Duke Heart Pulse — May 12, 2024 – The Pulse

Chief’s message:

Hope you all have a happy Mother’s Day, and for those of you having kids graduate from college and or graduate school this weekend – congratulations.

This week’s Pulse highlights several of the things that make Duke a special place to work. Stories include teams developing breakthrough research findings (Senthil Selvaraj and others), innovative NHLBI funded research (Monique Starks and team with drone delivery AEDs for cardiac arrest survival), AHA go red for women with Camille Frazier-Mills as a woman of impact, and finally shout outs to clinical research coordinator Kim Biever and Cathy Ritchie from our cardiac rehab team on helping increase access to care.

Highlights of the week:

ESC-HF: Common Genetic Variant Among Black Americans Leads to Significant Increases in HF, Death at Individual and Population Levels

A genetic variant carried by 3-4 percent of self-identified Black Americans increases the risk for heart failure and death similarly in men and women, contributing to a significant decrease in longevity at the population level, according to a new study led by researchers at Duke University School of Medicine and Brigham and Women’s Hospital. The findings show that individuals who carry the amyloidogenic V142I transthyretin variant are at significantly increased risk for heart failure hospitalization beginning in their 60s, with an increased risk for death beginning in their 70s. Nearly half a million currently living carriers above age 50 will collectively lose 1 million years of life due to the variant.

The study results were presented earlier today by Senthil Selvaraj, MD, MS, MA, advanced heart failure cardiologist at Duke, as part of late-breaking science at the European Society of Cardiology’s Heart Failure Congress 2024 in Lisbon, Portugal; the findings were simultaneously published online in JAMA. Additional Duke authors on the publication include Svati H. Shah, MD, MHS; Robert J. Mentz, MD; and Michel G. Khouri, MD.

The V142I variant causes transthyretin, a protein in the blood, to misfold leading to deposits of abnormal amyloid protein in the heart and other parts of the body. In the heart, these deposits cause the muscle to become thick and stiffened, a condition known as cardiac amyloidosis, which can ultimately lead to heart failure. Originally considered a rare condition, researchers are increasingly finding that cardiac amyloidosis is underdiagnosed and underrecognized — particularly among Blacks.

The researchers pooled data from self-reported Black participants in four NIH-funded studies in the U.S. (ARIC, MESA, REGARDS and Women’s Health Initiative). Altogether, the team examined data from 23,338 self-reported Black individuals, 754 (3.23 percent) of whom carried the V142I genetic variant.

The team found that carriers of V142I had an increase in their 10-year risk for heart failure (HF) hospitalization by age 63 and risk for death by age 72, while individual carriers with the V142I variant live 2-2.5 years less on average than expected. The risk was more prominent for heart failure with reduced ejection fraction (HFrEF) hospitalization compared with heart failure with preserved ejection fraction (HFpEF) hospitalization. The variant’s contribution to HF risk increased substantially with age but was not itself increased by other known risk factors such as diabetes and hypertension.

“Since 3-4 percent of self-identified Black individuals in the United States carry this variant, a significant number are at elevated risk for developing cardiac amyloidosis, being hospitalized for heart failure, and dying several years earlier than expected,” said Selvaraj, first author of the study. “With our improved understanding of the risks with the variant, future efforts to increase disease awareness and ultimately connect carriers with the disease to effective therapies will be important.”

The team also showed that female and male carriers of the variant were equally at risk, contrary to some previous clinical studies showing that men were more affected. Using these epidemiological data, this suggests that women are likely underdiagnosed with the condition.

The research showed that variant carriers on average died 2 to 2.5 years earlier than non-carriers. With approximately 48 million Americans self-identifying as Black, approximately 1.5 million people are estimated to carry the variant. Of those over age 50, which is about half a million people, the team estimates that nearly a million years of life will be lost due to the variant in this natural history study.

Although the association between the V142I variant and HF has been previously described, precise estimates of how the variant increases risk were unclear until now. The good news is the increasing availability of treatment options for cardiac amyloidosis.

“There is currently one approved targeted therapy with a number in the pipeline,” says Selvaraj, adding that he and his colleagues believe earlier identification of people who carry the V142I variant and providing appropriate therapies might decrease the risk of HF and dying. However, more research is needed to show whether early implementation of targeted treatments actually leads to decreased risk of disease.

“We found a relatively large magnitude of disease burden in the U.S., certainly at the population level, but the impact at the individual level is notable as well,” he says. “It’s important to think about diagnosing this disease relatively early on, since once it evolves to later stages, it becomes more challenging to treat and therapies may be less effective. Further, as you get older, the risk of the disease increases substantially. Therefore, we should be considering the diagnosis of this inherited form of cardiac amyloidosis earlier than we have before – closer to early 60s, rather than their 70s and 80s.”

The findings also indicate clinicians should think more broadly about those who are hospitalized with HF as perhaps having amyloid.

“Amyloid cardiomyopathy is more often associated with HFpEF. Our findings demonstrate that, in hospitalized settings, we should be looking at individuals regardless of ejection fraction,” Selvaraj added. “Since hospitalization for HF is an advanced marker of the disease, and the ejection fraction tends to fall over time with cardiac amyloid, it may be unsurprising that more frequently carriers have a reduced ejection fraction by the time they are hospitalized.

“Additionally, we should pay more attention to this disease risk in women. One challenge with cardiac amyloid is we often look for thick walls in the heart. Women in general have thinner walls than men, so using certain thresholds of wall thickness to diagnose disease, without this consideration, may cause us to overlook women who indeed have the cardiac amyloid.”

In future studies, the researchers plan to investigate why some, but not all, carriers of the V142I variant develop cardiac amyloidosis.

Note: This paper has been selected by JAMA as their featured article of the week and is accompanied by two editorials: Heart Failure in African American Individuals, Version 2.0 by Clyde W. Yancy, MD, MSc; and Addressing Health Disparities—The Case for Variant Transthyretin Cardiac Amyloidosis Grows Stronger by Mathew S. Maurer, MD; Edward J. Miller, MD, PhD, and Frederick L. Ruberg, MD.

Duke Heart Team Heads to Honduras for Medical Mission

A 42-member medical team representing Duke Heart departed yesterday, May 11, on a surgical mission trip to Honduras as part of our Duke Heart in Honduras program. This year we have adult and pediatric teams heading to care for patients in need of cardiothoracic interventions. Our teams will perform all intraoperative and postoperative care to support our Honduran partners in providing surgery at no cost to patients who would otherwise not be able to afford it.

Forty surgeries are planned, 15 of which will be with pediatric patients in need of atrial septal defect closures, ventricular septal defect closures, AV canal defects, and Tetralogy of Fallot. Most adult patients our Duke team will see need aortic valve and mitral valve replacement. One congenital patient with an anomalous left coronary artery from the pulmonary artery (ALCAPA) defect will undergo reimplantation. Another will be treated for a large atrial myxoma.

The mission is in partnership with Hugo Orellana, MD, an adult cardiothoracic surgeon based at Honduras Medical Center, and with Victor Paz, MD, a pediatric cardiothoracic surgeon based at Hospital Maria. Both hospitals are located in the city of Tegucigalpa, the capital of Honduras.

The Duke Heart for Honduras 2024 team includes:

Cardiothoracic surgeons: Drs. Adam Williams, Jacob Schroder, Joseph Turek, and Doug Overbey; Cardiac anesthesiologists: Drs. Brandi Bottiger, Alina Nicoara, and Natalia Diaz-Rodriguez; Pediatric cardiac ICU attendings: Drs. Jennifer Turi and Jennifer Sherwin; CT fellows: Drs. Alejandro Murillo, Navin Vigneshwar, Jason Pang, Kathryn Pearson, and Ethan Garrigan; pediatric cardiac anesthesiologist Dr. Michael Greenberg; CT Surgery residents: Drs. Rebekah Boyd and Hiba Ghandour; CTICU, CTOR and critical care nurses and APPs: Bryan Hampton, Adeline Kranzburg, Timothy Matusz, Eric Velasquez, Chelsey Weinbrecht, Nicole Garcia, Cheyenne English, Mambo Kwaambwa, Michelle Figuerres, Figz Figuerrez, Tina McEachin, Aireen Vergara Casale, Audrey Sakae, Dorothy McVay and Danielle Wood; Perfusionists: Felicia Shugars, Amy Evans, Robert Degiosio, Katharine Nanry and Julie Walker; Respiratory therapist Chris Lappe; Biomedical engineer Brian Gore; Research lab member (and Honduran physician) Alejandro Alvarez Lobo, and medical students Cathlyn Medina and Lauren Parker.

Our Duke team will be joined by five medical professionals from Massachusetts General Hospital, including four attending physicians, Drs. Eriberto Michel, David D’Alessandro, Peter O’Chieng, and Robin Schiller and perfusionist Kenneth Shann. Also joining our team is a perfusion student, Cristina Parra, sponsored by the International Perfusion Association (IPA), and Bryan Lich, president of the IPA.

The team is supported, in part, by a grant from the Thoracic Surgery Foundation, the philanthropic arm of the Society of Thoracic Surgeons (STS). The grant funding of $35,000 is part of the Every Heartbeat Matters Award given to Dr. Adam Williams during the STS 60^th annual meeting held in January 2024. The funding was made possible through the support of the Edwards Lifesciences Foundation and will be used to cover the airfare costs for all team members.

We are pleased to support these Duke team members and wish them great success!

Forsyth County NC Runs 1^st Test of AED Drone Delivery

Congratulations to Monique Starks, MD, associate professor of medicine in cardiology, and her AED Drone study team! Forsyth County, NC was the first county to sign on for the partnership with Duke for feasibility testing of AED drone delivery to cardiac arrest bystanders. The Forsyth County Sheriff’s Office and Forsyth County Emergency Services conducted a test launch this week as part of an emergency management drill for cardiac arrest held at Agape Church in Clemmons, NC.

Starks is the principal investigator on the American Heart Association research grant “Developing and Testing Drone-Delivered AEDs for Cardiac Arrest in Rural America”. Her co-investigators include Dan Mark, MD, Hayden Bosworth, PhD, Audrey Blewer, PhD, MPH, and Hussein Al-Khalidi, PhD.

Starks is the first investigator in the U.S. to be funded by the National Institutes of Health to explore the development of a drone network that is capable of delivering AEDs to bystanders at an out-of-hospital cardiac arrest emergency.

Congratulations to all involved in this important work!

Frazier-Mills Celebrated at Go Red! Event

The Triangle’s annual Go Red for Women Evening in Red event was held on Friday evening, May 10, at the Raleigh Convention Center. The celebration recognizes survivors of heart disease and their family members and, via fundraising, supports vital research efforts for the American Heart Association.

The evening included dinner, dancing, a silent auction, and honoring each of the 2024 Triangle Women of Impact including our very own Camille Frazier-Mills, one of the finalists! Duke Heart’s service line vice-president Jill Engel and cardiology fellowship program director, Anna Lisa Chamis, MD were both on hand for the festivities and to support Camille.

Kudos to Ritchey & Cardiac Rehab Team!

Kudos to Cathy Ritchey for her tenacious work on behalf of our cardiac rehab patients. Ritchey proactively connected with representatives at Aetna regarding Cardiac Rehab (CR) coverage. Thanks to her efforts, Aetna has updated its CR coverage and will now cover the CPT code for non-continuous telemetry CR starting June 9. Awesome!!!

According to Erica Rao, this has been a barrier to enrolling Aetna patients into our Duke CR program. Ritchey, she says, “maintains a close watch on CR insurance guidelines and read that Aetna was updated theirs. After connecting to the Duke physician liaison with Aetna and the Revenue Integrity team, our team will now be able to enroll all Aetna patients, not just those with Duke Aetna insurance.”

Bill Kraus adds, “This is a huge well-earned victory for our CR program and the hospital to tear down barriers to patient care.”

Way to go, Cathy!!!

Shout-out to Biever

We received a terrific note this past week from Andrew Wang, MD, vice chief for clinical affairs for the division of cardiology:

“I highly commend Kim Biever, a clinical research coordinator in our cardiology clinical trials group. I have worked with her for the past 3-4 years on a randomized trial of mavacamten for obstructive hypertrophic cardiomyopathy (HCM) and its long-term extension study. In addition to her help in achieving a high enrollment in this study, her conscientiousness, efficiency, and communication have made the experience very productive and enjoyable.

“She is extremely well-organized and plans well for the expected and unexpected issues in a trial. She is often the “first call” person for our trial patients, even for matters unrelated to the study protocol, and manages these with compassion and professionalism. Most impressively, as our patients have transitioned from study treatment to commercial drug treatment, her dedicated work and commitment have helped to reduce any gaps in their treatment.”

Way to go, Kim!!!

Kudos to Duke HF Symposium Planning Team

A shout-out to Marat Fudim, Stephanie Barnes, Rob Mentz, Richa Agarwal, and Christy Darnell for a very successful HF Symposium last weekend. It was our first since the pandemic and it was a hit – our best turnout yet. Great job, everyone!

Upcoming Events & Opportunities

May is American Stroke Month and Asian American and Pacific Islander Heritage Month
May is Duke Health’s inaugural Team Member Appreciation Month
May 12-19 is National Hospital Week
Culture Pulse survey deadline extended to Thursday, May 16.

Cardiology Grand Rounds

May 14: Teaching, Quality Improvement, and Wellness in the ICU with Daniel Loriaux. 5 p.m., DN 2002 or via Zoom.

May 21: Capturing the Left Bundle: Insights Into Conduction System Pacing with Ilia Shadrin. 5 p.m., DN 2002 or via Zoom.

May 28: The Ross Operation — The Ultimate Aortic Valve Replacement? with Ziv Beckerman. 5 p.m., DN2002 or via Zoom.

All Duke Cardiology Grand Rounds recordings are housed on Warpwire. To access recordings please visit:

NET ID and password are required. Enjoy!

CD Fellows Core Curriculum Conference

May 15: HF/Txp Case Presentation with DaMarcus Ingram. Noon, DMP 2W96 (in-person only).

May 17: EKG Review with Neil Freedman. Noon, Zoom only.

Have news to share?

If you have news to share with the Pulse readership, please contact Tracey Koepke, director of communications for Duke Heart at tracey.koepke@duke.edu. We would love to hear about your latest accomplishments, professional news, cool happenings, and any events or opportunities that may be of interest to our Duke Heart family. Please call with any questions: 919-681-2868. Feedback on Pulse is welcome and encouraged. Submissions by Noon, on Wednesdays, will be considered for weekend inclusion.

Duke Heart in the News:

May 2 — Neha Pagidipati

Cardio Nerds

Episode 367: GLP-1 Agonists: Clinical Implementation of GLP-1 Receptor Agonists with Dr. Neha Pagidapati

May 3 — Marat Fudim

Web MD

What’s Behind Major Rise in Heart Failure Deaths?

May 3 — Duke University Hospital

Becker’s ASC Review

Meet the leaders of the 3 best hospitals in North Carolina for cardiac surgery

May 3 — Thomas Povsic

Medscape