Sunil Rao (associate professor of Medicine, Duke University, Medical Center, Durham, USA) feels lucky that he has felt not much career angst as he always knew that he wanted to be a doctor. He speaks to Cardiovascular News about his career highlights, including his research into the transradial approach and exploring ways to improve the safety of antithrombotic drugs.
Why did you decide to become a doctor and, in particular, why did you decide to specialise in interventional cardiology?
I was inspired to become a physician by my parents, both of whom are physicians. I saw the incredible impact they had on their patients’ lives. I am lucky that I have never had a lot of career angst. I knew by my second year in medical school at The Ohio State University (OSU) College of Medicine that I wanted to be a cardiologist. Cardiology made sense to me because if one learns the fundamentals of cardiac anatomy and physiology, one can diagnose most of the disease states through the history, physical examination, and ECG.
By the end of my third year in medical school, I knew I wanted to train at Duke. Two of my professors at OSU, Dr Earl Metz and Dr Stephen (Rick) Schaal, had trained at Duke and they were such amazing clinicians that I felt compelled to follow in their footsteps. I started my cardiology fellowship at Duke University Medical Center in the catheterisation lab, and although up to that point I never had an affinity for procedures, something about the catheterisation lab environment “spoke” to me and I could not imagine a career where I was no working in the cath lab.
Who have been your career mentors?
I have been extremely lucky in that I have had many mentors throughout my career. My earliest mentors in medical school were Dr Rick Schaal and Dr Harisios Boudoulas. Dr Schaal taught me the importance of the doctor-patient interaction, and Dr Boudoulas fostered in me an interest in clinical research. At Duke, I was again extremely fortunate to have mentors who, to this day, are continuing to guide me. Dr Robert Harrington is the person I credit the most for my career. He taught me everything I know about clinical research, showed me how clinical research is really a person-to-person enterprise, and has given me incredible opportunities. No matter how busy he is, he always has time to answer my questions or give me guidance when I need it. Another one of my mentors is Eric Peterson, who taught me the importance of asking the right research questions and examining the answers from every angle. In the clinical realm, Dr Kenneth Morris is the one who has had the most influence on me. He is a consummate clinician and taught me the importance of always asking “what is the goal of therapy?” when making therapeutic decisions. Another person who has given me great advice is my wife Carrie. She is also physician and has always been supportive of my career decisions and keeps me grounded.
What do you think has been the most important development in interventional cardiology during your career?
There have been so many important discoveries and inventions, thanks to the hard work of dedicated physicians around the world. Interventional cardiology is such a rapidly evolving field. During my career, I think that the shift in evidence generation from case series or observational research to adequately powered prospective randomised trials, the development and iteration of the coronary stent, and transcatheter structural (including valve) interventions are the most important.
Much of your work has focused on coronary interventions for the management of acute coronary syndromes. What are the three key questions in this area that still require an answer?
We need therapies that prevent acute coronary syndromes and management strategies that reduce the risk of recurrent myocardial infarction after acute coronary syndromes, especially in high-risk patients like those with chronic kidney disease. We also need to better individualise therapy so that patients can achieve the ischaemic benefits without the bleeding risk. Finally, we need to understand how best to treat acute coronary syndromes patients who have a requirement for chronic anticoagulation like those with atrial fibrillation. This is a major issue, especially for the patients who undergo percutaneous coronary intervention (PCI). In that context, I think the WOEST trial is a fascinating study and I am looking forward to the ongoing trials examining this issue. We still have a lot of work to do in acute coronary syndromes.
You presented the SAFE-PCI for Women trial at the Transcatheter Cardiovascular Therapeutics annual meeting last year. Women are often seen as an under-researched group in interventional cardiology. What steps can be taken to fill this gap in the knowledge base?
The first step is to recognise that heart disease is a major killer of women. Once we understand that, then we can address the underdiagnosis of coronary disease and acute coronary syndromes in female patients. Second, I think that studies that focus specifically on women are important. Third, it is extremely important to engage patients in the design and conduct of clinical research—this is true for both men and women. We need to understand what is important to patients, and design studies that address their values and priorities.
On behalf of the SCAI transradial working group, you and your colleagues published an article on best practices for transradial angiography and intervention. What were the key take-home messages of this document?
Our goal was to summarise the evidence that supports specific practices. The key messages are: 1) the risk for radial artery occlusion can and should be minimised; 2) radiation exposure during transradial procedures can be reduced and proficiency with radial approach is key; and 3) radial approach is preferred for primary PCI but again, requires proficiency in order to achieve the best outcomes.
Of all the research you have been involved with, which piece are you proudest of and why?
All of the research I have done has been a team effort so I am extremely proud to have been part of those teams. I guess the two projects that meant the most to me are our initial paper on the association between bleeding complications and adverse outcomes. This was a very difficult paper to get published because it was not a popular message, but my mentor Bob Harrington told me to stick with it and we finally got it published. Since then of course, there have been many other studies confirming our findings and an entirely new approach to treating patients with ischaemic heart disease that focuses not only on efficacy (reducing thrombotic risk) but also on safety (minimising bleeding risk).
Another project that was very meaningful was the SAFE-PCI for Women trial, which was a registry-based randomised trial comparing radial and femoral approach among women undergoing urgent or elective PCI. This was the first registry-based randomised cardiology trial in the US, specifically performed in women, and the first US-based multicentre randomised trial comparing radial and femoral access. I am proud of the team that was able to complete this important study.
What are your current research interests?
I am still very interested in exploring ways to improve the safety of antithrombotic drugs, but my interests have expanded to implementation science. I am involved in a trial to see if a coaching intervention can increase the adoption of transradial PCI. In addition, I am very interested in quality improvement and defining strategies that improve the quality of care without increasing the already untenable workload that we all have.
Given that so much information is available online these days, what are the additional benefits of attending medical conferences?
I think the main benefit of attending a medical conference is for networking. It is a central location where cardiovascular specialists from around the world can meet and learn from each other. There is also some excitement in being present when landmark trials are presented and discussed.
What advice would you give to someone starting their career in interventional cardiology?
When you start your first job after training, take on only the straightforward cases and do not be afraid to ask for help. Develop a rapport with your patients, always be honest with them and with your colleagues, be an advocate for your profession, and remember that family always comes first.
You won the 2011 ACC W Proctor Harvey Teaching award. In your view, what are the key elements of good medical teaching?
I think that enthusiasm and passion for the subject matter is the hallmark of a good teacher. That applies to teachers whether they are teaching young children, teenagers, medical students, or residents and fellows. Another key element is being able to present the information in an organised way. Using humour and personal anecdotes also helps.
What has been your most memorable case and why?
If I was younger, I would probably answer this question by recounting an incredibly complex interventional case that I did, but now that I am a bit older, the cases that mean the most to me are those where the patient’s life was significantly impacted. I remember one particular case of a young man who was brought in with an anterior ST-segment elevation myocardial infarction (STEMI). He was obese and had type 2 diabetes. Although he was actively having a STEMI, he was refusing to undergo primary PCI because he just could not believe he was having a heart attack. He was in denial about all of his medical problems. His wife was pleading with him to allow us to take him to the cath lab for primary PCI and finally he relented. The left anterior descending artery was occluded very proximally and we were able to open it, but the damage was quite extensive. I was convinced that this patient would be relegated to a life of heart failure if he even survived the hospitalisation. About six months later, I was called to the emergency department because a patient wanted to see me. I arrived to find a thin young man who proceeded to thank me profusely for saving his life. I did not recognise him at first, but he reminded me that he was the obese patient who was refusing to undergo primary PCI and told me how my explanation for what was happening, what needed to be done, and how he could take control of his life and habits to prevent future cardiovascular events, really changed his life. A case like this reminds me why I became a cardiologist.
What is your view of social networking sites (such as Twitter) and their role in spreading medical knowledge?
They are tools, and as such, need to be used to accomplish a specific task. There are significant disadvantages of course, because one can never be sure that the information being shared is accurate or truthful. But social media can be very powerful, and we are just learning how to harness it to disseminate information. In the future, I think it will also play a central role not only in how we communicate with each other and with patients, but also in how we treat patients and improve outcomes. Already, study results that have the potential to impact thousands of patients are shared immediately and spread virally through social media. This will only increase in the future. In addition, social media can create communities of patients and that “crowdsourcing” can be a rich source of ideas for future therapies.
Outside of medicine, what are your hobbies and interests?
When I am not working, I spend time with my family. I have a wonderful wife, four delightful daughters, and 18 nieces and nephews. My family has a great sense of humour and we always have a terrific time together. My hobbies include collecting vintage wristwatches and reading biographies and world history. I am very interested in learning where we have been so we can understand where we are going.
- Section chief, Cardiology, Durham, VA Medical Center, Durham, USA
- Associate professor of Medicine, Duke University, Medical Center, Durham, USA
- Director, Cardiac Catheterization Laboratories, Durham Veterans Affairs Medical Center, Durham, USA
2003–04: Warren S & Gloria R. Newman fellow in Interventional Cardiology, Division of Cardiology, Duke University Medical Center, Durham, USA
2001–02: Chief fellow, Cardiology, Division of Cardiology, Duke University Medical Center, Durham, USA
1999–2003: Cardiology fellow, Division of Cardiology, Duke University Medical Center, Durham, USA
1997–99: Resident, Internal Medicine, Department of Internal Medicine, Duke University Medical Center, Durham, USA
1996–97: Intern, Internal Medicine, Department of Internal Medicine, Duke University Medical Centre, Durham, USA
1996: Doctor of medicine, The Ohio State University College of Medicine, Columbus, USA
- â€¨â€¨American College of Cardiology (ACC)
- â€¨Society for Cardiovascular Angiography and Interventions (SCAI)
- Transcatheter Cardiovascular Therapeutics (TCT)
- Veterans Health Administration