Nieves Gonzalo

Interventional cardiology is a rapidly evolving field, offering the opportunity to learn procedures with immediate and life-changing results for patients. This is what has attracted Nieves Gonzalo (Clinico San Carlos University Hospital, Madrid, Spain) to the specialism, and why she believes it will continue to draw in future generations of physicians. Recently appointed as a course director for EuroPCR, Gonzalo also serves as a deputy editor of EuroIntervention, and as a co-chair of the European Association of Percutaneous Cardiovascular Interventions (EAPCI) Scientific Documents and Initiatives Committee. She tells Cardiovascular News about her career to date, research priorities, and the importance of representation.

Why did you choose to become a doctor and why, in particular, did you choose to specialise in interventional cardiology?

When I was in high school I loved biology and I was fascinated by the complexity of interactions that allow life to exist. Medicine was the perfect opportunity to continue learning about this and to apply this knowledge to improve lives. I decided to study cardiology because I found heart physiology enthralling and the specialty provided so many opportunities from diagnosis to treatment, and from the beginning, interventional cardiology was the choice for me. The possibility of performing a procedure that generates immediate results for the patient—for example primary percutaneous coronary intervention (PCI)—is extremely rewarding.

Who were the biggest influences on your early career?

I did my cardiology training at Hospital Clinico San Carlos (Madrid, Spain) and all of my colleagues in the interventional cardiology department were extremely supportive. The chief of interventional cardiology at that moment was a woman—Rosana Hernández— and she was a great inspiration. My mentor Javier Escaned, together with Manel Sabate, encouraged me to go abroad for a fellowship at the Thoraxcenter in Rotterdam (The Netherlands) with Patrick Serruys and this widened my view, helping me to incorporate research as a central aspect of my career. In Rotterdam, I worked very closely with Evelyn Regar to develop my thesis on optical coherence tomography (OCT) when the technique was starting out.

What has been the most important development in interventional cardiology during your career?

The most important developments in interventional cardiology during my career have been the incorporation of primary PCI (a lifesaving strategy), the invention of drug-eluting stents (DES) that have tremendously improved the long-term success of PCI, and the incorporation of intracoronary physiology and imaging techniques that have changed the way in which we perform PCI, providing a new insight into the pathophysiology of coronary heart disease. The other big development has been transcatheter aortic valve implantation (TAVI), another lifesaving procedure that has provided a new opportunity for many patients who did not have options before and is contributing to offer less invasive treatments for many others.

What has been the biggest technological disappointment?

The biggest disappointment for me was polymeric bioresorbable scaffolds. I worked intensively on the initial phase of the ABSORB studies during my fellowship in Rotterdam and the initial results were promising. We were all thrilled with the possibility of treating atherosclerotic disease without the need for a permanent metallic cage, it was a pity when larger trials revealed significant problems that precluded their clinical application. I still hope, however, that the concept will be revived. There are so many potential advantages for the future, especially with an ageing population that will probably require repeated interventions throughout their lives.

What are your current research priorities?

My current research priorities are focused on treatment of complex coronary disease, a growing problem as we treat older patients with multiple comorbidities. In this regard, strategies to improve treatment of calcific lesions are going to be key to improve the long-term results of our interventions. I am also very interested in the treatment of restenosis, which is much more challenging in the context of DES, especially with the development of neoatherosclerosis. Another field of interest and research is the relation between physiology and atherosclerotic plaque morphology and the treatment of left main disease.

What are the key unanswered questions around the field that future research should prioritise?

There is currently a renewed interest in the search for high-risk plaques to be able to detect them before they rupture and generate an event. I think this is an important field where intracoronary imaging techniques and potentially non-invasive imaging technologies can provide new insights and help us move toward preventing events instead of treating them. The incorporation of artificial intelligence (AI) will probably be important, especially in plaque characterisation and development of new physiological indices derived from invasive and non-invasive technologies. PCI guidance based on physiology, and imaging and impact on future events as compared with other treatment strategies, is another important area to be addressed. The concept of leaving nothing behind when treating coronary disease—either with bioresorbable devices or drug coated balloons—will also be relevant in future research.

What has been the most important paper published in the past year?

One of the most interesting papers published in the last year for me has been the long-term results of SYNTAX II. The paper demonstrated that applying a complete contemporary percutaneous revascularisation strategy incorporating heart team discussion, imaging and physiology to guide and optimise PCI can yield optimal clinical results in multivessel disease, making it competitive with more invasive strategies.

What are the current challenges facing women seeking to enter the interventional cardiology field, and how can these be overcome?

There are many challenges that women face when they decide to pursue a career in interventional cardiology ranging from the lack of role models and support to concerns regarding pregnancy and reconciliation of family and work life. Big efforts have been made in recent years to generate guidance to overcome these barriers and promote the incorporation of women in leading positions and I am sure they will take effect in the next generation. Promoting a meritocratic system in which gender is not an issue will bring more women into the field and will help them to reach leading roles. Equal representation in research and education is also an important aspect that needs to be considered and properly promoted.

What can interventional cardiology do to better attract young physicians into the field?

The best way to attract young physicians is to show them how fascinating this specialty is. Interventional cardiology is in continuous evolution, meaning that you always keep learning and it is impossible to get bored. From a personal point of view, it is demanding but also really rewarding, offering you a lot of options to help patients. Promoting enthusiastic young colleagues and generating a good working environment for the future is a task for every one of us.

Looking back over your career, what has been your most memorable case?

There are many cases that have been memorable especially, for example, my first case of a patient with a left main occlusion who arrived in a critical situation and was able to survive and recover after primary PCI. There is another case that we performed recently that was also transformative for me. This involved a lady with advanced renal disease, severe peripheral disease with no conventional accesses, critical left main disease with extreme calcification and very severe left ventricular (LV) function. In this case, after careful planning with computed tomography (CT) and with the help of the vascular surgeon, we were able to perform the PCI with LV support through a surgical left subclavian access that was the only route available. For me it was an example of how teamwork is going to be critical in the future as we tackle more and more complex patients and disease.

Outside of medicine, what are your hobbies and interests?

I like nature and outdoor activities. Taking care of my garden is especially relaxing for me. Also, doing exercise is essential to keep me happy. I especially enjoy spending time with my children and share with them my love for music and books.

Appointments and training

„ Director Consultant

Interventional Cardiologist, Clinico San Carlos University Hospital, Madrid, Spain

„ Fellowship, Thoraxcenter, Erasmus University Rotterdam, Rotterdam, The Netherlands

„ Doctor of Medicine, Universidad Autónoma de Madrid, Madrid, Spain

Memberships

„ European Society of Cardiology (ESC)

„ European Association of Percutaneous Cardiovascular Interventions (EAPCI)

Research

„ RIBS IV and V OCT sub-study

„ VISTA study

Appointments

„ Deputy Editor, EuroIntervention

„ EuroPCR Course Director

„ Co-chair, EAPCI Scientific Documents and Initiatives Committee)

Comment & Analysis

A recent study revealed higher readmission and mortality rates following percutaneous coronary intervention (PCI) among Black patients. According to the study's lead author, Stephanie Spehar (University of Michigan, Ann Arbor, USA), the research highlighted stark disparities in patient outcomes, likely influenced by the structural barriers to health equity. In this interview, Spehar tells Cardiovascular News about the rationale behind the retrospective analysis, and considers some of the steps that need to be taken to address the socioeconomic gaps in post-PCI pathways to care between Black and white patients.

Can you summarise the significance of the findings from the study?

Firstly, to give an overview of the findings, when looking at longterm outcomes like readmission and mortality, we found that […] Black patients following PCI were more likely to be readmitted within 90 days and were more likely to die than white patients in long-term follow-up. In general, we found minimal differences in in-hospital process measures and outcomes between Black and white patients following PCI.

Another important piece of our study was trying to understand exactly why those disparities occur—some of the big drivers or mediators we saw were personal wealth and economic status of the patient’s community, as well as patients’ underlying comorbid conditions. This is significant as we know these differences still exist and it shows that there is some disparity of care outside of the hospital setting. We are doing a better job of adhering to guidelines and making sure everyone gets high-quality care, but once a patient leaves the hospital, we know that there are a number of important factors and structural barriers that may be driving long-term disparities in outcomes.

It is challenging but important, and it highlights the need for our providers to care not only about the immediate procedure and what is happening in the acute hospital setting, but also overseeing the post-discharge pathways as well. Moreover, as a healthcare system, we must attempt to make improvements in preventive care to delay the onset of coronary artery disease and other comorbid conditions.

Do the common risk factors for coronary heart disease differ among ethnic groups?

In our research we were able to identify many baseline characteristics that may indicate differences in the severity of cardiovascular disease and could impact long-term outcomes.

Black patients were more likely to have diabetes, hypertension, and had higher rates of chronic kidney disease necessitating dialysis. It is well established that such conditions not only put one at risk for cardiovascular disease, but may also impact long-term outcomes.

Underlying conditions are certainly one of the most important factors that may explain the differences in longterm post-PCI outcomes between Black and white patients, but that is not to say there are not other things happening too. Particularly concerning are personal wealth and the economic wellbeing of the community.

Moreover, the relationship between personal wealth, economic wellbeing of the community, and underlying conditions or comorbidities are complex and interconnected.

What are the most significant risk factors contributing to mortality among Black patients post-PCI?

It is hard to know because we do not necessarily have a grasp on what is specifically happening, or not happening, in the outpatient setting. One of our important findings was that Black patients were less likely to be referred to cardiac rehabilitation. We know that cardiac rehabilitation is a guideline- recommended therapy after heart attacks and stenting. We believe a very tangible thing that can come from this study is focusing on cardiac rehabilitation referrals and understanding why Black patients are not being referred. This disparity is important as it is something we have already begun targeting within our state-wide quality improvement collaborative. Other than that, it is really hard to know exactly what is happening in the outpatient setting and we definitely need more research in terms of post-acute care pathways and care co-ordination.

Patient navigation assistance has been used in different populations, like the oncology population, and may be helpful after PCI. Again, working through some of the socioeconomic barriers like transportation, having access to healthcare, which a lot of folks do not have here, is really critical. These are not necessarily measures that we are tracking as physicians, but they are extremely important in terms of outcomes. Finally, optimal management of risk factors in terms of underlying conditions—so better management of hypertension and diabetes—will continue to improve long-term outcomes following heart attacks as well.

You conducted a statewide quality improvement collaborative to discuss improvements that can be made concerning patient care—what were the outcomes of this?

Michigan has a state-wide collaborative which collects data on all PCIs performed at 48 hospitals across the state. It is a robust body of data that we can use to understand care here. The group meets regularly to debrief and understand these outcomes and we have begun to try to understand these observed disparities for how we can attempt to reduce these disparities.

Within our state-wide quality collaborative we have focused on improving the use of cardiac rehabilitation after cardiovascular procedures, such as PCI, with a specific goal of improving the rate of referral to cardiac rehabilitation prior to discharge. Our hope is that through collaboration across the state with health care facilities and providers, we can improve upon this disparity.

Lastly, understanding the root cause of many of these structural barriers to health equity remains critical.

What do the results tell us about racial disparities more generally in the USA, and does the study raise questions that may lead to further study?

That is one of the limitations of our study—it is based in the state of Michigan and so certainly the patient population and the economic landscape may be different than in other states. So, I think it is hard to generalise across the entire USA, although we are a racially, socioeconomically diverse state, and we saw that in our data. And so again, I think it is hard to generalise, but I do not think anyone would be surprised if these same disparities were true at a more national level.

How generalisable are the results to the other ethnic groups that were excluded from the study, and are you able to extend these findings?

I cannot comment on other races or ethnic groups—we specifically focused on Black and white patients as they were the largest racial/ethnic groups. Patients who identify as multiple races were around 2.9% of our entire population. I do not know that we would be able to generalise, although when you look at what mediated the difference in outcomes, again it was personal wealth, community socioeconomic status, and comorbid conditions. Race is a social construct not a biological one.

I think cardiac [rehabilitation] cannot be understated. Why is it that people are being referred less for cardiac [rehabilitation] and how, as a system, can we make sure that this stops happening? It is a really strong collaborative group that comes together and thinks through different strategies

I think one big takeaway for us is [the need for] post-procedure routes to care and the options that are available so that we can better support patients to make sure they are getting the follow-up care they need and are not being readmitted and having bad outcomes. And, more broadly, we as a society need to focus on understanding the root causes of many of the structural barriers to health equity such as ensuring economic mobility and affordable and adequate health insurance coverage, to name a few.

Stephanie Spehar is a chief resident physician at University of Michicigan Medical School, Michigan, USA, specialising in health disparities, female cardiovascular disease and cardio-obstetrics.