Nuclear Cardiology: Celebrating the Past and Present While Looking Towards the Future
Nuclear cardiology has played an important role in understanding the pathology and guiding management of cardiovascular disease. In the following interview, Renee Bullock-Palmer, MBBS, FACC, interviews Jennifer H. Mieres, MD, FACC, and Leslee J. Shaw, PhD, FACC, both past presidents of the American Society of Nuclear Cardiology (ASNC) and experts in nuclear cardiology and cardiovascular disease in women, on how they began their careers and advice for others in their field.
What attracted you to the field of nuclear cardiology?
Mieres: My interest in nuclear cardiology was sparked as a first-year cardiology fellow during a cardiology grand rounds presentation by Alan Rozanski, MD, FACC, who had just joined the cardiology faculty. His intriguing lecture on the role of nuclear cardiology in the evaluation of the patient at risk for coronary artery disease highlighted the important link of the identification of extent of ischemia on stress myocardial perfusion imaging and incidence of myocardial infarction.
After spending a few rotations in the nuclear cardiology laboratory with Rozanski and E. Gordon DePuey, III, MD, FACC, I decided on a subspecialty in nuclear cardiology. My first job after cardiology fellowship was as an assistant director of nuclear cardiology at North Shore University Hospital in Manhasset, where I then became the director of nuclear cardiology. Several years later, I was the director of nuclear cardiology at NYU Medical Center (2006-2010).
Shaw: I was attracted to the field of nuclear cardiology because it was exciting to examine the relationship between nuclear findings and prognosis. We learned so much and it just seemed like there was a lot of promise in what we could find.
What are the greatest contributions that nuclear cardiology made to the field of cardiology?
Mieres: The greatest contribution is the prognostic evaluation of patients with or who are at risk for coronary artery disease. Contemporary nuclear cardiology techniques are now increasingly used for the evaluation of the anti-ischemic effects of various cardiovascular treatment strategies, based on the changes in myocardial perfusion defect size defined by sequential myocardial perfusion imaging. This facilitates the ability to follow and assess a patient’s risk for subsequent cardiac events on the basis of the magnitude of ischemia suppression (e.g. the COURAGE trial).
Another contribution is viability assessment with positron emission tomography (PET) and single-photon emission computed tomography (SPECT) imaging to determine the presence and extent of dysfunctional but viable myocardium in the patient with reduced left ventricular function.
Shaw: The key contributions have to do with the relationship between stress myocardial perfusion findings and prognosis, as well as the findings from numerous clinical trials. These are major to the field of cardiovascular medicine and help guide clinical care of millions of patients. These findings have been critical to improve care and formed the basis for ischemia-guided management.
How has nuclear cardiology impacted women's heart health?
Mieres: Nuclear cardiology plays a major role in the identification of the full spectrum of ischemic heart disease in symptomatic women at risk for cardiovascular disease. This includes the detection of obstructive coronary artery disease, non-obstructive coronary artery disease, and the interrogation of the coronary microvasculature with coronary flow reserve with PET.
Contemporary techniques of SPECT and PET myocardial perfusion imaging can be used to accurately risk stratify women at risk or with ischemic heart disease. The addition of coronary flow reserve with PET improves risk detection, including for women with non-obstructive coronary artery disease and coronary microvascular dysfunction.
Shaw: The evidence obtained from several research studies in the field of nuclear cardiology was part of the initial scientific evidence that showed that a focus on obstructive coronary artery disease only — which was the focus of most diagnostic tests in years past — was misguided.
Moreover, we demonstrated that women were increasingly at risk and even in some cases at higher risk than men. The disconnect between diagnostic accuracy and risk stratification was a fundamental segue to where we are today in our understanding that women are different and physiology plays a key role in understanding symptoms and risk.
What are the most exciting advances in the nuclear cardiology field?
Shaw: There have been so many exciting advances in nuclear cardiology. Most recently, the growing evidence and indications for use of PET: a better safety profile with reduced radiation exposure for perfusion imaging (~3 mSv) and the added benefit of coronary flow reserve.
This makes for a phenomenal test that has improved accuracy, better image quality, is safer, and provides novel measures of myocardial blood flow with perfusion. It is our perfect test, at least from what we can offer our patients.
Where do you see the future of nuclear cardiology?
Shaw: It is hard to say what the future of nuclear cardiology will look like. I think we need more dedicated research, especially in the development of strategies of care. However, there is promise of a lot of new areas of inquiry — including sarcoidosis – that allow us to provide novel applications to patients.
What is your motivation?
Mieres: My motivation is the long-term goal of empowering people to be partners in their health and health care decisions. It is the adoption and inclusion of our cardiovascular health care delivery model, with the patient as a partner.
Shaw: Improving patient care is always a goal. We have to develop high-quality evidence to improve the lives of our patients. My goal is to do my best to develop high-quality, randomized trials in the hopes that we can find new avenues and findings to improve patient care.
What are the key factors of good leadership?
Mieres: I think that it is important to focus on the adoption of a “transformational leadership style.” Important leadership traits of this style include:
- Motivating and inspiring team members and others with a shared vision of the future.
- Effective communication.
- Effective listening.
- Flexibility and adaptability.
- Being accountable, self-aware, authentic, empathetic and humble.
- Setting clear goals.
- Refining the ability to have crucial conversations.
- Good conflict-resolution skills.
Shaw: Caring, fairness and intellect are factors of good leadership. All are important and, in that order, reflect someone who offers sustainable leadership! I have and still see many who shortcut several of these factors. To get buy-in from others, you must have all three qualities.
What career advice would you give to your younger self?
Mieres: Take time to reflect and celebrate with family and friends. Do not be too hard on yourself in the setting of a failure. Learn that it is okay to fail and take time to learn from failures. F.A.I.L. means First Attempt In Learning. Keep an open mind for learning, learn to appreciate the power of meditation, do not overcommit, and seek and engage mentors.
Shaw: Do not give up and stay true to your vision. See a better world and set out to change one part of it at a time.
What advice would you give to avoid burnout?
Shaw: Take time off or get away, even for a short time. Do not beat yourself up with failure. We have a complicated health care system and failure will happen. Get as many people – family and friends – to be your support system. We all need support and it is fundamental to your healing!
Why do you think it is important to be involved in a national cardiac society?
Mieres: Networking, shared interest, finding mentors and sponsors, and fostering academic growth are major reasons to be in a cardiac society. I have enjoyed being a mentor and sponsor and expanding the network of colleagues committed to and passionate about cardiac imaging and nuclear cardiology.
Shaw: You can make a difference! All national societies need help in so many ways. There is always something that you can do to help. You have a voice and it can help others.
How can people who are currently not involved in national societies get more involved?
Shaw: Reach out to anyone in leadership. Set up a call and see what sounds interesting to you. Start small. Do things that you know you have time to do and then build on your work. You can make a difference.
How does ASNC interface with other societies like the ACC? Is there benefit to both?
Shaw: There is a benefit to both societies as ASNC members are largely also ACC members. Imaging is a core component of cardiovascular medicine. Problems for ASNC are also important to the ACC. Both of these societies work closely to guide policy, clinical guidelines, and appropriate use criteria for all of the imaging societies.