“…it’s been bandied about that the classic risk factors account for only 50% of the risk of atherosclerotic vascular disease. … We refer to this as the ‘50% myth’ and we need to refute it.”
~ Ezra Amsterdam MD

"Mitral valve repair has been the gold standard for patients with mitral regurgitation (MR) for approximately 30 years. What is the likelihood that percutaneous procedures will be able to achieve the same sort of efficacy for MR in the future?"
~ Michael A. Borger, MD

"One of the more controversial issues in medicine has been that of hypertension in pregnant women. The guidelines have not changed much in the last 50 years, although some effort to update these guidelines has been made recently."

Marvin Moser, MD

“I am greatly concerned that, instead of supplementing what we learn at the bedside, we’re replacing it with modern imaging technology.”
~ John Michael Criley, MD

"The key point that we found is …that interpreting the treadmill test on the basis of the ST segment alone is obsolete and should be abandoned…I think an important point we need to make to clinicians is that the most important prognostic indicator is functional capacity."
~ Ezra A. Amsterdam, MD

"The standard of therapy is not known, so that’s why if you select a patient who we don’t want to operate on, there is no competition there."
~ Saibal Kar, MD

"Fibromyalgia is undoubtedly a valid condition characterized by widespread body pain as well as variable other symptoms, which can include fatigue; sleep disturbance; mood disorders; and other somatic symptoms such as headache, abdominal pain, and hypersensitivity to external stimuli. Fibromyalgia remains a clinical challenge as there is no defining test, symptoms are subjective with variable patient presentation, and ideal treatment is elusive."

Mary-Ann Fitzcharles

"We are now seeing many such patients [with heart failure with preserved ejection fraction]. They’re often elderly women with many comorbid conditions, and they’re sometimes admitted with atrial fibrillation, which makes the estimation of diastolic function problematic."

Gary Francis, MD

“I would say we probably need to define another category for severe MR, which is regurgitant volume above 100 mL, which would be a massive degree of MR.”
-Maurice Sarano, MD

"Diastolic function might also help you identify further people who have systolic impairment by providing additional information regarding the loading condition of the patient, ie, the LV [left ventricular] filling pressure. It also provides valuable prognostic information beyond EF [ejection fraction]."

Rami Doukky, MD

"The average person is gaining weight every year. So I get discouraged when people see that information and feel like everybody gains it back."
~Sherry Pagoto

“I think thiazides offer the advantage of an anti-calciuric effect, so that women will tend to retain calcium, which has been demonstrated to facilitate bone mineralization with older age.”
~ Matthew Weir, MD

"Over the last 2 decades, professional organizations have issued a number of screening guidelines. Initially, the AUA and ACS were very pro-screening. However, over time, they have acknowledged the fact that screening decisions are complicated, involving tradeoffs between benefits and harms, and that we need to help men make informed decisions."

Richard Hoffman

“Troponin was a pretty good test when it was a crappy assay, but now that it’s a good assay, it’s a crappy test.”
-Bob Jesse, MD, Chairman of Medicine, Veteran's Administration, as quoted by W. Frank Peacock, MD

Some people also have been advocating echocardiograms, but I don’t think I’ll be out of line with this audience to say that including echocardiograms is a bit on the fringe of what we’re talking about, and really the argument centers more on using the ECG as a primary screening tool.
-Ben Levine, MD

“The Lyon Mediterranean Diet Study had a 70% reduction in cardiac events—a benefit that exceeded that of most drug trials.”
~ Stephen Devries

"According to the ACC/AHA guidelines, routine exercise testing in the asymptomatic patient is a class III indication and therefore not recommended because the information you get is going to be more confusing and may lead to unnecessary further testing that could lead to complications."

Joseph Alpert

“Moderate-intensity activity is something that you can do while … talking comfortably, but you cannot sing.”
~ I-Min Lee, MD

"When I put a patient on an NSAID, …. I’m careful to ask the patients about bleeding and to warn them about the signs of GI bleeding, and I do periodic blood counts to look at hemoglobin and creatinine levels. I also do a urinalysis to rule out silent GI or renal effects of these drugs, but I do use NSAIDs frequently."

Eric Gall

"There are mechanistic studies that indicate that the effect of ezetimibe on LDL is really not so much on the production side; turnover studies show that hepatic catabolism of LDL particles is important, and that is remote from the enterocyte and the whole supply side mechanism."
Robert Hegele, MD

"HF [heart failure] is slightly more common in women—just over half of the HF population—and they certainly have more hypertension than we ever expected."

W. Frank Peacock, MD

“… digoxin is even more pertinent in the context of the increasing prevalence of heart failure with preserved ejection fraction.”
~ Michael White, MD

“Ezetimibe has a role for LDL cholesterol lowering when other options have been exhausted. A change in this approach will require compelling evidence from a clinical events trial.”
~ Robert S. Rosenson, MD

“There are a lot of patients who can’t tolerate the higher dose of a statin, and maybe even ... on an every-other-day basis. Then we have to use the other agents that are at our disposal, whether it’s extended release niacin, ezetimibe, a resin, and/or fenofibrate.”
~ Roger S. Blumenthal, MD

So in other words, for coronary artery disease, a clear J-shaped curve; for stroke there was no J-shaped curve.
-Franz Messerli, MD

“Certain activities like racquet sports, skiing, and basketball seem to be associated with a greater incidence of acute cardiovascular events. Many of these victims, especially those younger than 35, often have underlying structural cardiovascular abnormalities, most notably hypertrophic cardiomyopathy.”
~ Barry Franklin

“These therapies are now mainstream for the bridge-to-transplant population, as well as for patients who are ineligible for transplant … The outcomes in the destination therapy populations have been just as good in the transplant population—it’s certainly a leap forward, as compared to the previous generation of devices.”
~ Andrew Boyle, MD

“It is very common for these patients to report New York Heart Association functional class 1 after myectomy—that is, they can do virtually anything…”
-Barry Maron, MD

"We now know that sleep and the sleep/wake cycle are intertwined with most of our bodily systems, so sleep problems can lead to pathologies in many different physiological systems, possibly causing acute and chronic effects."

David Neubauer

“We have two studies, the randomized trial and the observational study that suggest that ACE inhibitors and ARBs … may not be useful, [and] may actually be harmful in patients with AR…”
~ Jeffrey Borer, MD

"There are a lot of… small studies that have evaluated whether or not the addition of a thiazide such as metolazone to a loop diuretic augments sodium excretion and urine output."
~ Tien Ng, PharmD

"Scientific advances in acupuncture research, coupled with the side effects of treating pain by conventional drugs, have promoted the use of acupuncture dramatically in the past 20 years. It is estimated that over 1 million practitioners outside China administer acupuncture treatments for chronic pain. Of these practitioners, over 300000 are physicians."

Brian Berman

“The data is pretty convincing that adding an aldosterone blocker on top of standard therapy is effective and an important strategy.”
~ Bertram Pitt, MD

"I think one of the things that is important for physicians to understand is that … we’ve had a long history of using a very complicated drug, warfarin. The new drugs are a significant advance, but they’re not necessarily going to be a cakewalk."
Peter Kowey, MD

"The [recently published new] guidelines incorporate other risk factors that can further identify those at intermediate risk—patients who would benefit from oral anticoagulation instead of aspirin."
~ Annabelle Volgman, MD

“...the value of performing a Valsalva procedure cannot be underestimated when using agitated saline for the detection of a right to left shunt.”
~ Michael Main, MD

"Low back pain is a perfect example of how complexity based on biopsychosocial-spiritual influences can influence the severity of pain as well as suffering."

David Rakel

“I always worry that we haven’t had the patients in there long enough to finally tidy up their drugs, particularly the diuretics, to make sure they understand instructions.”
~ Ileana Piña, MD

“I have to say my view of CRT is that it probably does make the heart better. Therefore the assumption that sicker patients are going die of progressive heart failure rather than from an arrhythmia can be overcome by having a CRT device in the patient who has significant dyssynchrony or wide QRS.”
~ Barry Massie, MD

"It seems like the biggest change in the guidelines is the addition of ticagrelor, or BRILINTA®.… a new antiplatelet therapy that has been shown to be effective in ACS. Actually, based on the PLATO trial and the current [US FDA] rulings, it’s the only antiplatelet agent that is superior to clopidogrel for reducing cardiovascular death following ACS.…"

Carl J. Lavie, MD

“I think what’s difficult is to take observational data and to say, well, because there’s a relationship … then lower the levels of all these things … but I really think that to decide whether to treat those particular risk factors, and how low to go with those, we … need clinical trial data.”
-William Cushman, MD

"I think everyone knows that there are chronic risk factors such as high blood pressure, dyslipidemia, diabetes, smoking, lack of exercise, and others that contribute to coronary artery disease. We’ve only become aware recently of the issue that there are other kinds of risk factors, including what might be called acute risk factors."
~ Robert A. Kloner, MD, PhD

"...we all agree that one of our strong recommendations from this particular discussion is going to be that every institution should have a protocol for the basic framework of applying these treatments for ACS."

Christopher B. Granger, MD

“…many of our clinicians get caught up in the diagnosis of coronary disease... I strongly believe that this is not the purpose of the ED evaluation.”
-Michael Farkouh, MD, MSc

Adding Experience to the Evidence

"African Americans, and in particular African American women … carry the highest risk in the United States for having [CAD, MI, and CV morbidity and mortality]. Unfortunately African Americans, Hispanics and women of all ethnicities suffer from a disparity in access to life saving technologies and pharmacologic therapies."
Christopher Leggett, MD

Although the two drugs lowered central pulse pressure in the brachial artery to the same degree, nebivolol lowered central pulse pressure more than atenolol.
-John Cockcroft, MD

"In general, if someone has an indication for revascularization, the stenting or an angioplasty approach is more commonly used in single- or double-vessel disease. More extensive multivessel disease and left main disease historically have been more often treated with bypass surgery."
Jeffrey Snell, MD

“Another critical step in the selection of patients is the assessment of aortic valve anatomy of the vascular accesses, and the presence of comorbidities. The main cause of mortality within the first year after TAVR are the comorbidities.”
~ Gian Paolo Ussia, MD

“So I think one key modification of ATP IV will be to focus on non-HDL cholesterol as a treatment target equal to that of LDL cholesterol.”
~ Michael Davidson, MD

“Some tend to use sildenafil as a starting agent since there is evidence of symptomatic and functional benefit. However, this remains controversial.”
-Patricia A. Uber, PharmD

“The new finding was that an elevated heart rate above 70 beats per minute was also associated with an increase in hospitalization for fatal and non-fatal myocardial infarction.”
~ Kim Fox, MD

“The NIH State-of-the-Science Conference concluded that [antipsychotics and barbituates] have significant risks and cannot be recommended for the treatment of insomnia. So I think that’s important for clinicians to remember.”
~ Sonia Ancoli-Israel

"We know the younger the patient is with thoracic aortic disease, the more likely there is to be an underlying genetic cause for the disease. The older the patient is … the less likely they are to have genetic risk factors and the more likely they are to have chronic wear and tear on the aorta over a lifetime causing the thoracic aortic disease."
~Dianna Milewicz

"I think one of the challenges we deal with is how to handle patients who don’t have a high enough blood pressure to get all the evidence-based therapies we want them on. In many patients with MI, at least in the early phase, blood pressure is tenuous."

James de Lemos, MD

"We know that celiac disease is a genetic autoimmune disease, and we know that non-celiac gluten sensitivity is not considered an autoimmune disease… In order to obtain a diagnosis of non-celiac gluten sensitivity, celiac disease and a wheat allergy would both need to be ruled out."

Melinda Dennis

"HIV clinicians often spend more time addressing comorbid chronic illnesses such as diabetes, cardiovascular disease, mental health and substance disorders, liver disease, and cancer than managing antiretrovirals or opportunistic infections."

Todd Korthuis

“It could be tremendous for prevention in children. After being followed, maybe they will come back to have fewer drug problems, smoking issues.”
~ James Dalen

“We have substantial outcomes data with spironolactone and eplerenone; eplerenone in the post-MI patient, spironolactone more so in the Class III or Class IV heart failure patient. Clearly there has been a renaissance for the drugs.”
~ Bill Frishman, MD

“Atrial fibrillation always looks essentially the same on the ECG, but it’s certainly not one disorder.”
~ James Reiffel, MD

“[Redistribution of abdominal fat is] one of the most rewarding things that we can see, as physicians caring for these patients, because we know that ... means we’re going to see gradual improvements in the HDL and triglycerides over time.”
~ Malissa Wood, MD

"[There] is a group of migraineurs who have increased frequency and some change in quality. The treatment effects are perhaps important for them…Does analgesic use drive or follow the problem?"

Peter Goadsby

"Knowing that efficacy is not 100% and that comorbidities can add to a poor response, we realize that some patients need to move on to second-line therapies."

Charles Butrick

“... only about 10% of the patients in RALES were on a beta blocker, but those who were ... seemed to have just as good, if not a better, result from spironolactone."
~ Bertram Pitt, MD

"Cholesteryl ester transfer protein has been an important target for the management of risk for cardiovascular disease. It began a number of years ago when it was noted that this protein transfers cholesteryl ester in exchange for triglyceride from different lipoproteins specifically, apoB-lipoproteins to HDL lipoproteins."
~ Michael Davidson, MD

“That implies that the percutaneous-inserted prosthesis implanted inside the existing native valve without excising that valve has hemodynamics after implantation that are nearly as good as a stented bioprosthetic valve replacement. That was surprising to me…”
~ Paul Grayburn, MD

“When you say the word fitness to people it often confuses them; they’ll think about flexibility, they’ll think about muscular strength, and they’ll of course think about how easily they get out of shape. Today we’re specifically talking about cardiorespiratory fitness, which is really your maximal aerobic capacity.”
~ Timothy Church

"Certainly, the procedure is performed safely in this study. There were no significant adverse events... In fact, there were fewer events, albeit ... significant in terms of the overall mortality."
~ Vivek Reddy, MD