneficial role of ACEIs and ARBs in reducing blood levels of inflammatory markers but reveal potential differences in their anti-inflammatory effects. However, regardless of the class of medications used, the implications of the results merit the need to better understand the inflammation-alleviating effects of renin-angiotensin-aldosterone system (RAAS) inhibition.Heart Disease and Kidney Failure in the Black Community
In the United States, Black Americans suffer from a disproportionately high prevalence of cardiometabolic disorders including cardiovascular disease (CVD) and chronic kidney disease/end-stage kidney disease (CKD/ESKD) compared with their White peers.1,2 The reasons for these disparities are multifactorial. These disparities are primarily driven by societal factors, racial- and ethnic-based inequities in the allocation of health-affirming resources and opportunities, which is commonly termed structural racism.Even When the Heart Stops, the Sex Differences Remain
Cardiovascular disease remains the leading cause of death in women,1 but mechanisms of sex-related differences that affect many facets of cardiovascular disease remain underrecognized and poorly understood. Men historically have been disproportionately represented in clinical studies, and consequently, guidelines have been built on data that are predominantly applicable to men.1 There has recently been an increasing commitment to better understand sex-related differences that affect the epidemiology, presentation, diagnosis, treatment, and outcomes of cardiovascular disease.Diuretic Resistance—A Key to Identifying Clinically Significant Worsening Renal Function in Heart Failure?
Worsening renal function (WRF) in patients hospitalized with acute heart failure (AHF) presents a frequent clinical dilemma that is compounded by the inconsistent results of studies seeking to determine whether WRF in AHF is associated with worse clinical outcomes, such as death or readmission. More recent studies suggest that when serum creatinine concentration rises from a hemodynamic process such as appropriate blood pressure lowering or decongestion, WRF is no longer associated with adverse outcomes.Transforming Diversity, Equity, and Inclusion in Medical Education—Mayo Clinic Alix School of Medicine
Mayo Clinic is committed to eliminating racism and reducing health care disparities. Without systemic change, these inequities compound and detract from the very patients and communities we serve. Racism limits the ability of learners, staff, and faculty to do their job and to be their full authentic self in clinical and learning environments. An effective path toward equity requires elimination of systemic barriers for both patients and staff. To do so, we must embrace opportunities to learn what is actually needed to improve their experience.TRIO Risk Score: Simple, Yet Complex
Tricuspid regurgitation (TR) occurs in 65% to 85% of the population in the United States.1,2 Although mild TR in the setting of a structurally normal tricuspid valve apparatus can be considered a normal variant, progression to moderate-severe TR increases with age and is estimated to affect nearly 1.6 million adults in the United States.3 Echocardiographic data from the Framingham Heart Study reported an overall prevalence of moderate or higher TR of 0.8%, with a majority due to functional TR and only 10% due to an organic cause.The Optimal Dietary Calcium Intake for Preventing Incident and Recurrent Symptomatic Kidney Stone Disease
Until the early 1990s, it was presumed that dietary calcium intake should be limited for preventing the onset and recurrence of calcium kidney stone formation, assuming that frequent consumption of milk and dairy products could unfavorably influence urinary calcium excretion. However, a prospective investigation conducted on 45,619 men without baseline history of kidney stones, published in 1993, showed an inverse relationship between baseline dietary calcium intake, assessed by a semiquantitative food frequency questionnaire, and the risk of incident symptomatic kidney stone disease after a 4-year follow-up period.Solving the Puzzle of Coronary Artery Disease in the Elderly
In the process of aligning treatment options to fit each individual patient, the clinician must carefully evaluate how each decision affects the overarching goals of care. In the management of coronary artery disease, however, these tradeoffs are often confounded by a bias toward less invasive strategies in the elderly. Given that women outnumber men by 54% beyond the age of 80 years,1 this predisposition can also contribute to an insidious form of gender discrimination. Older patients are often excluded from major clinical trials,2 contributing to a lack of awareness surrounding the efficacy of aggressive treatments in this demographic.The Right Stuff
Currently in clinical cardiovascular medicine, prospective randomized controlled trials are considered the “gold standard.” The larger, the better. Such studies are considered to have high internal validity. In recent years, such studies are often subsequently compared with “real-world” data from individual institutions and registries to augment their external validity. This approach has been the foundation for the enormous progress in understanding the pathobiology and treatment of cardiovascular disease during the past half-century.Coronary Artery Calcium and Cardiorespiratory Fitness: The Simple Keys to Truly Personalized Atherosclerotic Cardiovascular Disease Risk Prediction?
Atherosclerotic cardiovascular disease (ASCVD) risk prediction is the cornerstone of decision-making strategies for the prevention of ASCVD.1,2 Whereas guideline recommendations for ASCVD risk prediction are still largely based on the measurement of traditional ASCVD risk factors, there are well-established limitations to this approach, and other predictors of ASCVD risk are needed to better personalize ASCVD risk prediction. Accordingly, the most recent American College of Cardiology/American Heart Association guidelines place added emphasis on refining risk beyond traditional ASCVD risk factors.Importance of More Potent Antiplatelet Therapy in Myocardial Infarction With Cardiac Arrest or Cardiogenic Shock
Current treatment of acute myocardial infarction complicated by cardiogenic shock (CS) or resuscitated cardiac arrest (CA) (whether in hospital or out of hospital) almost always includes percutaneous coronary intervention (PCI) as studies have shown improved in-hospital and long-term outcomes with PCI compared with medical therapy alone.1-3 Use of dual antiplatelet therapy with aspirin and a P2Y12 receptor inhibitor is considered standard of care with PCI regardless of the circumstance, unless the patient is at a very high risk of bleeding, although the post-PCI duration of therapy is often debated.When Will American Patients Start Benefitting From Biosimilars?
The United States has one of the most expensive health care systems in the world. Annual health care cost in 2019 was almost $11,100 per person, representing some 17% of the US national income. The Organisation for Economic Co-operation and Development average cost per patient was around $5500, less than half of that in the United States. Higher health care spending can be beneficial if it results in better health outcomes. However, that is not consistently the case in the United States. Despite significantly higher health care spending, America’s health outcomes are generally not better than those in other developed countries.Making the Case to Measure and Improve Cardiorespiratory Fitness in Routine Clinical Practice
Substantial data have accumulated for decades demonstrating the protective effects of regular physical activity (PA), including exercise training, and cardiorespiratory fitness (CRF) on cardiovascular disease (CVD) morbidity and mortality as well as all-cause mortality.1 In fact, PA and CRF may have stronger correlations with CVD prognosis than any of the traditional CVD risk factors.1 In recent years, Mayo Clinic Proceedings has emphasized papers in the areas of PA and CRF,2-8 including publications that also incorporate adiposity, obesity, and the obesity paradox.Now Is the Time to Implement Physical Activity Counseling in Clinical Practice—A New Universal Tool
It has been more than 25 years since the first US Surgeon General’s report Physical Activity and Health. Since that report, the research evidence has continued to mount related to the importance of physical activity (PA) as a key contributor to health and well-being. Updated physical activity guidelines have been published in many countries and by the World Health Organization. Unfortunately, despite the well-established evidence and public health messaging promoting PA, rates of participation have not improved, and physical inactivity remains a major risk factor for the development of most chronic diseases.Language, Respect, and the Medical Profession
Respect is a cornerstone of professionalism in medicine. The language we use is a critical medium through which respect is conveyed to colleagues and patients. Conversely, inappropriate language can also communicate lack of respect. Changing language to promote respect also promotes professionalism. In short, language matters to upholding the fundamental principles of medicine.Proton Pump Inhibitors, Dual Antiplatelet Therapy, and the Risk of Gastrointestinal Bleeding
Dual antiplatelet therapy (DAPT) with aspirin and oral P2Y12 inhibitors remains the cornerstone of therapy for patients with acute coronary syndrome (ACS). However, the administration of DAPT carries the significant risk of gastrointestinal bleeding. The 2016 American College of Cardiology/American Heart Association focused update on duration of DAPT in patients with coronary artery disease1 and the 2018 European Society of Cardiology/European Association for Cardio-Thoracic Surgery guideline on myocardial revascularization2 have recommended proton pump inhibitors (PPIs) among strategies to avoid bleeding complications in patients with ACS.Improving Outcome Prediction in Alcohol-Associated Hepatitis: Blood Urea Nitrogen and Albumin Help
Alcohol-associated hepatitis (AH) represents one of the most relevant types of alcohol-related liver disease.1 It has a wide clinical spectrum ranging from nonsevere forms, which often improve rapidly with alcohol abstinence and do not require specific treatment, to severe forms associated with high mortality that require aggressive intervention.Findings From Mayo Clinic’s Post-COVID Clinic: PASC Phenotypes Vary by Sex and Degree of IL-6 Elevation
A significant proportion of individuals suffer from persistent symptoms after acute infection with SARS-CoV-2. This syndrome, called long COVID by patient advocates, has been named post-acute sequelae of COVID-19 (PASC) by the National Institutes of Health. The World Health Organization developed a clinical case definition that includes (1) history of probable or confirmed SARS-CoV-2 infection with onset at least 3 months earlier and (2) symptoms that last for at least 2 months that cannot be explained by an alternative diagnosis.Understanding Heart Failure Risk in a Diverse Cohort With Human Immunodeficiency Virus Infection
After 4 decades of study and numerous therapeutic advancements, human immunodeficiency virus (HIV) infection can today be considered and managed as a chronic disease, and in some parts of the world, the life expectancy of persons living with HIV (PWHs) is comparable to that of persons living without such infection.1 Since it was discovered in the early 1980s, HIV has been known to affect the heart. As PWHs are living longer, their burden of cardiovascular disease (CVD) and their clinical relevance have grown, raising important questions about the pathophysiologic process through which the HIV affects the heart despite optimal treatment with antiretroviral therapy (ART).The Pandemic: Health Care’s Crucible for Transformation
In this issue of Mayo Clinic Proceedings, Shanafelt et al1 publish the fourth triennial survey of physician burnout in the United States. Taken during the first 6 to 9 months of the pandemic, the survey found that burnout continued to decline from its peak 54.4% (2014) to 38.2% (2020) using the 2-item Maslach Burnout Inventory. Yet, 2 years into the pandemic, the notion that burnout is declining may be met with skepticism.
