Melissa Walton-Shirley


November 17, 2014

I looked out over Michigan Avenue this morning as snow flurries encircled the doorman, practically clad with black earmuffs, accentuating the collar on his bright red woolen coat. Later his breath would fog in the early morning chill as he dutifully and eagerly hailed my cab. I politely avoided my usual rant that "humans aren't meant to inhabit areas of the world where the temperature varies more than 10° from 72°F and sunny." At that moment, I realized I must love late-breaking clinical trials to get out in 21° weather. The DAPT data await us, along with consumer news on energy drinks, secondhand pot smoke, and stress in women with heart disease.

I am eager for the 3:45 pm talk on heart failure and preserved ejection fraction (HFPEF) in room 100 that would be finally located "two escalators down and to the left." There is a booth recording in the afternoon with Dr Magnus Ohman (Duke University, Durham, NC). There's no topic yet, but he's always fun, insightful, and sage. Even 10 minutes prior to booth time, we were empty-handed, but as usual, picked each other's brains until we were satisfied we had concluded something interesting. Next, there was to be a video on social media with fellow bloggers Drs Seth Bilizarian and John Mandrola as well as Dr Mintu Tahlakaria, the EP director of the Palto Alto VA.

By 5:30 pm, with the help of a free frozen yogurt from the exhibit hall and some pressroom food, I accomplished nearly all that I'd planned except this written blog. By 11:08 pm, though, as Mandrola puts it, I am "drilled out."

We started the day appropriately with Dr Steven Lipshultz, pediatrician in chief at Children's Hospital of Michigan, who spoke on one of the all-time dumbest trends in mass marketing: energy drinks. Neurologic symptoms of dizziness, tremor, and headache were manifested in 20%, and CV symptoms of chest pain and tachycardia were noted in 57%. Young people who have more energy at this time of their lives than any other are the target of these marketing campaigns. I thought of my cousins who were genetically less fortunate with long QTs and hope they never try them. Children younger than 6 are accidentally overdosing on these worthless "drinks." It's a shame.

Dr Viola Vaccarino (Emory University, Atlanta, GA) found comparable ambulatory stress results between men and young middle-aged women with coronary heart disease. However, when subjected to stress by being asked to deliver a 3-minute speech, women exhibited three times more ischemia, most of which was silent. It raises important questions about job choices, decisions for disability, retirement, etc. It gave a whole new meaning to the phrase, "This stress is killing me." For women, it probably is.

Pulmonary issues were next. Along with Dr Matthew Tattersall (University of Wisconsin, Madison), Dr Duk Won Bang (Soonchunhyang University Hospital, Seoul, South Korea) presented data revealing that asthma sufferers had a 60% to 70% higher risk of MI. Dr Matthew Springer (University of California, San Francisco) exposed rats to secondhand marijuana smoke and showed a significantly negative impact on vasoreactivity nearly identical to tobacco-smoke exposure. "Smoke is smoke," and smoke is bad was the message of the day.

About 10 am, it was time for all things platelet. We heard from DAPT and other trials that sought to answer whether what we've been doing for years is correct. DAPT showed a benefit for prolonged dual antiplatelet therapy after stenting. Already, most of us stop clopidogrel and prasugrel (Effient, Lilly/Daiichi-Sankyo) for much-needed surgeries or accidents. We beg patients to delay procedures for at least 12 months for things like bad knees and marginally aggravating gallbladders. Although I've been doing the right thing for years, I was doing it for the wrong reasons. If a patient had lots of atheroma not treated by stents, I'd continue them on lifelong thienopyridines. It turns out that it's the milieu that makes them vulnerable to plaque rupture, not the actual plaque volume that drives MI rates in patients who've had their antiplatelet meds stopped. Perhaps we've headed off the insurance companies' badgering on this one. Then again, don't bet on it.

That afternoon, Magnus and I went to the booth to talk some more about how long we should continue to kill platelets poststenting. John, Seth, Mintu, and I hashed out our opinions on the pitfalls and virtues of social media. I love it and talk to my patients frequently on the private side of Facebook if they initiate the conversation. My copanelists hid their mortification at this revelation. I then landed in a DVT-inducing position in the back of room for the HFPEF data and squinted at illustrations of reduced NO production, hypophosphorylated titin, and oxidative-stress pathways. While sick conference attendees coughed and blew their noses all around me, hopefuls like ranolazine (Ranexa, Gilead Sciences), nonhydropyridines, tolvaptan, and diuretics met with lukewarm results. New atrial-septal-defect–producing devices to unload the left atrium and reduce wedge pressure are being developed. They, along with remote hemodynamic monitoring, wait in the wings like shy schoolgirls hoping for a prom date.

The dark sad truth about HFPEF is that it's pretty much tough luck, so we're better off backing away from the buffet table and putting on a pair of sneakers to keep our body-mass indexes in that sweet spot between 18 and 25. Until we learn to spend more money preventing it than we do trying to figure out how to treat it, we're always going to be on the losing side of this disease. Processed foods and avoidance of exercise have caused our beautiful and unique machines to go horribly rogue. HFPEF is the perfect storm of transmitters and hormonal aberrations to cut off years of life and ruin the quality thereof.

It's 11:17 pm and I'm meeting Mike O'Riordan in the lobby at 6:45 am tomorrow. I've not looked at the talk today that I'm giving at a satellite meeting tomorrow night. I learned yesterday there is no way to project the slides the hospital secretary worked on all week. I'm not being paid, but I wonder if I'll show up on the sunshine roster insinuating I'm a prostitute, when in fact, I'll just be hungry. Although I'm a little smarter tonight than when I left the hotel room this morning, I'm tired, stuffed from a too-late dinner while working in the room, and just a little homesick. I missed my sister-in-law's surprise birthday party, and I miss my husband and daughter who made it there to represent us. My mind drifts to our other daughter studying for finals, and I regret her oxidative stress. Despite all that, I'll get up again tomorrow and head over to the convention center in the cold like all the other thousands of healthcare providers, researchers, vendors, and academicians who've converged upon the city of Chicago. Yep, we'll show up . . . because that's just what we do.


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