In this special Lifetime Achievement Award Spotlight, we asked this year's recipient Lynne Warner Stevenson, MD to share career highlights, opinions on the future of heart failure care, and her professional advice on entering a career in the field of heart failure.
Dr. Stevenson will receive the award alongside a co-honoree at the HFSA Annual Scientific Meeting 2021 on Saturday, September 11. Learn more >>
Please share with us some “highlights” from your distinguished academic career that have significantly impacted the field of heart failure.
Since 1984, I have been tailoring therapy to Take the Congestion Out of HF, establishing the wet-dry-warm-cold profiles and measuring changes in dynamic mitral regurgitation, neurohormones, exercise, and quality of life, with wonderful colleagues at UCLA, the Brigham, and Vanderbilt. On chronic background therapy, ESCAPE studied decongestion in hospital, and standardized it for subsequent HF Network and other trials. Ambulatory hemodynamic monitoring revealed gradual re-congestion in time to avert hospitalizations, not only for HFrEF in combination with GDMT but also for HFpEF, for which hospitalizations are reduced by almost half. Sharing vigilant observation, we have chronicled early recognition of the cardiorenal syndrome, bimodal patient preferences, right-left mismatch of filling pressures, and HFbetterEF. Another major direction has been toward clarity for HF triage and personalized decision-making, from rendering patients “too well” for transplant to identifying “less sick” ambulatory patients for LVADs. After REMATCH, I contributed to the original design of INTERMACS, introducing its trajectory profiles and preparing for comparisons to contemporary medical therapy through MedaMACS and REVIVAL, which reveal sustained quality of life for many ambulatory patients with advanced HF.
In your opinion, what are important next steps in research to improve heart failure care?
Current research in HF spans from prevention for populations to personalization for individuals with disease. Discovery accelerates for genetic contributions to cardiomyopathy, with growing recognition of multiple hit etiologies, including synergistic mutations, inflammation, and toxic injuries. Anticipate tighter targeting of therapies to etiology, but evaluation will require better coalescence of imaging and biomarkers to track early disease as decreasing congestion limits reliance on hospitalizations as metric for impact .
Until more precise definitions, personalization is enhanced by phenotypic “Bins and Boundaries” that are actionable, despite limitations of subset analysis. Vigilance drives revision of bins, such as for EF improvement into “remission”, breakthrough hospitalization despite GDMT, and secondary right HF. HFpEF unfortunately is a reservoir that overflows in search of defining buckets.
Current recommendations address initial up-titrations but lack guidance into continuity HF management. Although strategy trials are difficult to sponsor and perform, they are vital; we need better maps upon which to track and re-route for improvement, for progression with silence or symptoms, for advanced therapies or revision of life goals. Where we can neither prevent nor cure, we desperately need research into technology to empower patients to help pilot their own journeys.
Over the years, you have served in many key and critical roles within the Heart Failure Society of America. What do you consider to be some of the pivotal activities that you have led within our Society?
Invited to the first HFSA scientific meeting in 1997, I felt a new identity within this community of vision and future. On the HFSA guidelines for the next 10 years, I grew up into both evidence and process. This prepared me for my most important HFSA role, as chair of the scientific program from 2010-2012, with responsibility to stimulate new engagement despite the sunset of sponsored faculty expenses. With co-chairs Steve Houser and Barbara Riegel and a phenomenal program committee, research into our faculty and emerging helped us to integrate each session with the laboratory, the bedside, and the expertise of nursing and pharmacy specialists, creating topics with a twist away from “canned talks”. My longest home has been the Education Committee, working to translate the HFSA mission to the larger groups who dominate HF care, to formalize our fellowship training, and to nurture the young into HF. During the many events for them from Boca Raton to Turnberry, I grew wiser with them each year as my career colleagues shared new science and lasting life lessons.
What do you think are new opportunities to grow the Heart Failure Society of America that will enhance its role as a leader amongst professional societies engaged in heart failure education, research, advocacy, etc.?
Our HFSA membership of 2,200 is not large enough to address the challenge of HF. The skilled army could be created through training in HF before graduation for nurse specialists, nurse practitioners, pharmacists, and physician assistants.
Our support for advanced HF fellowship training should emphasize the unmet needs for all stages of HF. Training and early faculty hires are weighted toward care of heart transplants and ventricular assist devices. In addition to continued advocacy for use and reimbursement of recommended therapies, HFSA should advocate for early recognition of potentially treatable causes of HF in patients and families.
The majority of care is provided by primary care providers, to whom we should reach out more broadly, but will be turned away unless we offer relevance. Contemporary recommended HF regimens are so costly that they underline care disparities. Lastly, even if the field must be labelled Heart Failure, providers seeking to prevent progression to failure may prefer a positive label like Heart Savers.
What advice do you have for early career professionals who are entering the field?
Do not try to follow anyone else’s career path too closely because the landscape is changing too quickly. People heading into HF careers now often benefit from having a related diagnostic expertise. I also recommend staking territory at the boundaries between two specialties, where there is often room for definition.
Very few of you will be physician scientists who support your salary solely on research. Those who might be will know who you are or your mentors will tell you. In this era it will be very difficult to make promotion to an associate level there without extraordinary work, strong mentoring and some luck.
If you want to do research, ask a question for which the answer matters (from Steve Houser), then take some time with a yellow tablet until you get the question right and predict how the answer might look (from my father), and design a study from which you will learn something useful even if the primary result is negative (from me).
For the rest of you, like me for my early career, you will do clinical care more than half of your time, some administration, and to a variable degree will publish to advance knowledge and the care of patients. Promotion will be supported by all of your contributions so document them, including teaching materials, formal care pathways, QI, focused specialty programs, and other initiatives. Remember always that our greatest privilege is that patients entrust their lives into our hands, for connections which provide our truest rewards.
Embrace uncertainty as a gift and allow serendipity to influence your path. Recognize that life is not fair and move on each time. Develop a brand of work and a style of collegiality of which you will be proud. Nurture your colleagues as well as yourself. Do not work to be recognized but to make a difference. I am often asked what I would do differently if I knew then what I know now; I would probably work just as hard but I would not worry so hard.
About the HFSA Lifetime Achievement Award
The HFSA Lifetime Achievement Award is presented by the Executive Council of the HFSA. The purpose of this award is to recognize a lifetime body of work by an individual who has made a significant and sustained contributions to the field of heart failure. The 2021 Lifetime Achievement Award has been made possible with the generous support of Cytokinetics.