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December 2015 Newsletter


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December 2015 Newsletter

  1. 1. Phone: (407) 894-4880 Fax: (407) 894-2364 Toll-Free: 1-800-377-7858 | Vol. CARDIOVASCULAR INTERVENTION | 1 Dr. Pradip Jamnadas MD MBBS, FACC, FSCAI, FCCP, FACP Founder and Director of Cardiovascular Interventions ALSO IN THIS ISSUE DECEMBER 2015 Dec 2015 2 DECEMBER 2015 Dear Patient Happy Holidays everyone! We hope that everyone is staying safe and healthy going into the end of 2015. We here at CVI are eagerly awaiting our 2nd Annual Holiday Party that I am throwing. The staff at CVI loves to have a good time, but we are also well aware that with the holidays comes a great deal of stress for many people. Keeping that in mind, it is especially important to stay on top of your health during this part of the year! We hope that some of the information in this newsletter can help you stay knowledgeable about the cardiovascular risks that can unfortunately become very relevant for some during the holidays. That being said, Cardiovascular Interventions would again like to wish everyone an incredibly happy and safe holiday, and we hope to see you here at CVI next year! - Dr Pradip Jamnadas, MD Carotid Artery Disease: Current Treatment Strategies The degree of carotid stenosis increases the risk of stroke, with an annual incidence of about 3% for an 80 to 89% stenosis and 5% with a 90 to 99% stenosis in an asymptomatic patient. In symptomatic patients, the annual stroke risk is between 5 and 13%. However, since this data became published, aggressive medical therapy has changed outcomes. Medical therapy for patients with carotid disease includes antiplatelets, ACE inhibitors, angiotensin receptor blockers, and statins. As a group, antiplatelet therapy reduces strokes and Transient Ischemic Attacks (TIAs) by 22%. For secondary prevention of stroke, the use of Aspirin plus dipyridamole was equivalent to Plavix. A similar reduction was also noted with aspirin plus Plavix versus Plavix alone in patients with TIAs. In the TAIST Tiral, anticoagulants provided similar outcomes to antiplatelet therapy for primary as well as secondary stroke prevention. Treatment to control blood pressure in stroke victims should include a diuretic. It seems that stroke patients benefit from diuretic therapy significantly compared to the other patient populations. All patients should be on a statin, ARB and ACE inhibitor. High dose statins reduce the stroke rate for primary and secondary prevention (JUPITER Study). Revascularization using carotid endarterectomy or carotid artery stenting, one need to have a high-volume operator, with selective interventions only. The relative risk reduction in ipsilateral stroke was 53% in asymptomatic patients in the ACAS study Dietary Series with Julie Wiedman. Results of our 2015 customer satisfaction survey. Clinical Pearls of the Management of GERD (Gastroesophageal Reflux Disease) DON’T FORGET TO COMPLETE A REVIEW OF THE CARE YOU HAVE RECEIVED HERE AT CARDIOVASCULAR INTERVENTIONS, ORLANDO AT ANY OF THE WEBSITES BELOW    (Continued on page 2)
  2. 2. 2 | CARDIOVASCULAR INTERVENTION Editor-in-chief D R . P R A D I P J A M N A D A S , M D Founder and Director of Cardiovascular Interventions Associate Editor J I T E N K A P A D I A C H R I S S I C K I N G E R Our Doctors DECEMBER 2015 and 65% in symptomatic patients in the NASCET study with carotid endarterectomy versus medical therapy. Carotid artery stenting however is reserved for high risk patients who have a higher 30 day risk of stroke and death and it was better than carotid endarterectomy at 30 days in the SAPPHIRE Study. In the CREST Trial, the outcomes were similar with carotid stenting and carotid surgery. Take Home Points: Aggressive medical therapy improves vascular biology. Symptomatic patients should get intervention. Percutaneous Intervention and endarterectomy should both be considered. High grade lesions should be individually evaluated. (Continued from page 1) D R . B R I A N K E L L Y , D O D R . A L A N R O S E N B A U M , M D D R . C H A N D R A B O M M A , M D J O N I R U T H D I G A U M M S N , N P - C , C C R N - C M C J U L I E W I E D M A N M M S , P A - C OUR DOCTORS Survey Results Summer 2015 Average score in each category Quality care is very important to us here at Cardiovascular Interventions. Over the last several months you may have noticed some patient quality surveys being handed out. Here are some of the results from our survey on a scale of 1-5 (5 being perfectly satisfied). We are very proud to offer some of the best cardiac care in Central Florida. If there is ever anything we can improve on, please let us know!
  3. 3. CARDIOVASCULAR INTERVENTION | 3DECEMBER 2015 Is there a relationship between high triglyceride levels and increased cardiovascular risk? DIETARY SERIES WITH JULIE WIEDMAN Hypertriglyceridemia (HTG) is associated with low HDL, small dense LDL particles, increased VLDL remnants, coagulation changes and increased fibrinogen. Both LDL increase and TG (triglyceride) increase lead to atherosclerosis while an increase in HDL has no proven link to ASCVD risk. The TNT Study showed high TG and low HDL correlate with CVD risk even when LDL is well controlled. In the study, patients on a statin with LDL <70 who had HDL 37 and TG 186 had 39% higher 5 year risk of major CVD events than patients with HDL >55 and TG 122. The PROVE IT Trial confirms that people with LDL <70 and TG >150 have 6.2% higher CAD risk. HTG strongly predicts CVD risk even with excellent LDL C control on statin. This is because high TG are linked to small dense LDL which have many apoB. ApoB are atherogenic lipoproteins that carry cholesterol. On the other hand, apoA is good protective HDL. Even when you correct for low HDL, there is still an increased risk for CVD with high TG. Most forms of HTG are of secondary origin. There are some genetic causes such as familial HTG. Familial hypertriglyceridemia is associated with LDL >190. In the last 10 years, LDL has dropped 11%, but TG has increased 6%. This is due to obesity and diabetes, 50% of CKD patients have HTG also. Other causes of HTG are insulin resistance, hypothyroidism, increased alcohol intake, high carb diet, estrogen, thiazide diuretics, and beta blockers. Omega 3 has been shown to be beneficial in treating HTG with a 20-30% reduction with proper dosage. A four gram daily dose is recommended. Make sure to inquire about omega 3 if your triglyceride levels concern you. There is up to a 50% reduction in TG from diet and lifestyle. Diet should be low in sugar, carbohydrates, and fat. Exercise 30 minutes as many days a week as you can. TG reduction is the first and most notable effect of exercise on lipid profile. To increase HDL requires extensive activity, and LDL is not shown to decrease with exercise (though weight loss helps). A guideline is to treat by nutrition and physical activity for all. Medication is advised if the triglyceride level is above 500. If the level is between 200 and 500 in a high risk patient, a statin is advised. HTG is best treated generally with statins, fibrate (which works better if you have DM also), omega-3 (EPA only appears better but trials are pending), and Niacin last because there is no benefit if TG is less than 500 per current data available. More on Triglyceride Levels Triglycerides are a marker for coronary artery disease and should be treated when the fasting levels exceed 150. The cornerstone of therapy, in levels of triglycerides, up to 500, is intensive lifestyle changes and weight loss. Fibrates, niacin, and fish oils are indicated for levels greater than 500 because of the risk of pancreatitis. The risk of pancreatitis increases as triglyceride levels exceed 1000 with an approximate overall risk of 20%. Weight loss and diet can reduce triglycerides by 20%, aerobic activity 20%, decreasing carbohydrates 2%, fibrates 20-50%, niacin 20-50%, and fish oils up to 40%. In 2013, the ACC and AHA recommended treatment for levels greater than 500 but no recommendations for triglyceride lowering therapies less than 500. This does not mean that there is no benefit in the treatment, it just means that there are no trials. Dr Jamnadas recommends triglyceride levels to be less than 150.
  4. 4. 4 | CARDIOVASCULAR INTERVENTION DECEMBER 2015 Clinical Pearls for the Management of GERD Here is some useful information concerning Gastroesophageal Reflux Disease (GERD) that should come in use during the holidays! Manifestations of GERD can be typical or atypical such as cough, chest pain, or hoarseness of the voice. In most cases, a 6 week trial of a Proton Pump Inhibitor (PPI) is reasonable and cost-effective. Do not continue PPI indefinitely. Endoscopy is not necessary in most patients. However, if they have dysphagia, weight loss, or bleeding, it may be necessary. Ambulatory pH monitoring should be used in patients with symptoms that do not respond to PPIs and those in whom antireflux surgery is being considered. Head of bed elevation and aggressive weight loss are the only lifestyle interventions that have proven effective in GERD. Lifestyle modifications are the first line of treatment which includes weight loss, head of bed elevation, avoidance of tobacco, avoidance of alcohol, and abstaining from late night meals. Coffee, caffeine, chocolate, spicy foods, highly acidic foods such as oranges and tomatoes, and fatty foods aggravate GERD. Sodium bicarbonate, calcium carbonate, magnesium hydroxide, and aluminum hydroxide are available over-the-counter and relieve heartburn symptoms by neutralizing the acid in the esophagus. Sodium alginate acts directly on the acid pockets that occur and result in a change in the pH in the stomach and the sodium bicarbonate releases carbon dioxide and relieves the symptoms more effectively than simple antacids, H2 receptor blockers, and more swiftly compared to PPIs. PPIs relieve symptoms in 70-80% of patients after a 6-8 week course. PPI should be taken 30-60 minutes before meals. In 2010, the US FDA issued warning regarding the potential for wrist, hip, and spinal fractures in patients who are using PPIs. There is also an increased risk of community-acquired pneumonia but this link has not been clearly established. PPI may increase the risk of C. difficile infection, and some observational studies have demonstrated that. The antiplatelet activity of Plavix requires activation by the same cytochrome system CYP as required for metabolism of a PPI. Recent studies demonstrate no increased risk of adverse cardiovascular events in patients on PPIs based on well controlled randomized trials. The ACC therefore stated that PPIs may be used for appropriate indications in patients also taking Plavix. It is of note that PPIs may decrease magnesium absorption. GASTROESOPHAGEAL REFLUX DISEASE
  5. 5. CARDIOVASCULAR INTERVENTION | 5DECEMBER 2015 Non-Steroidal Anti-Inflammatory Drugs and Bleeding, Risk of Thromboembolism Patients with atrial fibrillation take anticoagulants to decrease the risk of stroke. A recent study showed that the use of Non-Steroidal Anti- Inflammatory drugs (NSAIDs) in these patients drastically increases their risk of GI bleeding, especially if taken for more than 14 days. More importantly, these agents also increase the risk of thromboembolic episodes. It is important to remember that NSAIDs decrease prostacyclius which causes endothelial dysfunction. Thus NSAID agents should NOT be used in patients on anticoagulant therapy. Hormonal Therapy for Menopause; Earlier is Safer In a recent study, patients given hormonal replacement therapy within six years of menopause had a decrease in the carotid intimal thickness progression compared to patients who are 10 years REMOVED from menopause. This is consistent with previous studies in which Hormonal Replacement Therapy given early, probably within 6 years of menopause, is safer than initiating it later on. Pradip Jamnadas,MD | | Brian Kelly, DO Alan Rosenbaum, MD | | Chandra Bomma, MD DRUG HEALTH
  6. 6. 6 | CARDIOVASCULAR INTERVENTION DECEMBER 2015 CARDIOVASCULAR HEALTH In symptomatic patients with suspected coronary artery disease, the initial CTA (computed tomography angiography) vs functional testing pathways were evaluated. There was no difference in outcomes at 2 years Stroke Prevention Left atrial appendage closure is an alternative to oral anticoagulation therapy that can be used to reduce the risk of stroke in patients with nonvalvular atrial fibrillation. The Lariat and Watchman are two types of devices. The morphology of the left atrial appendage needs to be determined by CT scan or MRI. The morphology can be categorized as a chicken wing, cactus, windsock, or cauliflower, the latter being the highest risk of embolic episodes. If contraindications to anticoagulation therapy exist, this is an alternative treatment that can be offered to patients. Nonrandomized clinical studies demonstrate equivalency of oral anticoagulation therapy with implantation of one of these devices. Keep in mind that with the Watchman device, the patients were anticoagulated for 5-7 days and then dual antiplatelet therapy for 6 months. This means that absolute contraindications to anticoagulation disqualifies patients from the Watchman therapy. Atrial Fibrillation Atrial fibrillation affects 1-2% of the population. It increases the risk of stroke by 4-500%. Stroke is the fourth most common cause of death and leading cause of disability in the United States. Atrial fibrillation accounts for 15% of strokes in people of all ages and 30% in those over the age of 80. Untreated, atrial fibrillation results in approximately 5% of patients suffering a stroke within a year. Most of them are embolic and originated from the left atrial appendage. Left atrial appendage is the most common site of thrombus formation in nonvalvular atrial fibrillation. Ninety percent of the thrombi are discovered in this position. In a previous study, in those patients who are not on anticoagulants, who have atrial fibrillation for more than 48 hours, about 15% of them have a left atrial clot. CHADS2VASC tools are used to assess risk, and a score of 1 in a man indicates moderate risk and a score of 2 or more indicates high risk. Tools for assessing bleeding risk include ATRIA 2, and HAS BLED. The HAS BLED risk factors are hypertension, abnormal renal or liver function, stroke, bleeding, labile INR, age over 65, and drug or alcohol use. Each of these carry ONE point. The risk of bleeding is considered high when the score is 3 or higher. If the patient is undergoing cardiac surgery for another reason, the surgeon can exercise, suture, staple, or clip the left atrial appendage. Closure is recommended as part of Left Atrial Appendage Closure Promise Study; CTA vs Routine Work up of Chest Pain
  7. 7. CARDIOVASCULAR INTERVENTION | 7DECEMBER 2015 CARDIOVASCULAR HEALTH valve surgery. Percutaneous occlusion: The PLAATO Device contains an expandable nitinol covered cage designed to be placed in the orifice of the left atrial appendage. Over time, tissue grows into the device, entirely isolating the appendage from the rest of the atrium. In the original study, the annual risk of stroke was 2.2% and reduction in relative risk was 65%. This device was then discontinued. The Watchman Device, evolved from the original PLAATO Device, and is a self-expanding structure, was in the PROTECT AF trial and it was compared to long term warfarin therapy. The device group was treated with warfarin for 4-5 days to allow the device to endothelialize. The warfarin was then discontinued if the transesophageal echocardiogram demonstrated complete closure, or there was significantly reduced flow around the device. Patients in the device group were then treated with aspirin and Plavix for 6 months, and then aspirin indefinitely. The results demonstrated that the Watchman reduced the rate of hemorrhagic stroke compared to warfarin and was not inferior to warfarin in all cause mentality and stroke. Most of the published data have been about efficacy of occlusion devices compared to long term warfarin therapy. Unfortunately the population that has not been studied extensively is patients who have contraindications to long term oral anticoagulation who would benefit most from an occlusion device. The Lariat System Delivery Device is approved by the FDA and this involves a magnet tipped wire that is passed to the epicardial side of the left atrial appendage by a pericardial access to meet a second magnet tipped wire introduced into the appendage by a transspetal access. Then, a lasso is placed around the appendage. Nothing is left inside the heart. This could eliminate the need for short and long term anticoagulation as there is no foreign body left withing the heart. At one year, there was a 98% stroke free success. The trials discussed above had specific inclusion and exclusion criteria, and therefore although they support the percutaneous intervention, and generalization, the results remain in question. In the PROTECT AF study, the average CHADS score was only 2.2 and it included patients who could tolerate aspirin as well as Plavix for a significant period of time. This cannot therefore apply to patients who have contraindications to anticoagulants. In my opinion, a device that does not require anticoagulants at all is the most desirable, but the Lasso technique is technically challenging. according to the PROMISE trial. Further, there was a similar cost for both strategies over 3 years. Greater than 10,000 symptomatic patients were randomized to coronary CTA or functional testing. The endpoints were death due to myocardial infarction or hospitalization. The primary endpoint was 3.3% in the CTA group and 3% in the functional testing group. CTA was associated with fewer cardiac catheterizations showing no obstructive coronary artery disease, but more patients in the CTA group underwent cardiac catheterization. The difference is about 3%. In office practice, it is still easier to do functional testing such as Nuclear Stress Testing. However, in the hospital, the real advantage of CTA is quicker availability of the test. Hence it is more practical in the ER setting. CARDIOVASCULAR INTERVENTION | 7DECEMBER 2015
  8. 8. CARDIOVASCULAR INTERVENTION | 8 OUR LOCATION Just North of Downtown at 1900 N. Mills Avenue, Orlando, FL 32803 Getting off Interstate 4 at exit 85 head East on Princeton Ave. Make a Right on Mills Ave. and take your next right. You are at CVI IN COMING ISSUES DECEMBER 2015 More to come from our Dietary Series with Julie Wiedman. Blood Pressure Target May not be what you think Lyme Disease. What is it? And what symptoms to looks out for. Updates on Mitral Value Repair and Replacement. New classifications from The American College of Cardiology Social Corner Our 2nd annual holiday party is almost upon us. We are planning on celebrating Christmas as a group with our families. The celebration will be held at the Double Tree hotel, with food, drinks, dancing, live entertainment and Santa might stop by. Dr Jamnadas is a great host so the party is sure to be a good time. We really appreciate his kindness on allowing us here at CVI to enjoy ourselves during these special times. The staff is very hard working and for this we are grateful for fun times. On our cruise on September 10-14, 2015, we voyaged to Cozumel, Mexico and that was an amazing trip, on the way there and back we were able to spend lots of time as a group along with Dr Jamnadas. In the spirit of the holidays, the giving and receiving of gifts is at the heart of actions this season, but we must not forgot its also a time to give back to those less fortunate. We look forward to celebrating more with Dr Jamnadas and the team at CVI. We would like to congratulate our staff and physicians for completing their ACLS and BLS certification last month. BIRTHDAYS 04th | Courtney 05th | Becky 12th | Kinjal HOLIDAY HOURS 24th | Half Day 25th | CLOSED 31st | Half Day 01st | CLOSED Calender — DecemberCALENDER - DECEMBER