Unpacking, Hacking and Re-stacking
New and notable studies and registries
Cover Story | Whether hitting the keys or twiddling the knobs, investigators constantly surprise with what they learn and share. The 2015 American Heart Association Scientific Sessions in Orlando, FL, offered a variety of interventional papers and news stories of interest to interventionalists. Gaining access to big data allows us to better understand what’s going on in clinical practice. Among the presentations were 19 highlighting data from five National Cardiovascular Data Registry (NCDR®) hospital-based registries and the outpatient PINNACLE Registry®.
STS/ACC TVT Registry®
The Impact of Atrial Fibrillation on TAVR Outcomes and National Variation in Post-TAVR Antithrombotic Therapy Utilization
It is not uncommon for patients with a history of nonvalvular atrial fibrillation (AF) to undergo transcatheter aortic valve replacement (TAVR), although there are no convincing data regarding the optimal antithrombotic therapy post-TAVR for these patients.
In an effort to better understand the use of antithrombotic therapy after TAVR and subsequent clinical outcomes, investigators at the Duke Clinical Research Institute (DCRI) used the Society of Thoracic Surgeons/American College of Cardiology (STS/ACC) TVT registry to analyze 16,293 patients with linked Centers for Medicare & Medicaid Services (CMS) data to evaluate 1-year outcomes.
Fully 45% of patients had preoperative AF, which was a strong independent predictor of poor clinical outcomes at 1 year, including death (hazard ratio [HR]: 1.66; p < 0.001) and any bleeding (HR: 1.28; p < 0.001).
Given the lack of evidence and clinical guidelines in this setting, it’s not surprising that there was significant hospital-level variation in the use of oral anticoagulation (OAC) therapy in AF patients after TAVR. As an example, while 50 hospitals discharged more than 80% of their patients on OAC, nearly 30 hospitals used oral anticoagulation in < 25% of their AF patients (Figure).
Surprisingly, patients on OAC had a similar adjusted risk for key outcomes as patients not receiving OAC, including 1-year mortality (HR: 0.94; p = 0.29), stroke
(HR: 0.86; p = 0.30), and bleeding (HR: 0.92; p = 0.41).
The data were presented by Matthew W. Sherwood, MD, a medical instructor at the Durham Veterans Administration Medical Center and a structural interventional cardiology fellow at Duke University Medical Center. While there was no significant benefit for OAC, he said, “The amount of variation in the use of oral anticoagulation and antiplatelet therapy really shades the issue—we really don’t know the best therapy and all kinds of combinations of therapies are being used.”
Dr. Sherwood added, “What we really thought was important was to highlight the fact that atrial fibrillation patients were at increased and extreme risk for bad outcomes after TAVR and we need further research, including randomized clinical trials, to define the best antithrombotic therapy after TAVR.”
Waiting for Good Ol’ Reversal
One thing thought to be holding back even wider adoption of alternatives to warfarin has been the lack of reversal agents. And understandably so: annually, 1% to 4% of patients treated with Factor Xa inhibitors may experience major bleeding, and an additional 1% may require emergency surgery. In the United States alone, during the 12 months ended April 2015, there were more than 50,000 rivaroxaban- or apixaban-treated patients admitted to the hospital due to bleeding. This number does not account for patients taking the injectable Factor Xa inhibitor enoxaparin or those on a Factor Xa inhibitor undergoing emergency surgery.
Andexanet is being developed as a universal reversal agent for patients anticoagulated with an oral or injectable Factor Xa (FXa) inhibitor who experience a serious uncontrolled bleeding event or who require urgent or emergent surgery.
At AHA.15, investigators reported their results in older rivaroxaban-treated subjects (n = 27; median age in the late 50s): compared to placebo (n = 14), andexanet reduced anti-FXa activity (by 97% vs. 45%; p < 0.0001), fully restoring thrombin generation (in 100% vs. 0% of subjects; p < 0.0001). The reversal of anticoagulation parameters was sustained during the duration of the infusion and persisted for 1 to 2 hours after the end of the infusion.
“The ANNEXA studies demonstrated that andexanet alfa can rapidly reverse the anticoagulant effect of Factor Xa inhibitors for both short and sustained periods with a good safety profile. This is important because it means that andexanet alfa, by allowing for flexible and controlled reversal, could address different clinical scenarios in which a reversal agent is needed,” according to John T. Curnutte, MD, PhD, executive vice president, research and development, for Portola Pharmaceuticals (San Francisco, CA). “These positive ANNEXA study results suggest that andexanet alfa, if approved, could become the first universal reversal agent for Factor Xa inhibitors and could also become the new standard of care for managing serious uncontrolled bleeding in patients treated with these novel anticoagulants.”
It’s also a new approach. As detailed in an accompanying editorial in the New England Journal of Medicine, by Jean M. Connors, MD, of Brigham and Women’s Hospital in Boston, MA, recombinant genetic technology was used to create a modified factor Xa molecule with a mutation in the catalytic site that abolishes the procoagulant activity of factor Xa while retaining its native structure; this allows factor Xa inhibitors to bind with strong affinity and effectively neutralizes their anticoagulant activity. The tail of the molecule also has been modified to prevent interaction with other coagulation factors.
This decoy recombinant factor Xa molecule has the ability to bind direct factor Xa inhibitors, such as rivaroxaban, apixaban, and edoxaban, as well as the factor Xa inhibitors that act through antithrombin: low-molecular-weight heparins and fondaparinux.
An ongoing ANNEXA-4 study is evaluating the efficacy and safety of andexanet in patients with factor Xa inhibitor–associated acute major bleeding. At the time of the AHA meeting, 33 study sites were enrolling patients with a goal of more than 60 sites. Including in the trial will be patients on apixaban, rivaroxaban, edoxaban, and enoxaparin.
Note: In Oct. 2015, idarucizumab, a humanized monoclonal antibody antigen-binding fragment that binds to dabigatran, received expedited approval from the Food and Drug Administration for use in the United States.
Siegal DM, Curnutte JT, Connolly SJ, et al. N Engl J Med. 2015 Nov 11 [Epub before print]
IVUS Guidance Improves DES Implantation in Long Lesions
Intravascular ultrasound (IVUS)-guided stent placement improves clinical outcomes in patients with complex coronary lesions compared to standard angiography-guided stent implantation. At least it does when using first-generation stents. There’s not much evidence to indicate whether it’s still true for second-generation drug-eluting stents (DES).
In the IVUS-XPL trial, Myeong-Ki Hong, MD, PhD, of Yonsei University in Seoul, South Korea, and colleagues from 20 Korean clinical centers randomly assigned 1,400 patients with long lesions (implanted stent length ≥ 28 mm) to IVUS-guided or angiography-guided everolimus-eluting stent implantation.
The composite primary endpoint of 1-year major adverse cardiac events (cardiac death, target lesion-related myocardial infarction [MI], or ischemia-driven target lesion revascularization) was halved in the IVUS arm from 5.8% to 2.9% (hazard ratio [HR]: 0.48; p = 0.007), driven primarily by a lower risk of target lesion revascularization (2.5% vs. 5.0%; HR: 0.51; p = 0.022). Cardiac death and target lesion MI were not significantly different between the two groups.
Also, more patients met predefined IVUS criteria for stent optimization, with a resultant lowering of the primary endpoint in those who did so: 1.5% vs. 4.6% for those who did not meet IVUS criteria for stent optimization (p = 0.017).
“What is interesting to me in this trial is its simplicity, in a way,” said discussant Marco Costa, MD, PhD, FACC, director of the Interventional Cardiovascular and Research and Innovation Centers, University Hospitals, Cleveland, OH. “It was a very low threshold for both criteria to what we call optimized stenting. Optimization of stenting is when you decide to stop the procedure, you are satisfied with the results and, in this case, they used a very liberal, a very unique single metric criteria of being just bigger than the distal size of the vessel for IVUS or at least 30% residual stenosis for angiography.” In a press conference, he said, “Those criteria are not standard criteria in clinical practice, at least not in the United States, but the data were very impressive; the results are unquestionable.”
The findings were published simultaneously with publication in JAMA.
Hong SJ, Kim BK, Shin DH, et al. JAMA. 2015;314:2155-63.
Troponin Teed-up in the Ambulance
In recent years there have been impressive successes in reducing the time to rule-in or rule-out MI in patients with chest pain. Given the value of troponin testing, it makes sense that the latest effort to speed things along was a randomized study evaluating troponin testing in the ambulance.
Investigators randomized 601 patients in 19 months; 296 to usual care (UC) and 305 to point-of-care (POC, ambulance) troponin. After ambulance arrival, the first troponin was available in 38 minutes in POC troponin and 139 minutes in UC patients. In the POC cohort, the troponin was > 0.01 ng/ml in 17.4% and > 0.03 ng/ml in 9.8%. The primary endpoint was shorter in patients randomized to POC troponin (median 8.8 hours) compared to UC (median 9.1 hours) but missed statistical significance at p = 0.05.
Certainly POC troponin testing in the ambulance is feasible and might increase the efficiency of an emergency department (ED) using current generation troponin assays. And, as with many biomarker studies in the acute setting, the majority of patients in the study were low risk, despite presentation with chest pain. Which means that this pragmatic study suggests that this approach might be able to streamline pre-ED and ED care for low-risk patients and faster triage and treatment of high-risk patients.
Ezekowitz JA, Welsh J Am Heart Assoc. 2015;4(12);pii:e002859.
ACTION Registry®-Get With the Guidelines™ (GWTG)
Selection of Stent Types Among AMI patients with AF
Patients with AF were the subject of another NCDR analysis; this time, looking at stent selection in acute myocardial infarction (AMI) patients with AF, which may have important implications for duration of antithrombotic therapy. In short, oral anticoagulation + dual antiplatelet therapy (DAPT) = high bleeding risk. Recently in JACC, investigators reported that approximately one in four older AF patients undergoing primary percutaneous coronary intervention (PCI) were discharged on triple therapy. Those receiving triple therapy versus DAPT had significantly higher rates of bleeding requiring hospitalization (adjusted HR: 1.61) and a significantly greater risk of intracranial hemorrhage (adjusted HR: 2.04) without a measurable difference in composite MI, death, or stroke.
Didn’t Used to Be This Way
Time was that the common practice was to avoid or strictly limit drug-eluting stent (DES) use in patients requiring long-term antithrombotic therapy, like individuals with AF. Unless there was an expected significant net benefit to DES versus bare-metal stent (BMS) placement, the better choice seemed to be a BMS where long-term dual or triple therapy could be avoided.
Indeed, guidelines recommend BMS use in patients with high bleeding risk (Class I: Level of Evidence C) and give a Class III recommendation (Harm) for drug-eluting stent (DES) use for “patients with STEMI who are not able to tolerate or comply with a prolonged course of DAPT because of the increased risk of stent thrombosis with premature discontinuation of one or both agents.”
Reality check: drug-eluting stents are now used in most AMI patients with AF. This applies even to patients with both high predicted stroke risk and high bleeding risk.
Vora et al. identified 14,427 AF patients presenting with acute MI undergoing PCI from 2008-2014. DES use increased from 47.1% in 2008 to 67.9% in 2014 (p < 0.001), with large variations between hospitals, with an interquartile range of 50% to 74%.
While you might think these numbers are based on thoughtful analysis of benefits versus risk, in some centers no thought process seems to be in effect at all, with nearly 100% of AF patients getting a DES, period (Figure). Conversely, a few centers use BMS almost exclusively (80% to 90%) in patients with AF.
Compared to those undergoing BMS placement, patients receiving DES were younger (median age 72 vs. 75 years) but had more comorbidities such as diabetes, dyslipidemia, prior MI, and prior revascularization (all p < 0.001).
DES placement was more common than BMS placement among patients at high stroke risk (CHA2DS2-VASc ≥2) and high bleeding risk (ATRIA ≥ 4) (59% and 56%, respectively; p < 0.01 for both).
“The variation in practices between hospitals in this high-risk population reflects the current lack of clear guidance, and the need for additional research on stent selection and antithrombotic strategy,” said lead author Amit Navin Vora, MD, MPH. “As a next step, outcomes data should be examined.”
Hess CN, Peterson ED, Peng S, et al. J Am Coll Cardiol. 2015;66:616-27.
MV Repair vs. Replacement
For years, the choice between mitral valve (MV) repair and replacement for severe, functional mitral regurgitation (MR) required weighing the lower short- and intermediate-term morbidity and mortality associated with repair against the more predictable eradication of MR with replacement. That may still be the case, but without the mortality issue.
Two-year results are now available from the Cardiothoracic Surgical Trials Network (CSTN), and in patients undergoing MV repair or replacement for severe ischemic mitral regurgitation, there was no significant between-group difference in left ventricular (LV) reverse remodeling or survival at 2 years. The rate of recurrence of moderate or severe MR over 2 years was higher in the repair group (58.8% vs. 3.8% in the replacement group; p < 0.001). However, there were no significant between-group differences in rates of serious adverse events and overall readmissions, although patients in the repair group did have more serious adverse events related to heart failure (p = 0.05) and cardiovascular readmissions (p = 0.01).
Several of the CSTN authors subsequently published an expert opinion paper asking the logical clinical question: Given the evidence, should you repair or replace? Based on the data, including their own study, they write that the presence of basal aneurysm/dyskinesis, echocardiographic evidence of significant leaflet tethering, and/or moderate-to-severe LV dilation favor the use of chordal-sparing MV replacement over MV repair for treatment of medically refractory severe ischemic MR. On the other hand, in the absence of those factors, MV repair using an undersized, complete, rigid ring may be reasonable. (They added that more complex mitral repair operations that specifically address leaflet tethering have shown promising results, but remain investigational and incompletely validated.)
Goldstein D, Moskowitz AJ, Gelijns AC, et al. N Engl J Med. 2015 Nov 9 [Epub ahead of print]
Acker MA, Dagenais F, Goldstein D, Kron IL, Perrault LP. J Thorac Cardiovasc Surg. 2015;150:1425-7.
Inter-Hospital Variation in Medication Adherence After MI
How well—or not—a hospital manages transition of care may influence patient adherence to secondary prevention medications post-discharge.
Investigators linked 20,124 myocardial infarction patients treated at 459 hospitals to Medicare Part D data for prescription fills. Discharge prescriptions ranged from 96% of patients who received a beta-blocker to 76% who got a prescription for angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARBs). Adherence at 90 days varied from 72% for thienopyridines to 63% for ACEI/ARB therapy (Figure). Medication adherence was defined by the proportion of days covered (PDC ≥ 80%). The largest drop-off in adherence was seen with beta-blockers, falling 28 percentage points to 68% at 90 days.
Hospitals were divided into high (> 75th percentile), medium, or low (< 25% percentile) adherence, and rates for secondary prevention medications varied markedly across U.S. hospitals (Figure). Hospitals with higher 90-day adherence rates were associated with significantly lower risks of major adverse cardiovascular events and readmissions/death at 2 years.
According to William T. Wang, MD, of DCRI in Durham, NC, hospital-level variations may be attributed to differences in transition of care practices, meaning development of coordinated initiatives between discharging hospitals, outpatient health care providers, and patients aimed at improving post-discharge medication adherence might enhance patient outcomes.
“Now the challenge is to figure out what we need to do to improve adherence for all patients and determine what specific discharge practices hospitals are employing that work,” said Dr. Wang.
Lead Removal vs. Abandonment
An NCDR® ICD Registry Analysis
Despite the increased number of implantable cardioverter-defibrillator (ICD) recipients and the frequent need for device upgrading and/or occurrence of lead malfunction, the optimal approach to managing abandoned leads remains debated.
Using the NCDR® ICD Registry (2010–2011, Zeitler and colleagues examined in-hospital events among propensity-matched subjects undergoing lead replacement where the existing lead was either abandoned or extracted. Six-month complications, as well as 90-day and 1-year mortality rates, were examined in a subset of Medicare subjects. They excluded procedures involving infection and those performed by a cardiothoracic surgeon (in those cases, extraction was predetermined).
They had data on 41,744 subjects, including 2,362 Medicare-aged patients. Overall, there were more in-hospital complications and deaths among extraction versus abandonment subjects. In the Medicare subset, there were no differences in longer-term outcomes.
Thus, abandonment may be a reasonable alternative to extraction for sterile lead revision in some cases (Table). At 90 days and 1 year, there was no difference in survival (p = 0.55).
Questioning the Value of a (Very) Common HF Drug
Practice changing. That’s what Margaret Redfield, MD, FACC, a professor of medicine at the Mayo Clinic in Rochester, MN, and her colleagues at the National Heart, Lung, and Blood Institute Heart Failure Clinical Research Network call the results of their study, presented at AHA and subsequently published in the New England Journal of Medicine.
While up to half of patients with heart failure (HF) and a preserved ejection fraction are treated with nitrates, in their study, isosorbide mononitrate did not improve the daily activity level, submaximal exercise capacity (6-minute walk distance), or perceptive exercise tolerance (post-walk dyspnea score), quality of life (QOL) scores, or N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels in such patients. Indeed, dose-dependent decreases in daily activity levels were seen among patients receiving isosorbide mononitrate.
For the study, Redfield and colleagues randomly assigned 110 HF patients to 6 weeks of daily treatment with an increasing dose of isosorbide mononitrate—from 30 mg to 120 mg—or to placebo. Six weeks into the study, the groups switched medication regimens, and the trial continued for another 6 weeks, according to the report.
The NEAT (Nitrate’s Effect on Activity Tolerance in Heart Failure with Preserved Ejection Fraction) trial did allow Dr. Redfield, the lead investigator, to use the line “this is a NEAT primary endpoint” in a press conference. That endpoint would be daily activity level, quantified as the average daily accelerometer units during the 120 mg phase, as assessed by small patient-worn accelerometers (think pedometer, but a little different).
Compared to placebo, isosorbide mononitrate decreased daily activity levels and did not improve submaximal exercise capacity, QOL scores, or NT-proBNP levels in HF with preserved ejection fraction patients. “This study should change practice,” said Dr. Redfield. “Long-acting nitrates should not be used for symptom relief in heart failure.”
Redfield MM, Anstrom KJ, Levine JA, et al. N Engl J Med. 2015;373:2314-24.
Outcomes of Off-Label Use of TAVR
Insights from the STS/ACC Transcatheter Valve Therapy Registry
TAVR is approved for treatment of severe aortic stenosis (AS) in symptomatic inoperable and high-risk patients. What about off-label use of TAVR? That has not been previously studied.
Ravi S. Hira, MD, FACC, director of Harborview Medical Center Acute Cardiac Services & Cardiac Catheterization Service (and assistant professor of medicine at the University of Washington, Seattle, WA), and colleagues assessed 23,841 patients from 328 sites performing TAVR.
Data were linked with the CMS for 15,394 patients to evaluate 30-day and 1-year outcomes.
Off-label TAVR was used in 2,682 patients (11.2%). TAVR indications were: a known bicuspid valve (n = 445; 1.9%), failing bioprosthetic aortic valve (n = 303; 1.3%), moderate AS (n = 319; 1.3%), severe mitral regurgitation (n = 962; 4.0%), severe aortic regurgitation (n = 953; 4.0%), or subaortic stenosis (n = 3; 0.01%).
Compared to on-label use, off-label use patients were more likely to be younger; male; receive care in urban, teaching hospitals with higher TAVR volume; and have higher STS score (median 7.2 vs. 6.8; p < 0.0001); and were less likely to have elective procedures.
In CMS-linked data, patients undergoing off-label TAVR had higher 30-day mortality compared to on-label TAVR (Table) but similar 1-year mortality (24.1% vs. 22.2%; p = 0.0593).
The authors said their results suggest an urgent need for additional research on the efficacy of TAVR in specific patient cohorts for whom TAVR currently is being considered in clinical practice.
Varenicline + Counseling for Post-ACS Quitters
Proving just what a difficult habit smoking is to break, fewer than one-third of smokers hospitalized with an acute coronary syndrome (ACS) remain abstinent after discharge, their resolve to cease smoking going up in smoke.
In a multicenter randomized trial, however, researchers tried to smoke out in 302 ACS patients (75% male; mean age, 55 years) whether a 12-week course of the smoking-cessation agent varenicline (Chantix; Pfizer), combined with counseling and begun in the hospital, is efficacious to snuff out smoking following ACS. Varenicline reduces cravings and withdrawal symptoms and decreases the reinforcing effects of nicotine. The trial was conducted at 40 Canadian and U.S. centers.
Participants had smoked for an average of 36 years and were smoking about 22 cigarettes a day before their acute event. More than half were admitted with ST-segment elevation MI.
Compared to low-intensity counseling alone, added varenicline increased the smoking abstinence rate at 24 weeks from 32.5% for placebo to 47.3% (p = 0.012). In those who didn’t manage to completely abstain, varenicline helped more patients reduce their number of cigarettes smoked daily by 50% or more (67.4% vs. 55.6% for placebo; p < 0.05).
No differences were noted in major adverse cardiovascular event rates within 30 days of drug discontinuation, although the study’s principal investigator and lead author, Mark J. Eisenberg, MD, FACC, from the Jewish General Hospital and McGill University in Montreal, Quebec, Canada, noted that more study is needed to definitively establish the safety of varenicline in this patient population.
“We all know it’s really important to get it started right while they’re in hospital because once you lose them, you know it’s all over,” said Dr. Eisenberg in a press conference. “A lot of our patients wouldn’t even come into the trial. A lot of the confirmed smokers didn’t even want to try to quit smoking.”
This sounds familiar. At ESC.15 we interviewed Mouaz Al-Mallah, MD, King Abdul-Aziz Cardiac Center, Riyadh, Saudi Arabia on this topic: Fewer Smokers, but the Ones Left May Be Really Addicted, discussing a paper in the Sept. 22, 2015 issue of JACC.
Morris PB, Ference BA, Jahangir E, et al. J Am Coll Cardiol. 2015;66:1378-91.
Women in Cardiology:
Discrepancies in Pay or Jobs or Both?
At AHA.15, a poster presentation had the distinction of simultaneous publication in JACC. In press reports, the attention focused on how women in cardiology make considerably less money than men do. Well, the subject is, shall we say, a little more complicated than that. (And some of those media outlets really should know better!)
Reshma Jagsi, MD, DPhil, University of Michigan, Ann Arbor, MI, and colleagues used data supplied by MedAxiom, a practice management firm, with access to detailed information about the work of individual cardiologists and what they are paid. They analyzed cardiologists from 161 U.S. practices, including data from 2,679 subjects (229 female, 2,450 male).
In their analysis, they first described the personal, job, and practice characteristics of the study sample, by sex, then compared procedure volumes after restricting the sample to those who performed each procedure at least five times in the previous year (TABLE).
There were striking differences between the male and female cardiologists in the type and amount of work they performed: women were more likely to have specialized in general/noninvasive cardiology and with a lower proportion reporting an interventional subspecialty compared to men. Numerous job characteristics differed by gender, too: women were more likely to work part time (20% vs. 10%) and take no call (17% vs. 7%).
Investigators analyzed work relative value units (RVUs) that Medicare uses when determining compensation level for a particular service. These RVUs are generated based on several factors, including the relative level of time, skill, training, and intensity to provide a given service. Female cardiologists billed for 22% fewer work RVUs (7,404 vs. 9,497), and had 22% lower mean salaries ($400,162 vs. $510,996) than male cardiologists.
The raw 22% difference in mean pay ($110,834) was reduced to a 12% difference after adjusting for work RVUs alone and reduced to a 7% difference after further adjustment for other recorded differences in work activities and practice. Still, based on measured job and productivity characteristics, the study authors estimated that women in this sample would have been expected to have a mean salary that was $31,749 higher than that actually observed.
Multivariate analysis confirmed the direction and magnitude of the independent association between sex and salary.
While the authors had a lot of data to analyze, in an accompanying editorial comment, Mark A. Hlatky, MD, FACC, (Stanford University School of Medicine), and Leslee Shaw, PhD, FACC, (Emory University School of Medicine), noted that Jagsi et al. did not have data on quite a few important variables, such as the number of percutaneous coronary interventions (PCIs) each doctor performed, the number of years each doctor had worked in practice, whether they were a full partner, or how many referrals they generated, each of which could affect pay levels.
Hlatky and Shaw wrote: “The extent to which women may have had career interruptions due to pregnancy and child-rearing responsibilities, or were younger and not in senior administrative positions, might also have affected their pay level.”
While it’s uncertain how much of the residual pay difference is due to being a female cardiologist and how much is due to differences in unmeasured factors that affect pay levels, the most striking observations of the study, according to Hlatky and Shaw, were how few of the cardiologists were women, and how different their work was. “The proportion of women who enter cardiology continues to be much lower than the proportion of women in medical schools—why are only 20% of new cardiology trainees women?”
Clearly, within cardiology, women follow different career paths than men, and are particularly less likely to pursue careers in interventional cardiology and electrophysiology. In concluding their commentary, Hlatky and Shaw wrote: “The reasons for these very different career choices ought to be explored further, and we need to understand whether women physicians are repelled from cardiology, or simply attracted to other fields. Perhaps more attention to work-life balance in cardiology would make it more attractive to women, and better for us all.”
Jagsi R, Biga C, Poppas A, et al. J Am Coll Cardiol. 2015 [Epub ahead of print]
Hlatky MA, Shaw L. J Am Coll Cardiol. 2015 [Epub ahead of print]
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