“As we entered this era of drug-eluting stents, we obtained some evidence that we are decreasing the need for repeat procedures, but the question remains, is it really as safe as surgery?”
~ Spencer King, MD

"The difference between a prevalence of disease in patients with normal results or normal testing was in the order of 15% to 20%, which really questions how much better testing is than just flipping a coin and whether it might be just as well to proceed with angiography."
~ Mario Garcia, MD

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

"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

“…patients who are device candidates are far and away most interested in receiving a device that will make them feel better rather than live longer…”
~ Jonathan Steinberg, MD

"Guidelines [for heart failure with preserved ejection fraction] don’t have much to say…Treatment remains relatively empiric, and different clinicians have different biases that affect the treatment that they provide…Several small studies have shown that some agents seem to work…[but] there hasn’t been a lot of evidence of benefit."

Barry Massie, MD

“There is controversy over whether patients with chronic hypertension who have compensated concentric ventricular hypertrophy ever evolve into more dilated HF.”
~ David Kass, MD

"Practitioners will certainly want to keep in mind that to make optimal decisions, you need systematic summaries of the best evidence."

Gordon Guyatt

"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

“...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

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

“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 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

“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

“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

"One thing that I notice…is the lack of attention to IBS compared to Crohn’s disease and other GI disorders.…The unpredictability of IBS and its symptoms really affects the quality of life more than we give it credit for, in comparison to diseases that may have a greater impression on the doctor because they are associated with inflammation."

Mark Pimentel

“In depression care … we are increasingly calling for the use of standardized instruments and repeated measures.”
~ Alan Gelenberg

"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

"Narcolepsy is a disorder that’s interesting because it typically does get missed. Although patients may present with complaints of tiredness and fatigue, very often people don’t think of narcolepsy as being a possible cause."
~Michael Thorpy

"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

“The use of the plasma aldo to renin ratio is a source of considerable confusion …the ratio is irrelevant as a screening test for primary aldosteronism.”
~ Norman Kaplan, MD

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

"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

"I completely agree that we should avoid this kind of storm during the dialysis session. There are so many changes in the different ions that could trigger some arrhythmia. I completely agree that we should avoid important gradients, whether the ion is calcium or potassium."

Pieter Evenepoel

"Hypertension continues to be a major contributor of cardiovascular events, and there is sufficient evidence to indicate that adequate blood pressure (BP) control is associated with marked reductions in the risk of not only target organ damage but also cardiovascular events such as stroke, myocardial infarction, and chronic renal failure."

Carlos M. Ferrario, MD

“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

"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

"Most importantly, not everybody in the population with a migraine needs neuroimaging, but that depends on detailed clinical symptoms."

Tobias Kurth

“Investigations from those centers have shown a two- to three-fold rise in the occurrence of aneurysm disease compared to three to four decades ago. So, this appears to be bona fide, based on pretty comprehensive epidemiologic data from these isolated localities.”
~ John Elefteriades, MD

“If you show up in the ED and you have either an elevated troponin or an elevated adrenomedullin, your risk of death in the next two weeks is exceedingly high and you ought to get aggressive care.”
~ Alan Maisel, MD

“There is no question that these drugs have a major role to play in therapy. In every clinical trial over the past 50 years, where they have been used as monotherapy or in combination with other therapies they not only effectively lowered blood pressure, but morbidity and mortality were reduced not just from stroke, but from heart failure, progression of kidney disease, and coronary disease.”
~ Marvin Moser, MD

“Alzheimer’s disease is really much more than a memory impairment, … an older adult who is having changes in their mood, their interests, their patience, their behavior, their personality; these may all herald the beginning of Alzheimer’s disease.”
~ James E. Galvin, MD

"I would like to say there are many patients who get treated with clopidogrel. This applies to the PLATO trial as well. Since 46% of patients in the PLATO trial had already received clopidogrel administered in-hospital before getting randomized,² a clinician can still safely load with ticagrelor 180 mg followed by 90 mg twice daily."

Carl J. Lavie, 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

"Obstructive sleep apnea (OSA) is increasingly recognized as a significant public health problem. Recent research has shown that it is related to a number of common medical illnesses such as hypertension, cardiovascular disease, and diabetes."

Stuart F. Quan

“I think the field has begun to move away from looking at percent inhibition with respect to a given drug, and toward looking at the residual platelet reactivity during treatment, and how we can associate that with outcomes in patients. Certainly, there have been ample studies demonstrating that high on-treatment platelet reactivity is associated with a greater risk of subsequent cardiovascular events.1–3"

~ David J. Schneider, 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

"Atherosclerosis is a systemic disease, not a regional disease. If one has plaques in the coronary arteries, they also have plaques in the peripheral arteries including the carotid arteries."
~William C. Roberts

“…it’s difficult for me to think that FAIR-HF proves that giving iron in any form would necessarily be beneficial.”
-Stephen S. Gottlieb, MD

“... 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

"Patients and physicians may be attracted to a less invasive angioplasty and stenting approach for suitable coronary lesions, however, there are issues with the recommended anticoagulation regimens, which could include two antiplatelet drugs and another anticoagulant if the patient is in atrial fibrillation."
~ William Frishman, MD

“Reversing obesity prevalence in the United States to that of a decade ago has been estimated to save US adults 111,206 total knee replacements."
~ Gary Williams, MD

Adding Experience to the Evidence

“Unfortunately I think the level of understanding of the complexity of degenerative mitral valve disease, while increasing, is not at a high level among many imaging cardiologists.”
~ Randy Martin, 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

“We need to differentiate real life from what goes on in the clinical trials, because so often in the clinical trials patients with a history of myopathy … are excluded from the trials.”
~ Peter Toth, MD

“I try to avoid the term ‘vulnerable plaque’ because it implies that we possess a crystal ball that can tell the future of a particular lesion based solely on its morphology.”
~ Peter Libby, 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

"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

"Behavioral interventions have yielded improvements on the order of 35% to 55% reductions in headache from pretreatment to post-treatment indicating that they're viable interventions. Those observed outcomes are approximately equivalent to the best prophylactic medications for primary headache."
Donald B. Penzien

"When untreated or unsuccessfully treated, these attacks typically last 4 to 72 hours. Migraine varies widely in frequency, severity, and impact on the patient’s quality of life."
~Brian Grosberg

"The difference in clinical practice is that individuals may not be as stringent at monitoring, and so I think hyperkalemia gets captured potentially a lot sooner in clinical trials as opposed to in clinical practice."
Orly Vardeny, PharmD

“I think it’s been an evolving process and I think it’s a good one. Moreover, transparently acknowledging a medical writer’s contributions clearly highlights the fact that this is a legitimate area of scientific endeavor.”
-Carol Sanes-Miller

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

“You discuss with your patient what the available knowledge is, even though it’s limited, and you make the decision together.”
~ David Callans, 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

“I really feel conceptually, and, I guess, philosophically, that ablation can have major favorable effects on peoples’ lives, even in addition to symptom control.”
~ David Callans, MD

“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

“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

"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

"So in someone who’s in his 70s, do you think we are where we can say that one really ought to turn to destination therapy VADs?"
~ James Young, MD

"We have evidence of various properties of HDL [high-density lipoprotein] that might be theoretically useful for describing its potential benefit, but we don’t have either a clinical trial or other prospective evidence indicating that any of these properties are explanatory."

John LaRosa, 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

"With the improved respiratory flow monitoring that we have nowadays using a pressure transducer technique, the accuracy of detecting obstructive events— particularly when we speak about apneas— really has improved."
~ Ana Krieger, MD, MPH

"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

"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

"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

"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

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

"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