Introduction
The American Heart Association's (AHA's) EPI|Lifestyle specialty conference, with
an overall theme of promoting risk prediction and prevention, was held March 19 to
23, 2018, in New Orleans. The primary learning objectives were (1) identifying modifiable
risk factors and ways to meet AHA ideal cardiovascular health (CVH) standards, (2)
elucidating the causes and consequences of health disparities and ways to address
the AHA goals, (3) discussing the current guidelines and what adherence means for
CVH in both adults and juveniles, and (4) understanding and identifying opportunities
to incorporate precision medicine.1 Programming included sessions for all career levels,
from trainees to seasoned professionals. Attendees’ understanding of promoting CVH
was enhanced by oral and poster presentations and participation in networking opportunities.
Overall Conference Theme: “Health Promotion: Risk Prediction to Risk Prevention”
The conference theme was “Health Promotion: Risk Prediction to Risk Prevention.” This
topic was not only a focus of the plenary session but also intertwined throughout
the meeting with oral and poster presentations. The plenary speakers were Drs Alfredo
Morabia, Mintu Turakhia, and Angela Odoms‐Young.
Dr Morabia presented the history of risk prediction within the field of epidemiology.
He provided a whirlwind overview of how prominent epidemiologists first identified
risk factors and how combined exposures improved risk prediction for chronic diseases.
Dr Turakhia challenged the audience to consider “wearables” as a potential technology
to identify risk factors and discussed the tradeoff between risk identification and
an individual patient's confidentiality. Dr Odoms‐Young discussed the struggles in
improving dietary patterns and weight among African American women living in impoverished
communities in the south side of Chicago. She highlighted the importance of understanding
how barriers associated with low socioeconomic status interfere with a person's ability
to improve his or her individual cardiovascular risk through behavioral changes.
Biomarkers Session
The biomarkers session highlighted novel research in the use of biomarkers to identify
individuals at increased risk of cardiovascular disease (CVD). Dr Ambarish Pandey
reported on heart failure risk in the African American population and identified left
ventricular hypertrophy and high‐sensitivity troponin as a “malignant preclinical”
heart failure phenotype. Dr Gregory Shearer summarized results showing that eicosapentaenoic
acid was associated with reduced risk of heart failure. Dr Majken Jensen presented
results suggesting that free fatty acids were associated with cognitive decline and
increased risk of dementia over time. Dr Justin Echouffo Theugui reported that higher
early morning serum cortisol was associated with structural brain changes and impaired
memory in young adults.
Early Career Events and Mentorship
The early career events were well planned and attended. Both the Council on Lifestyle
and Cardiometabolic Health and the Epidemiology and Prevention Council incorporated
early career panel discussions into their networking luncheons. During the lifestyle
council's discussion, Ryan Demmer, Mercedes Carnethon, and Bethany Baron Gibbs shared
strategies for avoiding burnout in academia, including finding a mentor who practices
good work–life balance and developing resiliency to failure in order to reach goals.
In addition, they suggested seeking a career close to a support network. The epidemiology
council lunch panel comprised Gerald Bloomfield, Tom Riberio, and Kunihiro Matsushita,
who provided summaries of international cardiovascular studies, along with tips for
successful global collaboration in epidemiology. For example, they shared pointers
on how to choose the best times to conduct conference calls for participants at distant
locations.
Other early career programming included 2 new formats. First, “Connection Corners”
consisted of interactive and informative small round‐table sessions with established
investigators who led discussions with the early career researchers. Topics included
grant writing, communication, and career development. Drs Brooke Agarawal and Mercedes
Carnethon, for example, shared their strategies for writing an elevator pitch, placing
emphasis on the importance of preparing a pitch for each research topic of interest.
They suggested that the pitch open with a question to pique the listener's interest,
followed by a succinct picture with analogies of the potential impact of successful
results. Second, the “fire‐side chat” format evolved from a traditional question‐and‐answer
session to an exceptional discussion about building mentoring networks and reflection
as a key part of professional development. Anonymously submitted questions that are
often unasked because of their sensitivity included, “How do you separate your niche
from your mentor?” and “What can you do to fix a falling‐out with your mentor?” The
panel, including Drs Emelia Benjamin, Norrina Allen, Jean‐Pierre Després, Chiadi Nduemle,
and Lenny Lopez, provided useful guidance. Key suggestions were (1) fostering a mentoring
team of researchers with varying backgrounds and perspectives to create a support
network; (2) reflecting on past projects while exploring future interests to identify
the evolution of a research niche that may be overlooked; and (3) creating a 1‐page
personal statement to elucidate the researcher's career goals to reviewers, whether
on grant panels or potential employers.
Stamler Award Abstracts
The Jeremiah and Rose Stamler Research Award Finalist panel featured 5 abstracts by
early career investigators who were recognized for their important contributions to
CVD epidemiology. The award winner was Merrisa Reitsma from the University of Washington
Seattle for her work on tracking lifestyle behavior, healthcare access, and healthcare
quality for cardiometabolic diseases at the state level. Although Reitsma won the
award, all of the abstracts made a significant impact on the body of scientific knowledge.
An abstract presented by Dr Stephanie Mayne from Northwestern University evaluated
the impact of smoke‐free policies on blood pressure (BP) changes. Using data from
the CARDIA (Coronary Artery Risk Development in Young Adults) study, smoke‐free policies
in indoor public places were associated with reduction in systolic and diastolic BP
among nonsmokers. Dr Emily Bucholz from the Boston Children's Hospital explored prescription
rates for statins among patients with severe dyslipidemia or with diagnosed familial
hypercholesterolemia. Results indicated that only approximately half the adults in
the United States with familial hypercholesterolemia are on statin therapy, indicating
a need to improve treatments for patients in high‐risk populations. Dr Sadiya Khan
from Northwestern University presented information on the validation of a 10‐year
novel risk equation to identify individuals at risk of heart failure. The model focused
on readily available data that could be used in the primary care setting as a tool
to identify increased risk of heart failure. The final abstract, presented by Dr Yujin
Lee from Tufts University, examined the health and economic impacts of programs to
incentivize eating healthy foods, offered through Medicare and Medicaid for patients
with a history of cardiovascular events. Lee concluded that programs that incentivize
eating healthy foods could decrease the risk of cardiovascular events, ultimately
leading to cost savings.
Physical Activity Session
This session provided new insights into research suggesting that physical activity
may improve CVH. Dr Andrea LaCroix reported that in a cohort study of almost 6000
older women followed for up to 4 years, those with more light‐intensity physical activity
had reduced risk of CVD and coronary heart disease incidents after controlling for
other known risk factors, including moderate‐to‐vigorous physical activity. In a cross‐sectional
and longitudinal study of the ARIC (Atherosclerosis Risk in Communities) neurocognitive
study, Dr Priya Palta and colleagues found that high physical activity was associated
with higher brain volumes in late life, but midlife physical activity did not predict
late‐life brain atrophy. These results raised questions about the potential causal
interpretation of their cross‐sectional results. Over 30 years of follow‐up, Dr Amanda
Paluch reported that baseline cardiorespiratory fitness was associated with reduced
risk of chronic kidney disease. Dr Isac Thomas and colleagues found that high leisure‐time
physical activity was cross‐sectionally associated with higher coronary artery calcium
density but not higher coronary artery calcium volume; they posited that this may
explain why athletes have favorable CVD incidence even though they also have greater
coronary artery calcium density. Dr Kara Whitaker reported that women with higher
prepregnancy fitness had lower odds of developing gestational diabetes during pregnancy,
but neither moderate‐to‐vigorous physical activity nor high television viewing time
was associated with this condition. Finally, Dr John Bellettiere and colleagues found
that among older women, greater amount of sedentary time and longer bouts of sedentary
time increased the risk of CVD and coronary heart disease.
Tobacco and Behavior Change
The toxic effects of tobacco are well accepted. During the “Tobacco and Behavior Change”
session, Dr Aruni Bhatnagar expounded on the potential dangers of newly marketed e‐cigarettes
and cigars not only for a person's cardiac health but also for public health. The
particulate matter produced by combustible products is metabolically toxic and has
yet to be banned from public establishments, making it a risk to public health via
second‐ and third‐hand smoke. E‐cigarettes and cigars are marketed as cleaner, more
stylish products that will make it easier for smokers to quit; however, even short‐term
exposure may have detrimental effects. Long‐term exposure has the potential to decrease
air flow, preventing vasodilation and thus making combustible products 50% more harmful
than commercial cigarettes. In addition, whereas traditional tobacco products come
with a warning about adverse effects to deter new smokers and children, e‐cigarettes
and cigars are produced in flavors that may in fact attract new smokers, including
juveniles.
Omics
The omics session incorporated intriguing data concerning precision medicine by incorporating
lifestyle and genetics to improve CVH. The session started with Dr Deirdre Tobias
discussing a cohort study describing the role that circulating branched‐chain amino
acids and cardiometabolites play in women's CVH. It is commonly accepted that diet
and exercise significantly modulate heart health; however, the subsequent sessions
covered genetic participation in CVD. Summarizing data from the ARIC study, Dr Di
Zhao reported finding that the number of mitochondrial DNA copies contributed to the
onset of atrial fibrillation. This group further argued that mitochondrial DNA decline
with age increased the risk of atherosclerosis in older communities. In a phenome‐wide
association study, Dr Tianxi Cai indicated IL6R (interleukin 6 receptor) variants
could potentially be used to identify drug targets for medicinal therapy for CVD and
inflammation. Last, Dr Laura Raffield2 and colleagues analyzed platelet‐related traits
in the TOPMed (Trans‐Omics for Precision Medicine) whole‐genome sequencing project.
In this study they explored D‐dimer products in relationship to CVD in participants
of African American ancestry compared with those of European descent and found D‐dimers
are potential predictors of CVD that could be sex‐specific. These data indicate genetic
testing is an attractive method of researching vascular diseases and could improve
on precision medicine.
Hot off the Press
The “Hot off the Press” session focused on important publications released within
6 months of the conference. The findings of these research projects were published
in impactful journals. The publications included a cross‐sectional study, an analysis
using a large cohort study, simulation modeling using neighborhood‐level data, and
2 randomized trials.
Dr Paul Muntner3 leveraged the NHANES (National Health and Nutrition Examination Survey)
cross‐sectional study and discussed the population impact analysis of updated 2017
American College of Cardiology and AHA guidelines for prevention, detection, evaluation,
and management of high BP and the initiation of antihypertensive therapy. The new
guidelines will result in an increase in prevalence of hypertension, from 32% to 46%
of the US population, but only a modest increase in patients who will be recommended
for therapy and more intensive BP‐lowering approaches.
Type 2 diabetes mellitus has 6 historically been a pronounced disparity in US among
African American adults. explored modulating risk behaviors, including those affecting
biological, neighborhood, psychosocial, socioeconomic, and behavioral risk, among
young adults at risk for type 2 diabetes mellitus in the CARDIA cohort study. Their
work indicated that among adults with risk factors, incidence of type 2 diabetes mellitus
did not differ among African American and white men and women after including the
contribution of modifiable risk factors during young adulthood.
Dr Tiffany Powell‐Wiley studied the impact of crime on physical activity patterns
and rate of obesity in African American women, using simulation modeling of neighborhood‐level
data.5 The results indicated that women living in high‐crime areas had a 25% probability
of exercising; however, areas with lower crime rates perpetuated higher physical activity
among this group. An inverse association between neighborhood crime and leisure‐time
physical activity was found, suggesting that interventions to reduce neighborhood
crime may help encourage physical activity and reduce the prevalence of obesity.
In a randomized, double‐blind clinical trial, Dr Flávio Fuchs explored the efficacy
of combination low‐dose diuretic therapy as a mechanism to achieve optimal BP in adults
with prehypertension based on the definitions in the Seventh Report of the Joint National
Committee.6 They found a 6% increase in the number of adults in the treatment arm
achieving optimal BP levels (<120/80 mm Hg).
Last, Dr Christopher Gardner published the results of a randomized clinical trial
evaluating the effects of healthy low‐fat versus healthy low‐carbohydrate diets to
determine if genotype altered weight‐loss effects in either dietary pattern.7 The
results indicated no significant difference in weight loss by genotype, insulin interactions,
or difference in weight loss with either healthy low‐fat or healthy low‐carbohydrate
diet.
Patient‐Centered Outcomes Research Institute
The Patient‐Centered Outcomes Research Institute (PCORI) is an independent, nonprofit,
nongovernmental organization that funds studies aimed at healthcare effectiveness,
patient decision‐making, and patient‐reported outcomes. PCORnet, the National Patient‐Centered
Clinical Research Network, is an initiative of PCORI aimed at transforming clinical
research through large patient‐centered data sets. During the EPI|Lifetyles meeting,
PCORnet Cardiovascular Health Collaborative Research Group (CVH CRG) primary leads
(Drs Veronique Rogers, Mark Pletcher, Geoffrey Tison, Anitha John, and Ken Gregoire)
conducted a panel discussion sharing highlights of the PCORI preconference meeting.
The CVH CRG goals to catalyze high‐quality, patient‐driven studies to engage patients
in treatment plans will make a significant impact on what can and cannot be achieved
to improve CVH. In addition, they proposed mutual respect in patient/physician exchanges
to advance knowledge of the different perspectives in care, for example, understanding
what matters to patients and caregivers compared with clinicians. These data can be
shared as preliminary data that can be used in investigators’ CVH‐related grant applications.
CVH CRG is an ongoing project that seeks new collaborators to participate in supported
CVH interests.
American Society of Preventative Cardiology Annual Debate
The American Society of Preventative Cardiology is a multidisciplinary group of clinicians
and investigators with a shared interest in preventative cardiology. During an informal
discussion, Drs Matthew DeCamp and William Weintraub discussed the challenging issues
of “Medical Cost When Considering Cardiovascular Disease Prevention and Treatment.”
One argument was that reducing waste can reduce cost, which will create savings that
can be passed down to patients. Alternatively, it was proposed that financial incentive
programs to improve diet through Medicare and Medicaid can reduce CVH cost. Because
the cost of health care continues to be debated and more people are denied access
to care, the goal of this debate was to raise awareness of topics for consideration
and innovative tools that will assist clinicians and office staff in creating practices
that will contribute to cost reduction. However, Dr Yujin Lee summed it up with his
research findings that suggest economic incentives through Medicare or Medicaid could
contribute significantly to substantial health gains and cost savings.
Poster Sessions
As with most scientific meetings, the poster presentations were the most attended.
There were >450 posters at this year's meeting, 78 of which were moderated. Among
them, Andrea Stewart discussed the impact of social roles on women's CVH, as measured
by “Life's Simple 7,” when taking into consideration diet and activity. She suggested
that as social role stress increases, there is an increased prevalence of CVD. In
a moderated group, Nicholas Howell shared his work describing the effects of air pollution
on CVD; his results indicated that living in a high‐pollution area had a negative
effect on CVH. Jie Hu addressed clinical and subclinical BP, exploring factors before
and during pregnancy that affect CVD gravidae. Mary Rooney presented her work discussing
the inverse effect of magnesium levels on CVD factors before gestation. Having some
posters moderated gave them an interesting dimension. Moderated poster presentations
gave the feel of a small study group, allowing for the listener to hear the presenter
more easily. In addition, this concept of incorporating a moderator pushed the presenter
to give more detail and engage with the listeners.
Conclusion
The 2018 EPI|Lifestyles specialty conference was a resounding success. It included
innovative programming and presentations from world‐renowned researchers as well as
graduate students and early career investigators. Ample time was provided for networking
and impactful scientific discussions. Unfortunately, we could not report on the William
B. Kannel Memorial Lectureship presented by Dr Emelia J. Benjamin or the life course
epidemiology sessions, but readers are encouraged to visit the AHA EPI|Lifestyles
2018 Web page (https://professional.heart.org/professional/EducationMeetings/MeetingsLiveCME/EPILifestyle/UCM_316976_Programming-EPI-Lifestyle.jsp)1
for more information on those topics. We look forward to another successful meeting
next year in Houston.
Disclosures
None.