Recently, Cynthia Waldman of HCMBeat corresponded with Dr. Srihari S. Naidu of Westchester Medical Center the second edition of an HCM textbook he recently edited, as well as about medical education surrounding hypertrophic cardiomyopathy in general. What follows is a transcript of their correspondence (which has been slightly edited for readability).
HCMBeat: When and where did you go to medical school?
Dr. Naidu: I went to medical school at Brown University and graduated in 1997 as part of the 8-year program in liberal medical education (PLME). [Editor’s note – this program combines a traditional undergraduate bachelor of science (B.S.) and medical degree in one program].
HCMBeat: Were you taught anything about HCM in medical school?
Dr. Naidu: In medical school we were all taught a little about hypertrophic cardiomyopathy, but the focus was mainly on identifying obstruction during physical examination, and what could be done to improve or worsen the obstruction, including various medications. Besides that, very little was taught about the treatment of HCM. At the time, myectomy was not commonplace, and alcohol septal ablation had only been invented a year or two prior. HCM was felt to be an exceedingly rare condition. Thus, teaching about HCM was mainly as a curious disease which is fascinating from a physiology standpoint.
HCMBeat: How did you become particularly interested in HCM?
Dr. Naidu: I was always interested in heart failure and actually went into cardiology intending to be a heart failure and transplantation cardiologist. However, I then got more interested in interventional cardiology and invasive hemodynamics and ended up choosing an interventional cardiology fellowship instead. Nonetheless, I remained interested in the disease and once I started practicing, HCM patients were often referred to me. In the beginning, they came because at the time, I was one of the only physicians trained in alcohol septal ablation, but over time I started seeing patients with HCM whether or not they were in need of any invasive procedures. Slowly my practice grew from a 100 HCM patients when I was at Cornell, to over 600 when I was at Winthrop University Hospital on Long Island, and is now passing 1000 at Westchester Medical Center.
HCMBeat: Where did you do most of your learning about HCM? Was it a particular mentor who taught you about HCM or had a particular influence on you?
Dr. Naidu: I learned one patient at a time, and that’s what’s interesting about this disease. The main experts in HCM management achieved that status one patient at a time, as one became ten, then one hundred, then several hundred and now thousands; over time, you see most, if not all, phenotypes and treatment trajectories. Having seen things before makes it much easier to recognize what is going on and jump right to what the patient needs. It helps avoid mistakes in management or delays in treatment.
I also gained more understanding rapidly when I served on the American College of Cardiology/American Heart Association (ACC/AHA) HCM guidelines committee in 2011. It was enlightening to spend two years behind closed doors with top experts in HCM.
HCMBeat: Turning to your book, and more generally HCM education for physicians today, how much time would you estimate is spent on teaching about HCM in most medical schools today?
Dr. Naidu: Very little. Maybe a part of one day out of four years. Very little time was spent on treatment options because it was thought to be a rare disease. But everyone in medical school learns the paraphysiology because, in many respects, understanding HCM means that you understand cardiac physiology in general.
HCMBeat: Is there more focus on HCM during cardiology residencies and fellowships?
Dr. Naidu: Some may teach more about it; generally, this would happen more in those programs that have active HCM centers. When I trained in the 1990s, there were only a few HCM specialty centers, so we saw only the rare patient. Outside of these specialty centers, I don’t think any significant time is devoted to the disease unless a patient rolls in with the diagnosis. In our fellowships at Winthrop, and now at Westchester, our fellows get a tremendous amount of exposure to HCM in the hospital, in the outpatient office, and also in all the regular cardiology rotations because HCM patients get everything from echocardiograms to cardiac MRI’s, catherizations to electrophysiology evaluations, pacemakers to ICDs, and surgery to alcohol septal ablation. Therefore, our fellows receive specific teaching about HCM, and are particularly well prepared to take care of these patients.
In the new year we will be creating a specific HCM rotation and service solely for our HCM patients, and fellows can rotate onto the service and learn even more about the specifics of HCM care. If they spend time in our HCM outpatient office, they will see more than 40 HCM patients in just two days.
HCMBeat: What prompted you to put together this textbook?
Dr. Naidu: It became clear after the ACC/AHA Guidelines were completed that two things were needed: First of all, more specific training of physicians in septal reduction therapies, specifically alcohol septal ablation and myectomy, in order to make them generalizable and to increase their reach to all potential patients. And, secondly, because most of the knowledge about treating HCM is learned one patient at a time through experience, there has been no definitive resource which pulls all that experience together for the benefit of people new to the field. The book was meant to be that definitive and comprehensive resource, which will continually be updated over time.
HCMBeat: This is the 2nd edition of your book. How has it changed from the first edition?
Dr. Naidu: The second edition of the book is 50% longer. There are 8 new chapters which add important areas for discussion – from the management of hypertension in HCM, to sleep apnea and pulmonary hypertension, to the tackling of the structural heart interventions including transcatheter aortic valve replacement, as well as chapters on managing coronary disease in patients with HCM, among others. In addition, all figures and tables were updated and made more uniform. And, finally, each chapter ends with 10-20 board-review type questions and answers, to enhance learning and to assist people with different learning styles. The book has become a comprehensive textbook on the subject of HCM with appeal to physicians from many different specialties who have an interest in these patients, including those in clinical care, education or research.
HCMBeat: How is your book laid out? Who are some of the contributors to the book, and what are some of the topics that are discussed?
Dr. Naidu: It is laid out chronologically, beginning with the discovery of HCM, going through the various diagnostic modalities, and the management of HCM, including difficult-to-treat subsets. The history is given by Dr. Eugene Braunwald, a legend in the field of cardiology and also one of the physicians who discovered the disease, while the natural history of HCM is described by Dr. Harry Rakowski of Toronto’s Peter Munk Cardiac Centre. Dr. Chris Semsarian from Australia does a phenomenal job on the chapter on genetics, a field which has advanced rapidly, while Dr. Mario Garcia of Montefiore Medical Center leads the chapter on the expanding field of cardiac MRI. Lisa Salberg, president of the HCM Association, tackles diet, nutrition and the management of obesity which is a common problem in these patients as their exercise capacity decreases. Dr. Michelle Michels from the Netherlands wrote a fantastic chapter on family screening for HCM. The chapter on alcohol ablation is written by Dr. Paul Sorajja from Minneapolis Heart Institute, who contributed a lot to the published literature on the topic, while the surgical myectomy chapter was written by NYU’s Dr. Daniel Swistel. Dr. Paolo Spirito from Italy writes on how to handle HCM patients on the initial and follow-up visits which gives the reader an idea about continuity of care, while Dr. B. Robinson Williams from Emory writes a very nice chapter on building a center of excellence. The chapters on sudden cardiac death are written by the U.K.’s Dr. Perry Elliott, Dr. Mark Link of University of Texas, Southwestern Medical Center in Dallas and Dr. David Owens of the University of Washington in Seattle. Pediatrics management is covered by Dr. Steven Colan of Boston Children’s Hospital. The book ends with case discussions about interesting patients and their management, with contributions by several different authors. Many more interesting chapters, too many to mention!
HCMBeat: Who is the intended audience for the book? Is it geared toward physicians?
Dr. Naidu: The book is ideal for physicians interested in HCM overall and any of the sub-specialties dealing with these patients from surgery to critical care to pediatrics and genetics. The textbook is likely to be used in medical schools, hospitals and other venues that deal with HCM patients. In addition, some chapters are ideal for the patient who wants to get a more advanced understanding of their disease. What is nice is that you can purchase the full book online, or you can purchase individual chapters off of the Springer.com website.
HCMBeat: This book has the potential to broaden knowledge of HCM to a much wider medical audience. How are you marketing the book to medical schools and cardiology training programs?
Dr. Naidu: We were fortunate to work with Springer, which has a wide world-based network. Since it was originally published in 1995, the book and chapters have received over 10,000 downloads each year. We hope that the numbers for the newer edition will be even higher!
HCMBeat: What chapters are most helpful to patients?
Dr. Naidu: I would say the chapters on the history and background of HCM, the natural history of the disease (which provides an overview of what patients might expect as they live with the disease), dealing with diet, nutrition, obesity and exercise in HCM, novel medications, lifestyle modification and youth athletic screening may be the chapters that are most relevant to patients with HCM. The chapter on managing patients in the office might also appeal to patients who want to make sure they are being taken care of in an organized comprehensive way.
HCMBeat wishes to thank Dr. Srihari Naidu for taking the time to answer these questions, and for his work in helping to educate physicians about now to best treat patients with HCM.
EDITOR’S NOTE: You can find the book on Amazon.com or springer.com by clicking on these links.