Deepak L Bhatt (Executive director of Interventional Cardiovascular Programs, Brigham and Women’s Hospital Heart & Vascular Center, Boston, USA) was the co-principal investigator of SYMPLICITY HTN-3, which he believes highlighted the value of sham-controlled trials. In this interview with Cardiovascular News, he reviews the potential future of renal denervation and explains that asking him to choose his favourite piece of research is like asking him to choose a favourite child.
Why did you decide to become a doctor and why in particular, did you decide to specialise in interventional cardiology?
The first time I really thought about becoming a doctor was when I was lying in a hospital bed after a missed diagnosis of appendicitis led to a ruptured appendix—I almost died. The surgeon drove in through a blizzard to save my life. That experience formed the initial seed of interest in medicine at a young age. When I was a medical student, interventional cardiology was just getting off the ground and performing surgery in such a minimally invasive way seemed really exciting.
Who have been your career mentors?
I have been fortunate to train and work at some of the best places with some really great mentors. Dr Eugene Braunwald has been a major influence on my career. He has taught me a lot about leadership in academic cardiology.
What do you think has been the most important development in interventional cardiology during your career?
The introduction of coronary stenting was, of course, a huge development that was greatly facilitated by the concurrent emergence of dual antiplatelet therapy.
Of all the research you have been involved with, which piece of research are you proudest of and why?
That is like asking a parent which child is their favourite! There are several pieces of research of which I am particularly proud. The CHAMPION programme with cangrelor was a great experience. The first two trials did not meet their primary endpoint (although there were encouraging signals), but we reloaded with a third trial that was then very positive.
I also have been very proud of the work that has come out of the REACH Registry, which I co-chaired with Professor Gabriel Steg. We popularised the term “polyvascular disease”, which I think has helped to develop an appreciation of the frequent coexistence of coronary, peripheral, and cerebrovascular disease.
What are you current research interests?
I am co-chairing the THEMIS (A study comparing cardiovascular effects of ticagrelor versus placebo in patients with type 2 diabetes mellitus) trial. I am also chairing the REDUCE-IT trial, which is evaluating whether lowering triglyceride levels can help to reduce the risk of cardiovascular events, and chairing the data safety monitoring board of a new transcatheter aortic valve implantation (TAVI) trial.
Furthermore, we are still performing several analyses of cangrelor from the CHAMPION PHOENIX trial, which I co-chaired with Dr Bob Harrington.
As someone who has been a principal investigator of several major trials, what are the key elements of a well conducted trial?
A scientifically interesting and clinically relevant question needs to be asked. Ideally, the results should be useful to doctors and patients—regardless of whether the findings are “positive” or “negative”.
What are the implications of the sham-controlled SYMPLICITY HTN-3 trial, which (contrary to previous studies of renal denervation that did not have a sham arm)failed to show a benefit of renal denervation, for sham-controlled trials?
I think the sham treatment arm was an important feature of the trial design, but some interventionalists who really believe in renal denervation and who are still performing it do not agree with this view. Also, some researchers and device makers do not want the difficulty and expense of sham controls. However, that sham controls are often necessary is a lesson we relearn every few years in medicine and surgery.
A popular view, in Europe at least, is that renal denervation is “not dead” and that further studies are needed. What is your view?
If renal denervation is to have a future, I think the top priority is to figure out how best to do it. For example, are distal ablations more important than proximal ablations or vice versa? Are circumferential ablations necessary? How many ablations are optimal and at what energy level? Once these questions have been answered, then we just need to do a proper trial against sham control to show that the procedure really does lower blood pressure. After that, we can look for other effects, such as on heart failure or glycaemic control. But we need to make sure the foundation of this field is solid before we use this therapy on patients clinically.
At present, several trials of renal denervation are in the planning stages and these have incorporated the many lessons learned from SYMPLICITY HTN-3.
You are involved with several patient education initiatives, such as the Harvard Heart Letter. What is the best way to communicate important lifestyle messages to patients?
Giving patients the right lifestyle advice is very tricky, particularly dietary advice because patients receive so many conflicting messages about what they should and should not eat—even basics, such as lowering cholesterol and salt intake, seem to be quite controversial according to the way that they are portrayed in the lay media. I think the key is to be honest about what we know, what we don’t know, and what we think is true today but concede that this advice may not be entirely true tomorrow.
How do you think smartphones could potentially help to spread medical knowledge (ie. through apps and/or social media)?
Smartphones can be used to spread information and misinformation, so we need to be careful about what information is communicated. But, I do think apps and social media will become a big part of medicine because they have already become a big part of life in general. This will be even truer for people who have grown up surrounded by social media.
What has been your most memorable case and why?
Moonlighting one night, I was called to do a transoesophageal echocardiogram on a postoperative patient who was intubated and being coded. By the time I got there, they “called the code” (ie. pronounced the patient dead) after an hour or so of trying. About one minute later, the patient started moving! That taught me to never give up too soon.
What advice would you give to someone just starting their career in interventional cardiology?
Make sure you love it before you go into it. Sometimes people go into a speciality or subspecialty passively, just because they do not find anything else they like more. But I think there has to be passion and a feeling of excitement and purpose in choosing a field. That would probably be advice I give anyone for any field, but I think it matters more for an intense subspecialty such as interventional cardiology.
The work can be very stressful, the hours are long, unpredictable, and involve a great deal of sacrifice—it is not for trainees who have a shift mentality or whose main concern is work hour restrictions, since those do not exist in real life.
For someone who has made the decision to enter interventional cardiology, I do think it is an incredible time, with advances in science and engineering pushing the boundaries of what interventionalists can offer patients. I would suggest that those just starting their careers pay attention to the changes occurring in healthcare delivery and take a leadership role in that change. I would also encourage them to remain engaged in clinical research—participating as a site in clinical trials and registries helps keep doctors at the cutting edge, ultimately benefiting patients.
Outside of medicine, what are your hobbies and interests?
Because of clinical, administrative, research, and educational responsibilities, my week is generally very full. Whatever free time I have, I try to spend with my wife and children. So, my hobbies typically revolve around what the kids like to do. We watch a lot of films. We try to exercise together.
Executive director of Interventional Cardiovascular Programs, Brigham and Women’s Hospital Heart & Vascular Center, Boston, USA
Professor of Medicine, Department of Medicine, Harvard Medical School, Boston, USA
Senior Physician, Department of Medicine, Brigham and Women’s Hospital Heart & Vascular Center, Boston, USA
Medical education (selected)
Chief Interventional Cardiology Fellow; peripheral and cerebrovascular fellowship, Cleveland Clinic, Cleveland, USA
Fellowship, Interventional Cardiology, Cleveland Clinic, Cleveland, USA
Fellowship, Cardiovascular Diseases, Cleveland Clinic, Cleveland, USA
Residency, Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, USA
Doctor of Medicine, Cornell University, New York, USA
- Executive committee, PEGASUS-TIMI 54
- Executive steering committee, ODYSSEY Outcomes
- Chair, REDUCE-IT
- Co-chair, THEMIS
- Steering committee, HeartBEAT
- International co-principal investigator, SAVOR-TIMI 53
- Co-principal investigator, SYMPLICITY HTN-3
- Co-principal investigator, STAMPEDE
- Steering committee, OPTIMIZE
- Co-chair, international co-principal investigator, CHAMPION PHOENIX
- Co-chair, international co-principal investigator, CHAMPION PLATFORM
- Co-chair, international co-principal investigator, CHAMPION PCI
- Executive committee, ATLAS ACS-TIMI 51