COMMENTARY

Apr 2, 2021 This Week in Cardiology Podcast

John M. Mandrola, MD

Disclosures

April 02, 2021

Please note that the text below is not a full transcript and has not been copyedited. For more insight and commentary on these stories, subscribe to the This Week in Cardiology podcast.

In This Week’s Podcast

For the week ending April 2, 2021, John Mandrola, MD comments on the following news and features stories.

COVID-19 This Week

I walked through our ICU yesterday, and just one name on the board was red, signifying a COVID-19 positive patient. One. But I realize that COVID is a regional problem. The state of Michigan, the city of Paris, and the country of Brazil continue to struggle with COVID-19.

There was vaccine news this week. On the positive side, the hospitalization curve from Israel continues to plummet. This seems important because it provides real-world conformation of the vaccine trials. Also, the Pfizer BioNTech vaccine trial in 12 to 15-year-olds was extremely favorable—though it was just reported in a press release.

On the negative side, journalist Sue Hughes has news coverage of a European Medicines Agency (EMA) press conference on reports of clotting disorders occurring shortly after the AstraZeneca vaccine.

"EMA is of the view that the benefits of the AstraZeneca vaccine in preventing COVID-19, with its associated risk of hospitalization and death, outweigh the risks of side effects." But it adds: "Vaccinated people should be aware of the remote possibility of these very rare types of blood clots occurring.”

A preprint from a German group reported clinical and laboratory features of nine patients (eight of whom were women) in Germany and Austria who developed thrombosis and thrombocytopenia after they received the AstraZeneca vaccine. The researchers’ findings suggest that the vaccine appears to be linked to a condition that clinically resembles heparin-induced thrombocytopenia (HIT) and that it occurs mainly in younger women.

This news came out on Thursday afternoon, and I don’t want to say too much more. I need to read this study more closely, and see what others say. But given the slower vaccine rollouts and rising cases in the EU, the news seems highly pertinent.

Vaccine science isn’t directly related to cardiology, but three issues make this notable

  • Clinical trials designed to test efficacy (of any therapy) may not reveal rare adverse events. That’s why you need real-world surveillance. Pacing and implantable cardioverter defibrillator lead failures are an example.

  • Rare events have a base rate in the population. These clotting events, therefore, may associate in time with a vaccine, but may not be caused by the vaccine.

As per renowned psychologists Kahneman and Tversky, behavioral psychology holds that humans don’t always maximize decisions based on pure probability. Even though the net benefit may favor taking the vaccine, the chance of a fatal severe rare event looms large in many people’s minds. (The possibility of rare events greatly influence medical practice. That’s why it’s hard to get out of an emergency room without having a CT of the chest to rule out pulmonary embolism, or a CT of the head to evaluate headache.)

Long COVID

I’ve got an essay coming soon on one aspect of long COVID that worries me–medical iatrogenesis. While I love being a doctor because we make a living helping people, stop and pause for a moment about the notion of sending millions more people into the current healthcare system. If the base rate of harm is even a small percent, that means many will be harmed.

I see four main factors driving medical iatrogenesis from long COVID: fear, good intentions, uncertainty, and incentives to action.

Fear: The intense media attention, and its concentration on anecdotes, creates a social learning milieu in which people learn to be fearful. Also, the National Institutes of Health (NIH) announced it will spend billions on research, so look for even more attention from academics. Fear shreds good medical decision making.

Good intentions: We want to help, and there are two basic ways that clinicians demonstrate caring: one is by listening and expressing empathy. That is hard. Easier is to order tests. And that, my friends, sets up the potential for downstream cascades.

Uncertainty: I reviewed many of the studies documenting long COVID and here is a major flaw: most of them sample patients from post-acute COVID clinics, or use social media messaging like, “If you consider yourself a long-hauler, let us know about your symptoms.” This is classic selection bias. Another puzzle with long COVID are studies that find symptoms (except loss of taste or smell) are similar in patients who have tested positive vs those who never had a positive test.

That’s peculiar. While testing in the pandemic was not always available, a finite fraction of people with long COVID never had infection with SARS COV-2.

Incentives: In the US system, everything is set up for doing more not less. A cardiologist faced with a patient with fatigue months after COVID makes more money if she orders an echo or a monitor and reads it. At the hospital level, post-COVID care clinics help capture market share.

In the essay, I offer my solution to the problem. I won’t give it away—please go to theheart.org | Medscape Cardiology in a few days to read it—but the teaser has to do with an empirical, medically conservative, and humble approach to patients with real symptoms.

The Language of Medicine

This podcast has commented often on the linguistics of medicine. The phrase ‘congestive heart failure,’ for instance, is terrible way to communicate with patients with chronic heart disease.

Well, there is also an ongoing debate in the world of nephrology. In 2019, a group of experts convened a consensus conference, spending many hours talking and writing, and came up with this advice: use ‘kidney’ rather than ‘renal’ or ‘nephro.’ As a seasoned doctor, I’ve often been corrected in the hospital: “John, we don’t say renal insufficiency anymore, it’s chronic kidney disease, stage whatever.”

Last month, a group of nephrologists pushed back, and recommended keeping renal and nephro, especially in the academic literature. Renal replacement therapy is ok; it doesn’t have to be kidney replacement therapy. I guess I would ask, perhaps stupidly, what about simply saying ‘dialysis’?

My take: some revisitation of terms is reasonable. In the same way that ‘heart failure’ is awful, so is ‘end-stage kidney disease’ but we should also be mindful of distraction. Time spent on the minutia of syntax is time not spent on important things—like finding better therapies to help patients with kidney (or renal) disease. Economists call this ‘opportunity costs.’ To wit, imagine the potential benefits if all the time spent speaking and writing and submitting manuscripts with the correct format for Journal X, was spent on teaching clinicians about the SGLT2 inhibitor trials?

In the atrial fibrillation clinic, I often see patients who have chronic kidney disease and diabetes and too often they are not on an SGLT2 inhibitor. To me, this is a bigger crisis than linguistics.

Another thing that worries me a lot more than the language of kidney disease is the lack of trials in these patients. Bandwidth spent on language is bandwidth not spent on doing more trials. Maybe you disagree – let me know what you think on this.

Childhood Obesity

The Journal Pediatrics published alarming findings on the rates of childhood obesity during the pandemic. This was an observational descriptive study from a large primary peds network in Philadelphia, and included nearly 170,000 patient visits in 29 urban, suburban, and semi-rural clinics. The researchers measured average obesity rates during the 6 months pre-pandemic (June-December 2019) vs June-December 2020

Overall obesity prevalence increased from 13.7% (June-December 2019) to 15.4% (June-December 2020). This increase was more pronounced in kids who were Hispanic/Latino, Non-Hispanic Black, publicly insured, or lower income. Figure 1b was super discouraging; it showed the rates of obesity by ethnicity. First, I did not previously know that Latino and Black kids had nearly double the rate of obesity vs white kids, roughly 20% vs 11%. Then, when the pandemic hits, the rates of obesity in both groups go up but it goes up more in the Latino and Black kids relative to white kids. The authors succinctly write: “Pre-existing disparities appeared to have worsened.” In the discussion, the authors discuss why this would be.

“Efforts to reduce COVID-19 transmission have likely contributed to worsening pediatric obesity. Families with children have faced the difficulties of managing virtual schooling, limited physical activity, and increased reliance on more heavily processed and calorie dense foods.”

The first thing to say is: very early in the pandemic, everyone agreed that COVID-19 had a steep age gradient; thankfully, SARS COV-2 essentially spares children. This research letter makes the podcast because it highlights the important concept of tradeoffs. I often say to patients, no intervention comes free; we must always consider the downsides. There are many tragedies of this pandemic. The death toll of course is terrible. What I am about to say does not minimize that—you can think cancer is a terrible disease and also think some cancer therapy is also terrible.

But as we study this pandemic, and the passage of time permits discussion, I predict more and more papers like this will chronicle the truly tragic effects of our interventions. Given that this virus poses no more of a threat to kids than any of the pre-pandemic respiratory viruses, it is extremely distressing and sorrowful that children bore such a heavy brunt during COVID-19 mitigation.

Even worse, though, and especially regretful is how the mitigation worsened the pre-existing disparities between rich and poor kids. I don’t know how you can look at the data in this paper and not come to the conclusion that COVID-19 mitigation worsened structural racism in healthcare. This, to me, is an utter failure of American public health decision-making. Rich kids went to private schools and poor kids suffered. It would have been understandable to allow these errors for a few months, when information on the virus was sparse, but public schools in many American cities remain closed.

The analogy in clinical medicine would be that your patient has a low-grade, slow-growing cancer but you so fear your patient is going to die of that cancer, you give strong chemotherapy, which reduces the cancer a smidge, but causes severe damage to the heart. In other words, you tried to help but you didn’t pay enough heed to off-target effects.

It shocks me that with all the attention paid these days to improving healthcare disparities, we let that COVID case ticker blind us to the harms our interventions are doing to those with less resources. My friends, always, always, think about the harms of your interventions. Diseases can be bad, but so can our attempts to help.

Open Notes

Next week, a new US law kicks in, allowing patients to have free, full, and immediate access to their clinician’s notes. This was part of the 21st Century Cures act. It’s sort of been going on for months so I don’t think next week will bring a rush of patient queries, but this story deserves a few words because it is a significant change in how doctors and patients interact.

Obviously, the old way of jotting a few notes in the chart with a pen are long gone. This podcast has commented often on the negative way electronic health records have influenced the patient-doctor interaction. But on the matter of Open Notes, I mostly think it is a net positive. My practice is to show patients what I write in the chart—I don’t type well, so it has to be short writing.

My view of notes has changed over the course of my career. When I was training, and learning, I favored long narratives about the differential diagnosis and why this or that was more, or less, likely to be the cause. But once in practice, I learned from master clinicians that no single person was ever healed by words written in the chart. The more time you spent in charting, the less time you spent with people at the bedside.

Now, my take of using words in the chart is to use the minimum needed to convey important medical information for colleagues and the minimum needed to support billing. One of the criticisms of the Open Notes initiative is that it will inhibit some of the nuance of medical communication. For instance, if you know a patient can read the chart, you might be hesitant to write certain things. But I don’t agree. As a person who likes to write, I think you can convey, important issues in clever ways. I like to use quotes. Instead of saying someone is “noncompliant with meds”, I will cite the patient who says “I adjust my blood thinner according to how much bruising I see.”

Another advantage of open notes, is that it helps clarify reporting of tests. For instance, when I read a monitor, now I will clarify that the usual non-specific atrial tachycardias seen in older patients are not “clinically worrisome.” Making medical information more transparent, reducing jargon, and involving the patients with their data seems to me a net positive.

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