Background While telehealth utilization has decreased following the COVID-19 pandemic, the incorporation of remote visits into ambulatory cardiology practice guidelines remains a necessity. The aim of this study was to survey cardiologists' perceptions on telehealth practices post-pandemic, and to propose clinical workflow models for remote visit types.Methods A 25-item survey was distributed to 481 American College of Cardiology CardioSurve panelists from 14 April 2023 through 11 May 2023. Descriptive analyses were conducted to evaluate provider demographics and reported percentages of responses to opinions and statements in the questionnaire. Chi-square and Fisher's exact tests were performed to determine statistically significant associations between categorical variables. Kruskal-Wallis H tests were performed on telemedicine visit frequency offered before, during, and after the pandemic.Results Seventy percent of respondents continue to offer telemedicine visits post-pandemic. Early career cardiologists were more likely to offer telemedicine visits compared to later career colleagues (p = 0.004). The odds ratio for offering telemedicine visits for early career compared to late-career was 5.56 (95% CI [1.910, 16.277]) and 1.394 (95% CI [0.594, 3.269]) for mid-career compared to late-career. Sixty-three percent of respondents reported that lack of reliable internet access posed challenges for outpatient visits, and approximately one-third believed that the risk for malpractice increased when providing care remotely. Only 22% of cardiologists reported the use of telepresenters. Three clinical workflow models were then constructed to address potential barriers to telehealth implementation.Conclusions Cardiologists continue to offer telehealth visits, but concerns persist regarding the feasibility and appropriateness for a variety of ambulatory encounter types. To address these concerns, we have proposed several models for telehealth integration into various outpatient settings to optimize access to care and lighten the burden placed on an already diminishing cardiology workforce.

BACKGROUND:The Veterans Affairs (VA) Healthcare System maintains the largest integrated health system in the United States but also supports fee-for-service insurance for veterans receiving care in community facilities outside the VA. We sought to evaluate the management and outcomes of patients referred for consultation in either venue, using cardiovascular evaluation as a model. METHODS:We conducted a retrospective cohort study identifying patients enrolled in the VA Healthcare System referred for cardiovascular evaluation from October 2020 through September 2024 and stratified the population based on the venue in which evaluation was completed. The primary outcome was major adverse cardiovascular events (acute coronary syndromes/stroke/mortality) in a matched population. RESULTS:Among 235 197 consultations for cardiovascular evaluation, 201 453 were completed in the chosen venue within 6 months. The time between consultation and evaluation was similar across venues (community, 35 days [95% CI, 17-65] versus VA, 33 days [95% CI, 19-53]), with comparable delays to diagnostic testing or therapeutic interventions. Patients receiving care in the community were more likely to undergo stress testing (43.2% versus 36.4%, P=1.5×10-46) and coronary angiography (23.1% versus 17.4%, P=2.1×10-51) within 2 years compared with those treated in the VA Healthcare System. Despite this, patients treated in the community had a significantly higher rate of major adverse events at 2 years (17.6% versus 15.3%, P=5.9×10-10) compared with those treated in the VA Healthcare System. CONCLUSIONS:Patients undergoing cardiovascular evaluation in community practices were not evaluated more rapidly than those seen in the VA, though they were more likely to receive initial and repeat diagnostic testing. Adverse events were more common among community-treated patients than those in the VA, suggesting an opportunity to optimize access to care while improving clinical outcomes.

Background Previous work has demonstrated disparities in the management of cardiovascular disease among men and women. We sought to evaluate these disparities and their associations with clinical outcomes among patients admitted with acute coronary syndromes to the Veterans Affairs Healthcare System. Methods and Results We identified all patients that were discharged with acute coronary syndromes within the Veterans Affairs Healthcare System from October 1, 2015 to September 30, 2022. Medical and procedural management of patients was subsequently assessed, stratified by sex. In doing so, we identified 76 454 unique admissions (2327 women, 3.04%), which after propensity matching created an analytic cohort composed of 6765 men (74.5%) and 2295 women (25.3%). Women admitted with acute coronary syndromes were younger with fewer cardiovascular comorbidities and a lower prevalence of preexisting prescriptions for cardiovascular medications. Women also had less coronary anatomic complexity compared with men (5 versus 8, standardized mean difference [SMD]=0.40), as calculated by the Veterans Affairs SYNTAX score. After discharge, women were significantly less likely to receive cardiology follow‐up at 30 days (hazard ratio [HR], 0.858 [95% CI, 0.794–0.928]) or 1 year (HR, 0.891 [95% CI, 0.842–0.943]), or receive prescriptions for guideline‐indicated cardiovascular medications. Despite this, 1‐year mortality rates were lower for women compared with men (HR, 0.841 [95% CI, 0.747–0.948]). Conclusions Women are less likely to receive appropriate cardiovascular follow‐up and medication prescriptions after hospitalization for acute coronary syndromes. Despite these differences, the clinical outcomes for women remain comparable. These data suggest an opportunity to improve the posthospitalization management of cardiovascular disease regardless of sex.

During infancy, orienting and gaze aversion serve as major self-regulatory mechanisms and play an important role in the development of deliberate self-regulation and control. The present study examined the interaction of intrinsic factors (MAOA-uVNTR and 5-HTTLPR gene polymorphisms) and extrinsic factors (maternal sensitivity) on early infant self-regulatory behavior. We assessed 5-HTTLPR (ss + sl versus ll) and MAOA-uVNTR (3 and 4 among boys, and 3/3, 3/4, and 4/4 among girls) polymorphisms, determined maternal sensitivity during mother–child free play, and coded infant self-regulatory behavior (i.e., orienting shifts in a temperament test) in 281 six-month-old infants. We found that infants who experienced a lower level of maternal sensitivity and had the short allele of 5-HTTLPR variants and the 3/3 MAOA-uVNTR polymorphism displayed lower self-regulation capacity than did those infants with a higher level of maternal sensitivity. This finding suggested a modulatory role of maternal sensitivity. Moreover, these findings are consistent with the genetic vulnerability hypothesis, which states that beneficial environmental factors serve as a buffer against harmful genetic predispositions during child development.

The effects of nonphysiological flow generated by continuous-flow (CF) left ventricular assist devices (LVADs) on the aorta remain poorly understood.The authors sought to quantify indexes of fibrosis and determine the molecular signature of post–CF-LVAD vascular remodeling.Paired aortic tissue was collected at CF-LVAD implant and subsequently at transplant from 22 patients. Aortic wall morphometry and fibrillar collagen content (a measure of fibrosis) was quantified. In addition, whole-transcriptome profiling by RNA sequencing and follow-up immunohistochemistry were performed to evaluate CF-LVAD–mediated changes in aortic mRNA and protein expression.The mean age was 52 ± 12 years, with a mean duration of CF-LVAD of 224 ± 193 days (range 45-798 days). There was a significant increase in the thickness of the collagen-rich adventitial layer from 218 ± 110 μm pre-LVAD to 410 ± 209 μm post-LVAD (P < 0.01). Furthermore, there was an increase in intimal and medial mean fibrillar collagen intensity from 22 ± 11 a.u. pre-LVAD to 41 ± 24 a.u. post-LVAD (P < 0.0001). The magnitude of this increase in fibrosis was greater among patients with longer durations of CF-LVAD support. CF-LVAD led to profound down-regulation in expression of extracellular matrix–degrading enzymes, such as matrix metalloproteinase-19 and ADAMTS4, whereas no evidence of fibroblast activation was noted.There is aortic remodeling and fibrosis after CF-LVAD that correlates with the duration of support. This fibrosis is due, at least in part, to suppression of extracellular matrix–degrading enzyme expression. Further research is needed to examine the contribution of nonphysiological flow patterns on vascular function and whether modulation of pulsatility may improve vascular remodeling and long-term outcomes.

BACKGROUND Despite the increase in the number of female physicians across most specialties within cardiology, <10% of clinical cardiac electrophysiology (EP) fellows are women. OBJECTIVES This study sought to determine the factors that influence fellows-in-training (FITs) to pursue EP as a career choice and whether this differs by gender. METHODS The authors conducted an online multiple-choice survey through the American College of Cardiology to assess the decision factors that influence FITs in the United States and Canada to pursue cardiovascular subspecialties. RESULTS A total of 933 (30.5%) FITs completed the survey; 129 anticipated specializing in EP, 259 in interventional cardiology (IC), and 545 in a different field or were unsure. A total of 1 in 7 (14%) FITs indicated an interest in EP. Of this group, more men chose EP than women (84% vs 16%; P < 0.001). The most important factor that influenced FITs to pursue EP was a strong interest in the field. Women were more likely to be influenced by having a female role model (P = 0.001) compared with men. After excluding FITs interested in IC, women who deselected EP were more likely than men to be influenced by greater interest in another field (P = 0.004), radiation concerns (P = 0.001), lack of female role models (P = 0.001), a perceived "old boys' club" culture (P = 0.001) and discrimination/harassment concerns (P = 0.001). CONCLUSIONS Women are more likely than men to be negatively influenced by many factors when it comes to pursuing EP as a career choice. Addressing those factors will help decrease the gender disparity in the field. (J Am Coll Cardiol 2021;78:898-909) (c) 2021 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).

Maternal morbidity and mortality continue to rise in the United States, with cardiovascular disease as the leading cause of maternal deaths. Congenital heart disease is now the most common cardiovascular condition encountered during pregnancy, and its prevalence will continue to grow. In tandem with these trends, maternal cardiovascular health is becoming increasingly complex. The identification of women at highest risk for cardiovascular complications is essential, and a team-based approach is recommended to optimize maternal and fetal outcomes. This document, the second of a 5-part series, will provide practical guidance from pre-conception through postpartum for cardiovascular conditions that are predominantly congenital or heritable in nature, including aortopathies, congenital heart disease, pulmonary hypertension, and valvular heart disease.

HomeCirculationVol. 143, No. 7Temporal Trends in the Proportion of Women Physician Speakers at Major Cardiovascular Conferences Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBTemporal Trends in the Proportion of Women Physician Speakers at Major Cardiovascular Conferences Celina M. Yong, MD, MBA, MSc, Sowmya Balasubramanian, MD, Pamela S. Douglas, MD, Prachi Agarwal, MD, Ulrika Birgersdotter-Green, MD, Santosh Gummidipundi, MS, Wayne Batchelor, MD, MHS, Claire S. Duvernoy, MD, Robert A. Harrington, MD and Roxana Mehran, MD Celina M. YongCelina M. Yong Celina M. Yong, MD, MBA, MSc, Palo Alto Veterans Affairs Healthcare System Stanford University, 3801 Miranda Ave, 111C, Palo Alto, CA 94304. Email E-mail Address: [email protected] https://orcid.org/0000-0003-3054-6576 Veterans Affairs Palo Alto Healthcare System, CA (C.M.Y., S.G.). Department of Medicine, Stanford University School of Medicine, and Stanford Cardiovascular Institute, CA (C.M.Y., R.A.H.). , Sowmya BalasubramanianSowmya Balasubramanian Department of Pediatrics, Internal Medicine, and Radiology, University of Michigan, Ann Arbor (S.B., P.A., C.S.D.). , Pamela S. DouglasPamela S. Douglas Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (P.S.D.). , Prachi AgarwalPrachi Agarwal Department of Pediatrics, Internal Medicine, and Radiology, University of Michigan, Ann Arbor (S.B., P.A., C.S.D.). , Ulrika Birgersdotter-GreenUlrika Birgersdotter-Green https://orcid.org/0000-0002-0473-1826 UC San Diego Health, La Jolla, CA (U.B-G.). , Santosh GummidipundiSantosh Gummidipundi Veterans Affairs Palo Alto Healthcare System, CA (C.M.Y., S.G.). , Wayne BatchelorWayne Batchelor https://orcid.org/0000-0002-3016-1150 Inova Heart and Vascular Institute, Falls Church, VA (W.B.). , Claire S. DuvernoyClaire S. Duvernoy https://orcid.org/0000-0002-2879-9876 Department of Pediatrics, Internal Medicine, and Radiology, University of Michigan, Ann Arbor (S.B., P.A., C.S.D.). , Robert A. HarringtonRobert A. Harrington Department of Medicine, Stanford University School of Medicine, and Stanford Cardiovascular Institute, CA (C.M.Y., R.A.H.). and Roxana MehranRoxana Mehran https://orcid.org/0000-0002-5546-262X Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.). Originally published15 Feb 2021https://doi.org/10.1161/CIRCULATIONAHA.120.052663Circulation. 2021;143:755–757The field of cardiovascular medicine, and especially its procedural subspecialties, rank among the lowest of all fields in medicine in terms of female representation.1 Lack of role models has been cited as a major reason, driving recent efforts to highlight female role models as speakers at major cardiology conferences.2,3 However, few studies have quantified and examined the impact of these efforts.We collected data on 80 680 speakers from annual cardiovascular conferences with more than 2500 attendees, organized by the European Society of Cardiology, American College of Cardiology (ACC), American Heart Association, Transcatheter Therapeutics, Heart Rhythm Society, and American Society of Echocardiography. Using society/organization records, we ascertained self-reported gender of physician faculty from 2015 to 2019, with breakdown by speaker type. We applied a name algorithm to missing gender records (American Heart Association, 65%; ACC, 30%; Transcatheter Therapeutics, 100%).4 Statistical analyses included proportions, Cochran–Armitage test for trend, and 2-sample proportional test. The data that support the findings for this study are available from the corresponding author on reasonable request. This project did not require Institutional Review Board review because it did not use any identifiable private information.Overall, the proportion of women speakers increased over time (Figure [A]) (P<0.0001). Invasive fields had the lowest proportions of women speakers (5-year mean, 16% at Heart Rhythm Society; 10% at Transcatheter Therapeutics), although they were higher than the proportion of board-certified women in their respective subspecialties (9% electrophysiologists, 7% interventionalists).1,5 Subanalysis showed that the average number of talks given per woman was higher than per man at general and noninvasive conferences (1.81 per woman versus 1.74 per man at European Society of Cardiology, ACC, and American Society of Echocardiography combined in 2019), but not at an invasive specialty conference (1.52 per woman versus 1.58 per man at Transcatheter Therapeutics in 2019).Download figureDownload PowerPointFigure. Temporal trends in women speakers at major cardiovascular conferences and speaking roles stratified by gender and subspecialty category.A, Percentages of women speakers at major cardiovascular conferences (AHA, ACC, HRS, ASE, TCT, ESC), as well as overall trend, show a low but gradual increase from 2015 to 2019 (overall P<0.001). Cochran-Armitage test for trend was used to calculate P values for the relationship between gender and time for each conference. B, Mean percentages of women and men in each speaker role (moderator, panelist, speaker, abstract/case presenter) are shown for 2019, subdivided into noninvasive (general cardiology and echocardiography) and invasive categories (electrophysiology, interventional cardiology). Two-sample proportional test was used to calculate P values for the gender difference for each speaker role type. Note: Totals add to more than 100% given that most individuals gave more than 1 talk per conference. Analysis included AHA, ACC, HRS, ASE, and TCT. ACC indicates American College of Cardiology; AHA, American Heart Association; ASE, American Society of Echocardiography; ESC, European Society of Cardiology; HRS, Heart Rhythm Society; and TCT, Transcatheter Therapeutics.Speaker role (moderator, panelist, speaker, abstract/case presenter) also varied by gender, with more men serving in all roles than women (Figure [B]; P<0.0001 for all). Differences were most pronounced for high-profile talks (as defined by conference organizers) among invasive specialties. One hundred percent of high-profile interventional cardiology talks from 2017 to 2019 and 100% of the electrophysiology high-profile talks from 2015 to 2018 at ACC were given by men. Noninvasive specialties were more balanced; women gave 46% (n=25) of cardiovascular disease and 53% (n=21) of heart failure high-profile talks in the course of 5 years at ACC. Women were poorly represented among late-breaking clinical trial presenters (6% women at American Heart Association in 2019; 14% women at ACC from 2016 to 2019).We demonstrate a low but gradual increase in women physician speakers at major cardiovascular conferences over time. To achieve this, the same women are often being tasked with giving more presentations, albeit not more high-profile ones.The paucity of women in high-profile roles and near absence from the podium at late breaking trial presentations reflects a historical and contemporary exclusion of women in major roles at national meetings. This important finding highlights the challenges to helping trainees identify role models, but more importantly, high-profile speaking roles are often considered essential for career advancement and academic promotion, with impacts on access to funding and leadership growth.This study has several limitations. Faculty lists may not reflect last-minute changes. Name algorithms have inherent limitations, and we could not account for gender nonbinary individuals. Proportions of women who declined speaking invitations were not available, revealing the need for better tracking moving forward.Although conference organizers should be recognized for successes in diversifying faculty, the persistent lack of women in the most visible roles must be addressed to achieve the stated goals of equity and, ultimately, to develop a physician workforce that represents the patient population served. Further investigation of the career level of speakers (early versus late) may elucidate the degree to which a glass ceiling persists. Additional research should determine whether intentional efforts (often with female leadership) to increase gender representation at major meetings eventually leads to greater entry of women in the field and their advancement, particularly in subspecialties where women are most underrepresented.AcknowledgmentsSpecial thanks to the American College of Cardiology (Anne Rzeszut, Jack Reilly), American Heart Association (Melissa Jarvis), Heart Rhythm Society (Andrea Russo, MD, Christine M. Albert, MD, MPH, Jennifer Johnson, Jay Vegso), and American Society of Echocardiography (Kelly Joy) for providing data for this study.Research SupportDr Yong is funded by a Career Development Award from the United States (US) Department of Veterans Affairs Health Services Research & Development Service of the VA Office of Research and Development.Disclosures None.Footnoteshttps://www.ahajournals.org/journal/circCelina M. Yong, MD, MBA, MSc, Palo Alto Veterans Affairs Healthcare System Stanford University, 3801 Miranda Ave, 111C, Palo Alto, CA 94304. Email [email protected]eduReferences1. Accreditation Council for Graduate Medical Education. Data Resource Book 2018-2019.Accessed August 19, 2020. https://www.acgme.org/About-Us/Publications-and-Resources/Graduate-Medical-Education-Data-Resource-Book.Google Scholar2. Douglas PS, Rzeszut AK, Bairey Merz CN, Duvernoy CS, Lewis SJ, Walsh MN, Gillam L; American College of Cardiology Task Force on Diversity and Inclusion and American College of Cardiology Women in Cardiology Council. Career preferences and perceptions of cardiology among US internal medicine trainees: Factors influencing cardiology career choice.JAMA Cardiol. 2018; 3:682–691. doi: 10.1001/jamacardio.2018.1279CrossrefMedlineGoogle Scholar3. Yong CM, Abnousi F, Rzeszut AK, Douglas PS, Harrington RA, Mehran R, Grines C, Altin SE, Duvernoy CS; American College of Cardiology Women in Cardiology Leadership Council (ACC WIC); Society for Cardiovascular Angiography and Interventions Women in Innovations (SCAI WIN).Sex Differences in the pursuit of interventional cardiology as a subspecialty among cardiovascular fellows-in-training.J Am Coll Cardiol Cardiovasc Interv. 2019; 12:219–228. doi: 10.1016/j.jcin.2018.09.036CrossrefGoogle Scholar4. Driver C, Grosman A, Scaramozzino P. Dividend policy and investor pressure.Economic Modelling. 2020; 89:559–76.CrossrefGoogle Scholar5. American Association of Medical Colleges.2018 Physician Specialty Data Report.Accessed August 26, 2020. https://www.aamc.org/data-reports/workforce/interactive-data/active-physicians-sex-and-specialty-2017.Google Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Patel K and Birgersdotter-Green U (2022) Six percent of electrophysiology operators in the United States are women: Are we making enough progress?, Heart Rhythm, 10.1016/j.hrthm.2022.02.023, 19:5, (812-813), Online publication date: 1-May-2022. Coylewright M, Dodge S, Bachour K, Hossain S, Zeitler E, Kearing S, Douglas P, Holmes D, Reddy V and Nair D (2022) Women in procedural leadership roles in cardiology: The Women In Local Leadership (WILL) observational study, Heart Rhythm, 10.1016/j.hrthm.2021.12.012, 19:4, (623-629), Online publication date: 1-Apr-2022. Abdulsalam N, Gillis A, Rzeszut A, Yong C, Duvernoy C, Langan M, West K, Velagapudi P, Killic S and O'Leary E (2021) Gender Differences in the Pursuit of Cardiac Electrophysiology Training in North America, Journal of the American College of Cardiology, 10.1016/j.jacc.2021.06.033, 78:9, (898-909), Online publication date: 1-Aug-2021. Feigofsky S (2021) "And Then She Vanished", JACC: Case Reports, 10.1016/j.jaccas.2021.04.025, 3:9, (1241-1243), Online publication date: 1-Aug-2021. Nakayama A, Kamiya C, Kanki S, Ide T, Bando Y, Uemura Y and Tsukada Y (2022) Awareness and Feasibility of Women Chairing Cardiology Sessions in Scientific Meetings: A Nationwide Survey by the Japanese Circulation Society, Frontiers in Cardiovascular Medicine, 10.3389/fcvm.2022.871546, 9 February 16, 2021Vol 143, Issue 7 Advertisement Article InformationMetrics © 2021 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.120.052663PMID: 33587663 Originally publishedFebruary 15, 2021 Keywordsdisparities, healthcarewomengender equityPDF download Advertisement SubjectsDisparitiesWomen, Sex, and Gender

Objectives To examine the association of operator sex with appropriateness and outcomes of percutaneous coronary intervention (PCI). Background Recent studies suggest that physician sex may impact outcomes for specific patient cohorts. There are no data evaluating the impact of operator sex on PCI outcomes. Methods We studied the impact of operator sex on PCI outcome and appropriateness among all patients undergoing PCI between January 2010 and December 2017 at 48 non-federal hospitals in Michigan. We used logistic regression models to adjust for baseline risk among patients treated by male versus female operators in the primary analysis. Results During this time, 18 female interventionalists and 385 male interventionalists had performed at least one PCI. Female interventionalists performed 6362 (2.7%) of 239,420 cases. There were no differences in the odds of mortality (1.48% vs. 1.56%, adjusted OR [aOR] 1.138, 95% CI: 0.891-1.452), acute kidney injury (3.42% vs. 3.28%, aOR 1.027, 95% CI: 0.819-1.288), transfusion (2.59% vs. 2.85%, aOR 1.168, 95% CI: 0.980-1.390) or major bleeding (0.95% vs. 1.07%, aOR 1.083, 95% CI: 0.825-1.420) between patients treated by female versus male interventionalist. While the absolute differences were small, PCIs performed by female interventional cardiologists were more frequently rated as appropriate (86.64% vs. 84.45%, p-value <0.0001). Female interventional cardiologists more frequently prescribed guideline-directed medical therapy. Conclusions We found no significant differences in risk-adjusted in-hospital outcomes between PCIs performed by female versus male interventional cardiologists in Michigan. Female interventional cardiologists more frequently performed PCI rated as appropriate and had a higher likelihood of prescribing guideline-directed medical therapy.

Background Cardiac rehabilitation is an established performance measure for adults with ischemic heart disease, but patient participation is remarkably low. Home‐based cardiac rehabilitation (HBCR) may be more practical and feasible, but evidence regarding its efficacy is limited. We sought to compare the effects of HBCR versus facility‐based cardiac rehabilitation (FBCR) on functional status in patients with ischemic heart disease. Methods and Results This was a pragmatic trial of 237 selected patients with a recent ischemic heart disease event, who enrolled in HBCR or FBCR between August 2015 and September 2017. The primary outcome was 3‐month change in distance completed on a 6‐minute walk test. Secondary outcomes included rehospitalization as well as patient‐reported physical activity, quality of life, and self‐efficacy. Characteristics of the 116 patients enrolled in FBCR and 121 enrolled in HBCR were similar, except the mean time from index event to enrollment was shorter for HBCR (25 versus 77 days; P<0.001). As compared with patients undergoing FBCR, those in HBCR achieved greater 3‐month gains in 6‐minute walk test distance (+95 versus +41 m; P<0.001). After adjusting for demographics, comorbid conditions, and indication, the mean change in 6‐minute walk test distance remained significantly greater for patients enrolled in HBCR (+101 versus +40 m; P<0.001). HBCR participants reported greater improvements in quality of life and physical activity but less improvement in exercise self‐efficacy. There were no deaths or cardiovascular hospitalizations. Conclusions Patients enrolled in HBCR achieved greater 3‐month functional gains than those enrolled in FBCR. Our data suggest that HBCR may safely derive equivalent benefits in exercise capacity and overall program efficacy in selected patients. Registration URL: https://www.clini​caltr​ials.gov; Unique identifier: NCT02105246.

HomeCirculation: Cardiovascular Quality and OutcomesVol. 13, No. 8The Accreditation Council for Graduate Medical Education Mandates That You Attempt to Enhance Diversity in Your Cardiology Program Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessArticle CommentaryPDF/EPUBThe Accreditation Council for Graduate Medical Education Mandates That You Attempt to Enhance Diversity in Your Cardiology ProgramGreat! (How Do We Do That?) Claire S. Duvernoy, MD Quinn CapersIV, MD Claire S. DuvernoyClaire S. Duvernoy Claire S. Duvernoy, MD, VA Ann Arbor Healthcare System, 2215 Fuller Rd, Box 111a, Ann Arbor, MI 48105. Email E-mail Address: [email protected] https://orcid.org/0000-0002-2879-9876 VA Ann Arbor Healthcare System and University of Michigan Medical School Department of Internal Medicine, Division of Cardiovascular Medicine (C.S.D.). and Quinn CapersQuinn Capers VA Ann Arbor Healthcare System and University of Michigan Medical School Department of Internal Medicine, Division of Cardiovascular Medicine (C.S.D.). Originally published17 Jun 2020https://doi.org/10.1161/CIRCOUTCOMES.120.006912Circulation: Cardiovascular Quality and Outcomes. 2020;13:e006912A second-year internal medicine resident at University Hospital, Shawn, had always been interested in cardiology. Shawn was the only African American in the University Hospital program. During his postgraduate year 2 Shawn learned that his coresidents interested in cardiology were all working on cardiology-related research projects with cardiology attendings with whom they had rotated. On the first day of his next cardiology rotation, he informed the attending of his interest in pursuing cardiology as a career. After 1 month of enthusiastically working very long hours, Shawn was disappointed when no mentorship offers or opportunities to work on a research project materialized.When Shawn's coresidents met with their research advisors, they were given advice on the optimal number of cardiology programs to apply to and were steered toward programs where their advisors had close colleagues. Shawn received no such advice as he did not have a defined mentor. He applied to 8 cardiology fellowship programs that ranked high and were located in cities where he might like to live. With letters of recommendation stating that he was "dependable," "quietly competent," and had performed "solidly" on his cardiology rotations and a United States Medical Licensing Examination Step 1 score of 220 (passing but not outstanding), he received no interview invitations. Over the next year and a half, Shawn eventually warmed to the idea of a career as a general internist.The catheterization laboratory director looked at Julia with concern; his demeanor radiated empathy and sincerity. "Interventional cardiology is a tough job, especially for a young woman, given all of your added responsibilities. We work late and don't get to see our kids much. There is a reason you don't see many women interventionalists. Are you sure that this is what you want?" As she sat in his office, the only woman cardiology fellow, she struggled with the right response. Julia had always been able to translate hard work, perseverance, and a knack for doing well on standardized tests into success in achieving her goals. For the first time, she felt that her work ethic and intellect might not be enough. Feeling like she needed to debrief with a woman, she sought the counsel of Dr Smith—the echocardiography laboratory director (there are no women interventional cardiologists). Dr Smith was sympathetic, understanding, and was able to defuse the situation with humor. Julia had always considered Dr Smith a role model—she was a leader in the cardiology division, a productive researcher, and had a satisfying family life. Shortly after starting an advanced elective with Dr Smith, Julia made a decision: although she found cardiac catheterization and intervention more exciting than imaging, she would pursue the field of advanced echocardiography and follow in Dr Smith's footsteps.Recent reports show that only 13% of practicing cardiologists are women and that underrepresented minorities (URMs; including Hispanic, African American, American Indian, and Native Alaskan/Pacific Islander individuals) account for <6% of practicing cardiologists.1 Given recent information that URM and women physicians may enhance the quality of care provided to a diverse patient population in the United States,2–4 it is imperative that we enhance diversity in our workforce. This will include establishing strong pipelines from kindergarten onward that expose girls/women and URMs to medicine; mentoring programs in college and medical school; dismantling bias in application processes; active efforts to make the specialty more appealing and inclusive; and active (as opposed to passive) recruiting efforts. Ultimately, dismantling structural biases in the entire educational system and society will be required to enhance diversity in higher education and medicine. Such important efforts are beyond the scope of this essay; we will discuss the more immediate pipeline and its barriers to enhancing diversity in cardiology.In a 2009 survey, men and women internal medicine resident physicians were asked about what factors influenced their career choices to pursue cardiology.5 Interest in cardiovascular pathophysiology, high earning potential, and positive role models were considered the most important positive factors in choosing cardiology and were more likely to be considered important by male trainees; adverse job conditions, interference with family life, and lack of diversity were some of the highest ranked negative factors. Women were significantly less likely to choose cardiology as a career; those who ultimately did so were less likely to consider cardiology a male-dominated field and less likely to report having been discouraged from considering cardiology. Similarly, in a 2017 survey of cardiology trainees, women were more likely than men to be influenced against interventional cardiology by negative factors such as the physically demanding nature of the job, concerns regarding radiation exposure, lack of female role models, sex discrimination or harassment, and perception of an old-boys-club culture.6While women now comprise >50% of US medical students and nearly half of internal medicine residents, URMs are in short supply throughout. In fact, a recent publication by the Association of American Medical Colleges revealed that fewer Black men applied to medical school in 2014 than in 1978.7 Lack of resources in the early school years, lack of visible role models, and bias and racism throughout the educational journey are some of the underlying reasons. Women of color face similar hurdles.How can our profession counter these negative factors and bring in more women and minorities? The Table outlines strategies to enhance diversity in cardiology training programs. One of the strongest factors in positively influencing career choice is the presence of mentors and role models; women in particular report a need for female role models—individuals who look like them and can demonstrate that combining a rewarding career in cardiology with having a family is possible.5,8 Furthermore, a fundamental culture change is needed. Benevolent paternalism such as advice that directs young women away from cardiology because "it's too hard for women" has no place in our field and must be explicitly discouraged by program directors. Parental leave policies, duty-hour restrictions, and flexible training schedules must be clearly articulated and adhered to.Table. Strategies to Enhance Diversity in Cardiology Training ProgramsStrategyIssue(s) AddressedFirst StepEnsure mentorship for allMentorship pairing often serendipitous (introverts at a disadvantage)Institute a formal process that results in every trainee having an identified mentorRecruiting/outreach to the deep pipelineURMs in short supply in the pipelineContact local college/high schools, plan recurring events that expose students to cardiology, track resultsAdopt holistic review (evaluate candidates by placing equal emphasis on experiences, attributes, and standardized test scores)Overemphasis on United States Medical Licensing Examination scores when screening or ranking candidates. URMs and women tend to have lower test scores as a group; no evidence that test scores predict clinical competenceReview 5–10 y of program data assessing impact of United States Medical Licensing Examination scores on fellowship performance and establish evidence-based threshold; partner with medical school admissions committee for training in holistic reviewImplicit bias mitigation trainingApplication evaluation, interview scoring, ranking of candidates all influenced by implicit biasesInstitute annual, case-based implicit bias mitigation workshops for fellowship selection committeeForm fixed, standing fellowship selection committeeFluid membership/participation in selection process makes it difficult to train and keep all members on missionProgram director and cardiology chief select committee that is sex and URM diverse; fixed membership with term limitsCraft mission statement that includes diversity enhancement; keep visible at all times (on interview scoring sheet and during rank list meeting)Mission statements guide actions. When candidate selection/ranking proceeds without mission statement, actions are motivated by values of individuals vs the collectivePoll stakeholders (leadership, fellows, faculty, alumni): what traits do we want in our fellows? Add diverse; craft succinct, 2-sentence statementInstitute and publicize flexible leave policies (parental leave policies, duty-hour restrictions, and flexible training schedules)Can be important to house staff considering cardiology; survey data indicate that the lack of flexible policies in cardiology training may be a deterrentReview American Board of Internal Medicine and Accreditation Council for Graduate Medical Education policies and ensure that program policies leverage maximum flexibility allowedURM indicates underrepresented minority.With regard to URMs, programs can actively engage individuals from the immediate (internal medicine residents and medical students) and deep pipeline (college, high school, and earlier), by partnering with universities and schools. Cardiology training programs can host high school and college students in regular events to discuss cardiology as a career, provide hands-on experiences on simulators, and where possible, offer shadowing experiences. This could be done in collaboration with local American College of Cardiology chapters.For both Shawn and Julia, appropriate mentoring could have made all the difference in their ultimate career trajectories. Some studies suggest that white males are more likely to be offered mentorship than women or minorities.9 The formation of mentoring pairs should not be left to chance. Training programs should have formal processes to ensure that every trainee has 1 or more faculty mentors who can provide career guidance and, if advice outside of the mentor's specialty is required, introduce the mentee to appropriate colleagues.Graduate medical education programs can adopt the holistic review practice utilized by most medical school admissions committees and evaluate candidates by placing equal emphasis on an applicant's experiences, personal attributes, and standardized test scores.10 For programs that traditionally emphasize United States Medical Licensing Examination scores in the screening and ultimate ranking of fellowship candidates, this will be a sea change but consistent with the lack of evidence that test scores predict clinical competence.And finally, teaching faculty and fellowship selection committee members should be encouraged to reexamine their individual implicit biases and participate in annual implicit bias mitigation training. A recent study showed that the majority of a medical school admissions committee had implicit white race preference11 but that after undergoing annual bias mitigation training, the medical school began matriculating classes that mirror the diversity of the patient population in the United States. Training in holistic review and implicit bias mitigation works best if the selection committee is a fixed group of individuals—a captive audience for training and education. Intentional efforts to increase diversity in cardiology fellowship programs can be successful12 but are unlikely to lead to long-term changes unless leaders truly believe that diversity enhances the quality of patient care and research.In 2019, the Accreditation Council of Graduate Medical Education introduced a new accreditation standard requiring programs to "engage in practices that focus on mission-driven, ongoing, systematic recruitment and retention of a diverse and inclusive workforce of residents, fellows (if present)…and other relevant members of its academic community."13 Beginning July 2020, programs that fail to do so risk being issued a citation.Shawn and Julia never realized their true career goals. While they are composite characters, the authors have known many Shawns and Julias, and while most went on to promising careers in medicine, countless cardiac patients have been deprived of excellent, compassionate, and culturally appropriate care, and thousands of young women and URMs have been deprived of role models. Current national and world events like the novel coronavirus pandemic, which has disproportionately affected Black people, and frequent episodes of police brutality leading to fatal encounters between police and Black people have ignited a worldwide call for equity and justice.14 The cardiology community can answer this call by working to dismantle processes that have resulted in a persistent lack of diversity in our specialty.The authors recommend that cardiology programs operationalize diversity enhancement efforts with urgency, as if lives are at stake. We are convinced that they are.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Claire S. Duvernoy, MD, VA Ann Arbor Healthcare System, 2215 Fuller Rd, Box 111a, Ann Arbor, MI 48105. Email [email protected]eduReferences1. Mehta LS, Fisher K, Rzeszut AK, Lipner R, Mitchell S, Dill M, Acosta D, Oetgen WJ, Douglas PS. Current demographic status of cardiologists in the United States.JAMA Cardiol. 2019; 4:1029–1033. doi: 10.1001/jamacardio.2019.3247CrossrefMedlineGoogle Scholar2. Saha S, Beach MC. Impact of physician race on patient decision-making and ratings of physicians: a randomized experiment using video vignettes.J Gen Intern Med. 2020; 35:1084–1091. doi: 10.1007/s11606-020-05646-zCrossrefMedlineGoogle Scholar3. Tsugawa Y, Jena AB, Figueroa JF, Orav EJ, Blumenthal DM, Jha AK. Comparison of hospital mortality and readmission rates for medicare patients treated by male vs female physicians.JAMA Intern Med. 2017; 177:206–213. doi: 10.1001/jamainternmed.2016.7875CrossrefMedlineGoogle Scholar4. Alsan M, Garrick O, Graziani GC. National Bureau of Economic Research. Does diversity matter for health? Experimental evidence from Oakland.American Economic Review. 2019; 109:4071–4111.CrossrefGoogle Scholar5. Douglas PS, Rzeszut AK, Bairey Merz CN, Duvernoy CS, Lewis SJ, Walsh MN, Gillam L; American College of Cardiology Task Force on Diversity and Inclusion and American College of Cardiology Women in Cardiology Council. Career preferences and perceptions of cardiology among us internal medicine trainees: factors influencing cardiology career choice.JAMA Cardiol. 2018; 3:682–691. doi: 10.1001/jamacardio.2018.1279CrossrefMedlineGoogle Scholar6. Yong CM, Abnousi F, Rzeszut AK, Douglas PS, Harrington RA, Mehran R, Grines C, Altin SE, Duvernoy CS; American College of Cardiology Women in Cardiology Leadership Council (ACC WIC); Society for Cardiovascular Angiography and Interventions Women in Innovations (SCAI WIN). Sex differences in the pursuit of interventional cardiology as a subspecialty among cardiovascular fellows-in-training.JACC Cardiovasc Interv. 2019; 12:219–228. doi: 10.1016/j.jcin.2018.09.036CrossrefMedlineGoogle Scholar7. Association of American Medical Colleges. Altering the Course: Black Males in Medicine.2015. Available at: www.aamc.org. https://store.aamc.org/downloadable/download/sample/sample_id/84/. Accessed June 9, 2020.Google Scholar8. Burgess S, Shaw E, Ellenberger K, Thomas L, Grines C, Zaman S. Women in medicine: addressing the gender gap in interventional cardiology.J Am Coll Cardiol. 2018; 72:2663–2667. doi: 10.1016/j.jacc.2018.08.2198CrossrefMedlineGoogle Scholar9. Milkman KL, Akinola M, Chugh D. Temporal distance and discrimination: an audit study in academia.Psychol Sci. 2012; 23:710–717. doi: 10.1177/0956797611434539CrossrefMedlineGoogle Scholar10. Conrad SS, Addams AN, Young GH. Holistic review in medical school admissions and selection: a strategic, mission-driven response to shifting societal needs.Acad Med. 2016; 91:1472–1474. doi: 10.1097/ACM.0000000000001403CrossrefMedlineGoogle Scholar11. Capers Q, Clinchot D, McDougle L, Greenwald AG. Implicit racial bias in medical school admissions.Acad Med. 2017; 92:365–369. doi: 10.1097/ACM.0000000000001388CrossrefMedlineGoogle Scholar12. Auseon AJ, Kolibash AJ, Capers Q. Successful efforts to increase diversity in a cardiology fellowship training program.J Grad Med Educ. 2013; 5:481–485. doi: 10.4300/JGME-D-12-00307.1CrossrefMedlineGoogle Scholar13. ACGME. Common Program Requirements (Residency) Sections I-V Table of Implementation Dates.2019. Available at: https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRResidencyImplementationTable.pdf. Accessed June 9, 2020.Google Scholar14. Stolberg SG. 'Pandemic within a pandemic': Coronavirus and police brutality roil black communities.New York Times. June 8, 2020:A20.Google Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited ByCapers Q, Johnson A, Berlacher K and Douglas P (2021) The Urgent and Ongoing Need for Diversity, Inclusion, and Equity in the Cardiology Workforce in the United States, Journal of the American Heart Association, 10:6, Online publication date: 16-Mar-2021. August 2020Vol 13, Issue 8Article InformationMetrics Download: 640 © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCOUTCOMES.120.006912PMID: 32552014 Originally publishedJune 17, 2020 Keywordscardiologysocioeconomic factorsmentorscultural diversityPDF download SubjectsEthics and Policy

Despite the increase in the number of female physicians across most specialties within cardiology, less than 10% of cardiac electrophysiology (EP) fellows are women. The reasons behind this gender disparity are not known. We sought to determine the factors that influence fellows in training (FITs)

Introduction: The 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease recommends adults engage in ≥ 150 minutes of moderate or ≥75 minutes of vigorous intensity aerobic activity per week to reduce cardiovascular risk. Cardiologist adherence to these guidelines is unknown. Methods: Electronic surveys were sent to 437 ACC CardioSurve cardiologists, a representative sample of current ACC members. Demographic data was collected. Respondents were asked to quantify and rate intensity of exercise in an average week. Results: Between February and March 2020, a total of 189 panelists completed the survey for a response rate of 43%, of which 13% were women. There was even representation in number of years in practice: 33% early career, 27% mid-career, and 35% late career. Cardiologists across all career stages were evenly represented; 33% early career, 27% mid-career, and 35% late career. Overall only 56% of cardiologists met exercise guidelines (Figure). Less than half participated in vigorous activity (46%) with higher prevalence among mid versus early career (58% vs 38%, p=0.035). Interventional cardiologists were less likely to meet the standards for exercise intensity compared to general cardiology (44% vs. 59%, p=0.09). Early career respondents were less likely to adhere to activity recommendations (39% vs 59%, p=0.018). Those who reported vigorous activity were more likely to strength train at least twice per week (43% vs. 15%, p < 0.001). Conclusions: Nearly half of cardiologists are not adherent to the ACC recommended guidelines for aerobic activity. The impact on cardiologists’ health was not quantified, but this study suggests there is room for improvement in prevention behaviors. Since physicians are known to serve as role models for their patients, we hypothesize lack of adherence to activity guidelines may also negatively impact our patients.

Background The lack of diversity in the cardiovascular physician workforce is thought to be an important driver of racial and sex disparities in cardiac care. Cardiology fellowship program directors play a critical role in shaping the cardiology workforce. Methods and Results To assess program directors’ perceptions about diversity and barriers to enhancing diversity, the authors conducted a survey of 513 fellowship program directors or associate directors from 193 unique adult cardiology fellowship training programs. The response rate was 21% of all individuals (110/513) representing 57% of US general adult cardiology training programs (110/193). While 69% of respondents endorsed the belief that diversity is a driver of excellence in health care, only 26% could quote 1 to 2 references to support this statement. Sixty‐three percent of respondents agreed that “our program is diverse already so diversity does not need to be increased.” Only 6% of respondents listed diversity as a top 3 priority when creating the cardiovascular fellowship rank list. Conclusions These findings suggest that while program directors generally believe that diversity enhances quality, they are less familiar with the literature that supports that contention and they may not share a unified definition of "diversity." This may result in diversity enhancement having a low priority. The authors propose several strategies to engage fellowship training program directors in efforts to diversify cardiology fellowship training programs.

results when considering what kind of CR to offer patients with heart problems.