Advancements in heart health - January 29, 2017
Courtesy of The Times of Northwest Indiana • January 29, 2017
By Karyn Brodsky
When Sonny and Cher recorded the song “The Beat Goes On” in the 1960s, it’s improbable that anyone then could even imagine the progress that medical science has made in cardiac health. Although today’s statistics on heart-related deaths are staggering, there are many cardiac professionals in the Region who are keeping up with the latest trends in heart health and using cutting-edge technology to ensure your heart keeps on beating.
Cardiologists and their teams are faced with the daunting task of ensuring their patients don’t become one of the statistics. Sudden Cardiac Arrest (SCA)—a malfunction of the heart’s electrical system caused by abnormal, or irregular, heart rhythms or arrhythmias that may result in death—and vascular diseases claim nearly 350,000 lives each year, more than those lost to all types of cancer combined. That means every 30 seconds in the U.S. someone dies or is adversely impacted by a heart condition.
Heart attack, or myocardial infarction, which may cause cardiac arrest and sudden death, is caused when the blood flow that brings oxygen to the heart muscle is severely reduced or cut off completely by a blockage caused by a buildup of plaque. Though a heart attack indicates a death of heart muscle tissue due to the loss of blood supply, it does not necessarily result in death.
While proper nutrition, sleep, exercise, lowering alcohol consumption and smoking avoidance are necessary to lessen the chance of heart attack and other vascular diseases, lately there have been significant advancements in treatments and procedures.
In the past year or so there has been an “explosion” in innovative structural heart procedures, according to Hussam Suradi, MD, FACC, FSCAI, ABVM, medical director of the Structural Heart and Valve Center of Community Healthcare System, which includes Community Hospital in Munster, St. Catherine Hospital in East Chicago and St. Mary Medical Center in Hobart. Kevin Roesch, cardiac program director for Franciscan Alliance, agrees. “The hottest topic in treatment for cardiac disease today is structural heart treatments,” Roesch says. Abed Dehnee, MD, a cardiologist with Ingalls Health System, notes that there have been many new trials of these procedures this year.
Major advancements include the use of device therapies such as the Transcatheter Aortic Valve Replacement (TAVR), Boston Scientific’s WATCHMAN Implant for Non-Valvular Atrial Fibrillation (AFib) Stroke Risk, Abbott’s MitraClip for leaky heart valves, and the introduction of absorbable stents. In addition, there are new drug therapies such as the expanded use of Novartis’ Entresto for Congestive Heart Failure (CHF) and PCSK9 inhibitors for patients with high cholesterol.
Transcatheter Aortic Valve Replacement (TAVR)
According to Heart.org, TAVR is a “minimally invasive surgical procedure that repairs the valve without removing the old, damaged valve. Instead, it wedges a replacement valve into the aortic valve’s place.” Dr. Dehnee says a catheter is inserted through the groin, which makes open heart surgery for valve replacement unnecessary. “This is good for high-risk patients, or those who can’t deal with surgery,” he says. Roesch adds that studies completed this past year have made it possible to include those with intermediate risk and new studies are looking at whether it is an option for those with low risk. A team of cardiac specialists and cardiothoracic surgeons successfully performed the TAVR procedure on two patients on Jan. 11 at Community Hospital.
Dawn Nelson, WATCHMAN coordinator, and Terri Gingerich, director of cardiovascular services for Porter Regional Hospital, describe the WATCHMAN device as a mesh plug to contain a hole in the left atrial appendage to avoid a stroke for patients diagnosed with chronic AFib. “Blood pools in the left atrium and the appendage is where blood clots hide. The clot then travels to the brain and causes a stroke,” Nelson says. “The WATCHMAN is an ideal alternative for those who cannot tolerate anti-coagulation medication, or blood thinners, used for AFib.” Nelson notes that these anti-coagulation medications can cause gastrointestinal bleeding and intercranial bleeding, and those who fall frequently, such as the elderly, are at risk for bleeding.
Gingerich says that the WATCHMAN helps prevent 95 percent of strokes that are caused by blood pooling in the left atrial appendage. “Forty-five days after the procedure we test for clots and if there are none, the patient can be off blood thinners for life,” she explains. “In fact, in our experience, 100 percent of our patients have gotten off the Coumadin (Warfarin) for good.” Gingerich adds that Porter Regional Hospital performs the procedure with the team of Dr. Mark Dixon, electrophysiologist, Dr. Sandy Sehgal, cardiologist, and Dr. Jay Shah, cardiologist.
Roesch says the MitraClip, FDA approved in 2014, clips the tips, or leaflets, of the mitral valve together to decrease the amount of backward blood flow. Dr. Suradi says that it is the ideal way to repair a leaky mitral valve for patients considered high risk for open heart surgery. The clip is inserted on a catheter by a needle through the groin, which is less invasive than surgery because there is no incision, and the hospital stay is typically only one to two days. Suradi notes that the MitraClip is a relatively safe procedure and results overall have been successful. He adds that even if the procedure doesn’t work, patients can still undergo surgery.
Dr. Dehnee says two new trials found that stents with specific medicine on their platform to decrease the chance of further artery blockage performed similarly to bypass surgery, for that population that had blockage in the left main artery. There are also new, FDA-approved stents that are absorbable and “disappear” within one to two years. Roesch cautions that it is too early to assess the impact of use in the U.S., although absorbable stents have been used in Europe for some time. “Studying the outcomes on patients who had them generated mixed feelings,” says Roesch. “Currently, they may not be the best for all patients, as it’s a bigger stent, preparation is different for insertion and it is not as easy to place as other stents.”
Entresto and PCSK9 Inhibitors
The new drug Entresto is touted by Roesch as “a game changer.” Dr. Dehnee labels it a “blockbuster in the treatment of CHF.” This combination complex drug helps lessen the stress on the walls of the arteries and on the heart. It is an enzyme inhibitor that lowers pressure and makes the heart easier to pump. Dr. Dehnee says Entresto has been shown in trials to decrease mortality and morbidity in patients with CHF with reduced ejection fraction. This means it helps patients cope with the disease and reduces symptoms significantly. Compared to the optimal available state-of-the-art therapy, Entresto allows patients to live longer with fewer symptoms.
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Dr. Andre Artis, cardiologist and medical director of the Heart and Vascular Institute for Methodist Hospitals, says another breakthrough in drug therapy is PCSK9 inhibitors, which are used for patients with high cholesterol who either can’t tolerate statins or who can’t reach an ideal goal for lowering their cholesterol. “Injections are given once every two weeks or once a month, and lower cholesterol significantly,” Dr. Artis says. “The principal side effect is irritation at the injection site.”
So what’s on the heart health horizon in the future?
Dr. Artis lauds the new leadless pacemaker, which can be inserted via a catheter through the groin and goes to the tip of the right ventricle. Again, since no incision is necessary for the patient, it is a less invasive procedure. Artis notes that currently these are being used only for a single heart chamber, but the hope is that in the future, the leadless pacemaker will be used for two chambers.
According to the group of professionals interviewed, other areas that are being investigated are new technologies for arrhythmias, or irregular heartbeats, more procedures to correct AFib, TAVR for the mitral valve, and better treatments for peripheral artery (such as in the legs) disease. Physicians are testing newer ways of doing bypass surgery, such as “off pump”—which is performed on a beating heart—so no heart-lung machine is necessary. This decreases the complication rate and the recovery period.
In addition, the trend will continue in the U.S. to try to perform more cardiac catheterization and use stents inserted from the wrist into the heart. For example, coronary angioplasty performed through the wrist instead of the groin allows the patient to sit up almost immediately and reduces bleeding complications. There will be new emphasis on cardiac rehabilitation, with more government subsidy, so further heart episodes can be prevented, and the expanded use of digital devices to monitor people’s health.
Dr.Suradi points out that insertion of various heart-related devices through the groin is also the wave of the future and will allow people to have better quality of life as they age. “We treat patients of all ages,” he says. “Our oldest patient who had valve replacement via TAVR was 98 years old.”
Additional sources: sca-aware.org, uwmedicinehealth.com, heart.org
HEART FACTS 101
Does all this complicated medical information about the heart have your ticker skipping a beat? See our glossary below for the definitions of a list of cardiac-related conditions so you can keep your finger on the pulse of heart health:
Angina: Terri Gingerich, director of cardiovascular services at Porter Regional Hospital, notes that the term angina refers to “activity-induced chest pain.” According to the American Heart Association (AHA), “Angina is chest pain or discomfort caused when your heart muscle doesn’t get enough oxygen-rich blood. It may feel like pressure or squeezing in your chest. The discomfort also can occur in your shoulders, arms, neck, jaw or back. Angina pain may even feel like indigestion.” The AHA also notes that angina is not a disease and usually happens because one or more of the coronary arteries is narrowed or blocked. It is deemed a symptom of an underlying heart problem, which is typically Coronary Heart Disease (CHD).
Atrial Fibrillation (AFib): According to Kevin Roesch, cardiac program director, Franciscan Alliance, AFib is the “irregular beating of the heart that predisposes the patient to develop blood clots, which may then travel to the brain and cause a stroke.” AFib can be managed with anti-coagulation medications or other procedures, such as the MitraClip.
Cardiopulmonary Resuscitation (CPR): MayoClinic.org defines CPR as “a lifesaving technique useful in many emergencies, including heart attack or near drowning, in which someone’s breathing or heartbeat has stopped.” A series of heart compressions administered by a bystander, CPR can keep oxygenated blood flowing to the brain and other vital organs until professional medical treatment can restore a normal heart rhythm.
Congestive Heart Failure (CHF): CHF is a “weakness in the heart that prevents the heart from pumping normally,” says Dr. Abed Dehnee of the Ingalls Health System. “Fluids and salt build up, which can lead to shortness of breath, fatigue, swelling of the legs and overall weakness.”
Heart Murmur: Dr. Dehnee explains that a heart murmur can occur because of an abnormal narrowing of the aortic valve, or atrial stenosis. “The blood makes a swishing sound that can be heard via stethoscope.” He adds that sometimes, though less frequently, the heart murmur is caused by leakage, or mitral regurgitation, of the valve after it closes.
Palpitations: Basically a “fluttering” of the heart, says Dawn Nelson, WATCHMAN coordinator at Porter Regional Hospital. Often caused by anxiety, palpitations can make you feel like your heart is beating too hard or too fast, skipping a beat, or fluttering.
Myocardial Infarction (MI): Another name for a heart attack. Dr. Hussam Suradi, medical director of the Structural Heart and Valve Center of Community Healthcare System, says blockage to the artery causes injury to the heart muscle. According to the American Heart Association, it’s “the death of heart muscle tissue due to the loss of blood supply, not necessarily resulting in the death of the heart attack victim.”
“Silent” Heart Attack: Seen primarily in the elderly and in individuals with diabetic neuropathy, or nerve damage that doesn’t detect the pain of a heart episode, it is a heart attack where the classic symptoms are not typically displayed. Dr. Suradi notes that the patient “can be short of breath, choking, (experience) arm numbness or be completely asymptomatic.” He says that physicians discover the condition while doing a routine EKG.
Sudden Cardiac Arrest (SCA): The heart stops beating abruptly and without warning. When this happens the heart is no longer able to pump blood to the brain and throughout the body. The person suddenly passes out, loses consciousness and appears lifeless. SCA must be treated immediately with defibrillation or with cardiopulmonary resuscitation (CPR) followed by defibrillation to avoid death. For every minute that elapses after SCA, the chances of survival diminish 7 to 10 percent. The result is death for nine out of 10 victims.
Additional sources: sca-aware.org, hrsonline.org, bostonscientific.com