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*Cardiology Assoc. V1 #3 *Cardiology Assoc. V1 #3 Document Transcript

  • A publication of Cardiology Associates • Mobile, Alabama Volume 3 Number 2 CT Angiograms Coming to Cardiology Associates By J. Andrew Morrow, Jr., M.D., F.A.C.C. How the Successes of Interventional Cardiology Have Advanced the Beyond the Scope of EP Heart, Part 2 By Stephanie D. Grosz, M.D., F.A.C.C. By Frank T. Bunch, M.D., F.A.C.C.
  • NOW AVAILABLE FROM 820 West Maude Avenue Sunnyvale, CA 94085 ©2002 Scios Inc. All rights reserved. P0100101 Sept 2002
  • December 2004 In this issue of Cardiology Currents, our physicians take a look at the ever changing and evolving nature of cardiovascular disease. The amazing advances made Gerry M. Phillips, M.D., FACC in the areas of interventional and preventive cardiology are helping to keep patients Kenneth E. Francez, Jr., M.D., FACC J. Andrew Morrow, Jr., M.D., FACC alive for longer and with expectations for better quality of life. Many of these Frank T. Bunch, M.D., FACC M. Wail Hashimi, M.D., FACC patients, as they survive and thrive, may eventually find themselves in need of “sec- Richard J. Chernick, M.D., FACC Brian D. Dearing, M.D., FACC ondary cardiology services” – electrophysiology, or treatment of peripheral vascular William J. Hayes, M.D., FACC Erik A. Eways, M.D., FACC disease or heart failure. Charles W. Parrott, M.D., FACC Kenneth M. Burnham, M.D., FACC Elia Abboud, M.D., FACC In her article, Stephanie Grosz, M.D. demonstrates how the successes experienced David T. Trice, M.D., FACC in one field of cardiology translate into a need for new treatment options that elec- James R. Stinebaugh, Jr., M.D., FACC Michael W. Monson, M.D. trophysiologists can provide to their patients. She highlights the tremendous strides Karl V. Hakmiller M.D. Ralph S. Buckley, M.D., FACC made in the areas of device therapy and the evolution and advancement of catheter Jason H. Cole, M.D. based ablation. Electrophysiology Stephanie D. Grosz, M.D., FACC D. Scott Kirby, M.D. Frank Bunch , M.D. has written the second article in his series on Peripheral Pediatric Cardiology David C. Mayer, M.D., FACC, FAAP Vascular Disease. Again, we find that many patients who initially present with coro- Anne M. Hackman, M.D. FACC, FAAP Lynn Arnold Batten, M.D., FACC, FAAP nary disease or symptoms they believe are related to coronary disease, are often at Cholesterol and Lipid Disorders risk for the secondary complications of peripheral vascular disease. In this issue, Dr. Mary H. Honkanen, M.D. Bunch focuses on symptoms and treatment options for aortic, iliac and lower Terence E. Hale, M.D., FACC extremity vessel disease. (1955-2000) Vance M. Chunn, FACHE CEO/Administrator Drew Morrow, M.D. shares details about how CT angiography will benefit the 6701 Airport Boulevard patients of Cardiology Associates and discusses the arrival of a 64 slice CT scanner Suite D-330 Mobile, AL 36608 (251) 607-9797 Fax (251) 639-0940 in our city. 1720 Springhill Avenue Suite 500 • Mobile, AL 36604 As we approach the holidays, all of us here at Cardiology Associates wish you and (251) 438-4600 Fax (251) 432-1059 yours a blessed season. 3715 Dauphin Street Suite 4400 • Mobile, AL 36608 (251) 46O-0078 Fax (251) 460-4676 Sincerely 188 Hospital Drive Suite 100 • Fairhope, AL 36532 (251) 990-9500 Fax (251) 990-9501 1721 North McKenzie Street Foley, AL 36535 Gerry M. Phillips, M.D., F.A.C.C. (251) 943-4100 Fax (251) 943-3794 www.cardassoc.com 1-800-842-4009 Created by Publishing Concepts, Inc. Editor Virginia Robertson, President • vrobertson@pcipublishing.com Erik A. Eways, M.D., F.A.C.C. 14109 Taylor Loop Road • Little Rock, AR 72223 / 501.221.9986 / 800.561.4686 Cover Photograph by For advertising information contact: Jane Coker at 501.221.9986 or 800.561.4686 Vance M. Chunn, F.A.C.H.E. jcoker@pcipublishing.com visit our website www.pcipublishing.com Edition 8 3
  • CT Angiograms Coming to Cardiology Associates by J. Andrew Morrow, Jr., M.D., F.A.C.C. Cardiology Associates expects to have its GE 64 suite. Interventions in the invasive lab can be “target- slice CT scanner operational in the first quarter of ed” to already demonstrated blockages. 2005. It is anticipated to be the first scanner of its The new generation of scanners will have more type in Mobile. The scans will offer new possibili- applicability for cardiac evaluations. The breath ties in caring for our patients. CT angiography is a hold for a cardiac scan will be reduced from 20 to developing technology with promise to improve 30 seconds down to 5 to 8 seconds. There will be a the evaluation of several types of vessel disease. bit more tolerance for higher heart rates and heart The current generation of 16 slice scanners has rate variability. The new scanner will have higher shown promise- particularly in the area of periph- resolution around the edges of its field. These eral vascular disease. The new generation of 64 advances will allow scans to be obtained in more slice scanners will advance the technology and patients- and allow more patients to benefit from expand its use to more patients and more types of this new technology. cardiovascular abnormalities- especially those The CT angiograms are very sensitive and easily involving the heart. The faster scanner will allow demonstrate the presence or absence of plaque imaging of the beating heart with higher resolution buildup in the coronary arteries. CT angiograms and with much shorter breath holds by the patient. also show “blood clots in the lungs” - or pulmonary CT angiography uses approximately the same embolisms well. In addition, dissections or “tears” amount of radiation and slightly less contrast “dye” in the aorta are easily seen. Thus one test is able to as invasive angiography in the hospital. The major evaluate three of the most serious or dangerous advantages are that there is no need for an arterial causes of chest pain. Other causes of chest pain puncture and no need to manipulate catheters to such as pericardial effusions and hiatal hernias may find the arteries. This reduces the risk of the proce- be demonstrated as well. A great deal of informa- dure and eliminates the need for a hospital visit- as tion is available in one scan. well as the need for bed rest and observation after CT angiography is not as precise as a heart the procedure. The patient spends about an hour at catheterization for defining the fine details of the scan and then goes home. An IV line is required bypasses, stents, and exact percentage of blockage in for administration of the contrast agent. The heart- coronary arteries. The CT angiograms do not show beat is monitored by EKG leads so that the scans the amount of flow disturbance from fat buildup in can be timed to the cardiac cycle. the arteries- best seen with a stress test. The CT CT angiography provides excellent peripheral angiogram is a new test which complements rather arterial studies. In most patients the scanner can than replaces our current diagnostic modalities. evaluate any large peripheral artery as well as a tra- The physicians and staff of Cardiology Associates ditionally invasive angiogram. Studies of large por- are excited about the opportunities available with tions of the peripheral arterial tree can be done with this new technology. Look for more information in less X ray contrast than in the invasive angiography future issues of Cardiology Currents. 4
  • How the Successes of INTERVENTIONAL CARDIOLOGY Have Advanced the Scope of EP by Stephanie D. Grosz, M.D., F.A.C.C. Deaths from heart attacks have been s research and technological cut nearly in half over the last 20 A developments continue to advance the detection and treatment of coronary artery disease years. Conversely, since 1980, the death rate from arrhythmias has and heart attacks, the demand for increased from 27.6 per 100,000 to services and treatment options in the field of electrophysiology grows 69.8 per 100,000. proportionally. Our success in treating patients with coronary with a rhythm disorder. Many cardiovascular abnor- artery disease and improving life expectancy in these malities can contribute to AFIB including coronary patients has resulted in a new and exponentially grow- artery disease, valvular heart disease, heart failure, ing need to help those people who have either sur- hypertension, dilated cardiomyopathy, as well as non- vived a cardiac arrest or are at risk for a life threaten- cardiac disease such as thyrotoxicosis and a variety of ing rhythm disturbance. Expanding areas of applica- pulmonary diseases. Prior to AFIB ablation, the only tion for radiofrequency ablation, particularly for atrial option available for this large segment of patient pop- fibrillation, has provided exciting focus for the field, ulation was drug therapy. Standard medical regimens and help for these patients, many of whom are debili- usually consist of an anticoagulant to prevent stroke, tated by their disease. Improved device therapy with and a rhythm control medication with or without a the addition of biventricular devices to the armamen- rate control drug. These are chronic suppressive regi- tarium of treatment for congestive heart failure has mens, not considered curative. Atrial fibrillation improved both quality of life and mortality in this breakthrough on medical therapy is not uncommon, subgroup of patients. and can occur in as many as 50% of patients. Deaths from heart attacks have been cut nearly in AFIB ablation is an alternative treatment option in half over the last 20 years. Conversely, since 1980, the select groups of patients with atrial fibrillation who death rate from arrhythmias has increased from 27.6 have not done well on medical therapy. Research has per 100,000 to 69.8 per 100,000. Fortunately, in shown that if the electrical triggers that set off an many areas of arrhythmia management and treatment, abnormal rhythm can be localized to the pulmonary new and emerging options continue to be explored veins (the veins that drain the lungs to the left side of and utilized with great success. The new technologies the heart), and these veins can be isolated from the frequently complement with treatments that have heart electrically with ablation, then the triggers that become standard of care, such as electrophysiology “send” the heart into AFIB can never reach the heart. studies, catheter ablation, and device therapy. These The procedure is evolving, and has mixed results advances will be reviewed in this article. reported in the literature. As many as 50-70% of ABLATION patients may have long term “cure” of AFIB, in that One of the biggest breakthroughs in the field of EP they may be able to discontinue antiarrhythmic med- and certainly within the realm of ablation is ications. The therapy is not without morbidity, and is Pulmonary Vein Isolation or Ablation for Atrial not indicated for all patients with AFIB, but it is a Fibrillation (AFIB). This arrhythmia affects more than good alternative for some patients. half of the 4 million Americans currently diagnosed continued on the next page 9
  • DEVICE THERAPY who have not yet shown ventricular arrhythmias. Two subspecialty fields of cardiology- MADIT 2 was a landmark study in EP that showed Electrophysiology and Heart Failure- meet in an effort improved life expectancy in patients with EF<30% to treat the millions of patients who are now surviving who had defibrillators placed vs. those treated with heart attacks and cardiovascular events because of medical therapy. These patients had not shown any improvements in treatments in the areas of coronary arrhythmias yet. Cardiology Associates participated in disease. Almost every type of cardiovascular event or this trial that now supports prophylactic defibrillator risk factor can damage the heart and eventually lead to therapy for patients with coronary disease and one or both of these subspecialty fields of cardiology. impaired LV function. One of the ways the two disciplines work together is in the area of coronary disease, and left ventricular dysfunction. Currently, the mortality for patients with “Based on new studies, defibrillator therapy coronary disease and Ejection Fraction (EF) of < 30% has now expanded to include high risk is high, 20% at 2 years despite treatment with optimal medical therapy-ACE inhibitors, beta blockers, digox- patients who have not yet shown ventricular in, and diuretics. Part of the mortality in this high risk arrhythmias.” group of patients is due to arrhythmia. 400,000 peo- ple in the United States per year experience sudden cardiac death, caused largely by ventricular arrhyth- Many patients with left ventricular dysfunction mias. The mortality of out of hospital cardiac arrest also have interventricular conduction delay. This caus- remains extremely high so much recent research has es delayed lateral wall contraction, disorganized ven- focused on identifying high risk patients to prevent tricular contraction and decreased pumping efficacy in sudden death from arrhythmias. these patients. These patients are “asynchronous”. Morbidity and mortality remain high, with intense medical therapy, inotropic therapy, and transplant the options for many. Cardiac Resynchronization Therapy (CRT) has had significant success in improving quality of life and mortality for this very sick group of patients. It brings another tool to the arsenal of the heart failure physician to offer patients to improve output of the failing heart. To resynchronize, a patient must manifest asynchronous conduction. A standard defibrillator or pacemaker is placed, but a third lead is placed in the vein that wraps around the back of the heart, the coronary sinus. The lead is placed in a tar- get branch to pace the left side of the heart and all of the wires are attached to the pulse generator to pace both the right and left sides of the heart together. The defibrillator device also provides protection against sudden cardiac death as discussed previously. The mechanisms of CRT are 1)restoration of normal One of the primary treatments for this group of rhythm function 2)coordination of septal and free-wall patients is defibrillator therapy. A defibrillator is surgi- contraction and 3)improvement in pumping efficacy. cally and fluoroscopically implanted in the cardiac The field of interventional cardiology has pio- catheterization lab. The device “watches” the patient’s neered many advances that have improved the life rhythm at all times, automatically detecting any signif- expectancy and quality of life of patients that were icant arrhythmia, and will shock and abort a sudden previously “untreatable”. These efforts have led to death event quickly and effectively. Defibrillators new and important challenges for our field of have been indicated for patients who have shown Electrophysiology. The problems faced by our patients malignant arrhythmias, such as sudden death survivors have changed, and as physicians, we have focused on and those who have ventricular, or “bottom chamber” these new issues. As the field continues to evolve, we arrhythmias. Based on new studies, defibrillator thera- will review and update our patients with these excit- py has now expanded to include high risk patients ing advances. 10
  • The early warning signs of a heart attack give you the power to act — but they often go ignored. Why? It doesn’t always start with chest pain. Each heart is unique, and so are its ways of asking for help. Learn all the warning signs. Early Warning Signs of Heart Attack (referred to as the Prodromal Signs. Experi- enced by 60% of all heart attack victims – hours even days before a heart attack) • A mild discomfort or nagging ache in the center of the chest • Recurrent discomfort; feels like indiges- tion. Discomfort may increase in intensity. More intense pain with exertion that goes away with rest. Heart Attack Signs • Pain in the chest, shoulders, neck or arms • Pressure • Fainting • Sweating • Shortness of Breath • Nausea It’s never too soon to get good news about your heart. And in the event of a heart attack, crucial heart muscle is damaged every minute you delay. It’s Your Choice. Make it the Right One. The Chest Pain Center at Providence Comprehensive Chest Pain Evaluation – 24 Hours a Day – Without an Appointment Chest Pain Center Located within the Providence Hospital Emergency Room
  • Gerry M. Phillips, M.D., FACC Gerry M. Phillips, M.D., FACC Kenneth E. Francez, Jr., M.D., FACC Kenneth E. Francez, Jr., M.D., FACC J. Andrew Morrow, Jr., M.D., FACC, FACP Frank T. Bunch, M.D., FACC M.Wail Hashimi, M.D., FACC Richard J. Chernick, M.D., FACC Brian D. Dearing, M.D., FACC William J. Hayes, M.D., FACC Erik A. Eways, M.D., FACC Charles W. Parrott, M.D., FACC Brian D. Dearing, M.D., FACC William J. Hayes, M.D., FACC Kenneth M. Burnham, M.D., FACC Eliyya G. Abboud, M.D., FACC David T.Trice, M.D., FACC James R. Stinebaugh, Jr., M.D., FACC Michael W. Monson, M.D., Karl V. Hakmiller, M.D., FACP Ralph S. Buckley, M.D., FACC Jason H. Cole, M.D., MSc Electrophysiology David T. Trice, M.D., FACC James R. Stinebaugh, Jr., M.D., FACC Stephanie D. Grosz, M.D., FACC D. Scott Kirby, M.D., FACC Pediatric Cardiology David C. Mayer, M.D., FACC, FAAP Anne M. Hackman, M.D. FACC, FAAP Lynn Arnold Batten, M.D., FACC, FAAP Cholesterol and Lipid Disorders Stephanie D. Grosz, M.D., FACC D. Scott Kirby, M.D., FACC Mary H. Honkanen, M.D.
  • J. Andrew Morrow, Jr., M.D., Frank T. Bunch, M.D., FACC M. Wail Hashimi, M.D., FACC Richard J. Chernick, M.D., FACC FACC, FACP Erik A. Eways, M.D., FACC Charles W. Parrott, M.D., FACC Kenneth M. Burnham, M.D., FACC Elia G. Abboud, M.D., FACC Michael W. Monson, M.D. Karl V. Hakmiller, M.D., FACP Ralph S. Buckley, M.D., FACC Jason H. Cole, M.D., MSc David C. Mayer, M.D., Anne M. Hackman, M.D., Lynn Arnold Batten, M.D., Mary H. Honkanen, M.D. FACC, FAAP FACC, FAAP FACC, FAAP
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  • Beyond the Heart, Part Two in a Four Part Series on Peripheral Vascular/Arterial Disease Aortic, Iliac and Lower Extremity Peripheral Vascular Disease By Frank T. Bunch, M.D., F.A.C.C. In the United States, there are 12 – 20% of Americans 65 years of age or older affected by Peripheral Vascular Disease (PVD) which is manifested mainly in the lower extremities. Major Blood It is important to note that there is a 4 to 6 fold increase in Vessels in the cardiovascular mortality in patients who have PVD. Lower Body In lower extremity and aortic PVD, the hallmark symp- tom is intermittent claudication which is fatigue, tightening, squeezing type sensations that occurs anywhere from the level of the buttocks down to the foot and is typically pre- dictable. These symptoms tend to occur with exertion, mainly with walking, and are fairly predictable at a certain distance. Symptoms generally improve with rest and will Abdominal reoccur at about the same distance. Oftentimes symptoms aorta of claudication are mistaken for musculoskeletal or neuro- logic conditions. Peripheral arterial occlusive stenoses located in the lower extremities can be diagnosed with a thorough history as well as a physical exam. The exam should include palpation of pulses and listening for bruits, the noises that occur in the arterial vessels when stenosis is present. In addition, a relatively simple and noninvasive test which can be done in the office is an ankle brachial index (ABI’s). This test meas- ures the systolic blood pressure of the ankle in comparison to the brachial systolic blood pressure. It is very helpful in delineating the cause of leg pain. Oftentimes, patients will adjust their overall activity lev- els to accommodate their symptoms. Their symptoms may not be as prevalent unless one spends some time asking the patient specific questions. The adjustments are usually made gradually and many patients do not realize they have made the adjustments, to the point that they are highly inhibited from their normal daily activities. Overall, PVD, besides creating an increase in mortality and secondary car- 23
  • diovascular disease, can also cause a progressively sedentary lifestyle brought on in part to prevent symp- toms from occurring Historically, vascular disease in the aorta and lower extremities has been treated by either medical thera- py, exercise or surgical therapy. Over the past 15 or so years, there’s been a progression of catheter-based thera- pies for PVD which have become Above: more and more successful. People Right Iliac who were sedentary are now able to return to a more satisfactory lifestyle Angio without the risk of major surgery. Before Aortic Disease is located mostly in the abdominal aorta, usually at and Right: Right below the level of the renal arteries. The iliacs are the two branches off Iliac Angio the aorta leading into the left and After right lower extremities, then to the arteries of the lower extremities below the level of the hip. These ves- sels can be affected at any level either diffusely throughout the vessel or discreet stenosis. Aortic disease can be broken down into two types of disease. conjunction with hypertension. The it splits into left or right iliac arteries. One is aortic aneurysmal disease walls are greatly affected when the It can also occur above that level. In in which an aortic aneurysm forms (a aortic aneurysm reaches somewhere the past, the surgical therapy for this ballooning of the abdominal aorta). in the range of 5 cm in diameter. It is was bypass grafting with aorta This occurrence is secondary to a recommended that an aneurysm of bifemoral grafting. This now can be weakening in the vessel wall due to this size be repaired due to signifi- treated using a balloon with possible atherosclerotic changes as well as in cant risk of rupture. In certain stenting, if needed. The long term instances, the aortic aneurysm can be patency rate of this treatment has repaired through percutaneous thera- actually been shown to be very favor- “Historically, vascular dis- py without open surgery. This can be able and is again another modality ease in the aorta and done by placement of a stent graft which can be used instead of subject- which is a stent covered with a graft ing the patient to major abdominal lower extremities has been like material that excludes the aortic surgery. Typically the patient will go treated by either medical aneurysm. The usual hospital stay for home the next day after being treated. therapy, exercise or surgi- this procedure is one to two days, Iliac disease usually involves ather- after which the patient should be osclerotic changes which cause cal therapy. Over the past able to walk out of the hospital. This stenoses in the iliacs. 15 or so years, there’s procedure also prevents them having Symptoms of aortic and iliac major surgery. blockages are similar. Both have but- been a progression of The second type of aortic disease is tock and lower extremity pain when catheter-based therapies for stenosis or narrowing of the abdominal they walk and are actually better aorta. This can narrow to the point when they rest. The difference with PVD which have become where it can become either totally iliac pain is that it may only affect more and more successful.” occluded, typically occurring at the one side. The sciatic nerve or spinal very distal portion of the aorta before stenosis can be mistaken for claudi- (continued on page 30)
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  • Beyond the Heart, Part 2 continued from page 24 cation symptoms in the iliac arteries. and ultimately, if needed, bypass sur- e 3 Nu m be r 1 Treatment of the iliac arteries is actu- gery is not excluded. Vo lu m bile, Al abam a ally one of the more successful Below the level of the knee in • Mo ciates A pu blicatio n of Ca rdiolog y Asso modes of therapy which includes smaller vessels, the important consid- angioplasty and, if needed, stenting. erations need to be the changeover In the lower extremities, below in progression from intermittent the level of the hip, there are two claudication to a more severe form types of disease which occur either at which is ischemia and can be classi- the level of the thigh in the superfi- fied as critical ischemia when one cial femoral artery or below the knee develops a non-healing wound or hnique ure Tec ent of in the tibialperoneal arteries. pain at rest. Revascularization with ew Cloess the Treatmrent N c Advan ts with Recur d the Multiple treatments have been tried different types of therapies is indicat- BeyonPart 1 Patien , Stroke .C.C. Heart h, M.D ., F.A .C.C. for this lower extremity disease from ed and needs to be done to prevent f Age .D., F.A Bunc ays, M ank T. omes o A. Ew By Fr bypass surgery to intervention via the amputation of the affected limb. ik By Er Cardia c CT C .D., F.A .C.C. By M . Wai l Hash imi, M percutaneous route. Percutaneous More recently there have been stud- approaches include laser therapy, ies using excimer laser which have atherectomy (removal of plaque), demonstrated successful revascular- cutting devices, and angioplasty, as ization of vessels below the level of well as stenting. Different types of the knee to the point where that angioplasty are also available – those patient can heal and save the limb. Thank that use cryotherapy which is a cold Lower extremity atherosclerosis is balloon as well as balloons that have an entity which is being underserved. a cutting blade have both been used. Estimates throughout the country Various gradations of success are have been made and it has been you! present. Due to the long vessel and found that approximately 25 – 30% the diffuse nature of the disease, of peripheral vascular disease patients there is somewhat of a higher scar are undergoing the therapy which is tissue formation, or restenosis, rate in actually available to them. As with these vessels versus vessels that are any form of atherosclerosis, risk fac- above that level of the thigh. One of tor modification is clearly a necessity. the advantages to using percutaneous Smoking cessation, lowering choles- therapy for lower extremities below terol, blood pressure control as well to all our co-sponsors for the level of the hip is that if repeat as controlling diabetes are all very procedures need to be performed, necessary for successful outcomes helping to make our very rarely are bridges burned and long term. multiple modalities can be used again magazine a success. If you would like to “In the United States, become a co-sponsor there are12 – 20% of please call Jane Coker at Americans 65 years of 800-561-4686 or age or older affected by email: Peripheral Vascular Disease (PVD) which is jcoker@pcipublishing.com manifested mainly in the Publishing Concepts, Inc. 14109 Taylor Loop Road lower extremities.” Little Rock, AR 72223 501.221.9986 / 800.561.4686 30
  • Cardiology Associates Presorted Standard 3715 Dauphin Street U.S. POSTAGE PAID Suite 4400 Little Rock, AR Mobile, AL 36608 Permit No. 2437 Over 30,000 heart failure patients have received Cardiac Resynchronization Therapy. How many of your patients could benefit from this therapy? Two weeks after his implant, Wade Arledge felt a little sore. From dancing all night. Patient results vary; not every response to therapy is the same.