Archive for the ‘Chronic Angina’ Category
Share Our Mission to Heal
Holy Cross Hospital is seeking studio audience members for A Mission to Heal, a new show all about the heart.
Needed: 75 audience members for each show; Mix of demographics. No children under 18; Community groups are encouraged to have representation in the audience, as well as community leaders.
Where
A studio in Davie, FL. Details will be provided to audience members upon selection.
When
September 30, 2010; Refreshments will be served.
The show is not “live” but it is being recorded “live” so it will be edited and shown at a later date. Audience members should dress comfortably for long periods of sitting. No white blouses, shirts, hats or sweaters.
Please email info@holy-cross.com and put A Mission to Heal in the subject field OR call 954-776-3244 if you are interested in being part of the studio audience.
Please provide your full name, phone number, e-mail address, age range (20s, 30s, 40s, 50+) and race/ethnicity. Someone will be in touch to let you know if you have been selected and provide additional information.
Do statins make you immortal?
My blogs over the past week have been concerned about the screening of asymptomatic patients for coronary artery disease and whether we make a difference in their morbidity and mortality if we find it.
That’s really all we are concerned with: Can we, as physicians, change a patient’s outcome by putting in place a medicine or a lifestyle? What good is it to find a problem if you can’t act on it?
To date, what we do when we find a patient who we believe to be at risk is tell them to stop smoking, control their blood pressure and their diabetes. And, we put them on statins. As those that read my blogs know, statins are our first line of defense against progression of coronary artery disease when a patient already has an infarct, angioplasty or coronary artery bypass surgery.
An article was published in Arch Intern Med 2010;170:1024-1031 which addresses this question. It is titled Statins and All-Cause Mortality in High -Risk Primary Prevention: A Meta-Analysis of 11 Randomized Controlled Trials involving 65,229 Participants.
This represents over 244,000 person- years of follow up. The average LDL cholesterol was 138 mg/dl and the results of giving statins yielded an average LDL of 94 mg/dl. An average of 3.7 years of follow up occurred in these studies and there was no evidence of benefit in these findings (7 fewer deaths for every 10,000 person years of treatment).
Although compelling, I believe that this study is flawed by the short follow up. Remember, this is not a randomized clinical trial which is the highest level of significance; it is a Meta-Analysis and only collates the data already collected in like studies.
Statins were approved because they were tested in randomized clinical trials against placebo and there was always a statistically significant reduction in a triple endpoint of unstable angina, myocardial infarction and death. Death however is usually the least affected because we are much better at preventing it if patients who are affected by an acute event present to hospitals. Patients who are found to be “at risk” will continue to be offered statins and the data shows that the lower the LDL is driven, the lower the vent rate. There seems to be no plateau. Every time a study drives the number lower, the event rate follows and some studies have the LDL as low as 50 mg/dl. The study known as TNT, or Treating to new targets,
showed this result in a study with over 10,000 patients.
The real study we want to do can not be done because it is not ethical anymore. Withholding statins from patients would never pass muster. It could be done in patients who refuse statins but the numbers would never be great enough. We will just have to accept the premise for the time being until science moves ahead of need.
Time to relax
Two studies were recently published concerning the cardiovascular risk of working overtime. The first published in Occupational and Environmental Medicine (there is a journal for everyone) and the second in the European Heart Journal. The first studied nurses and the second London civil servants.
Over a 15-year period, 12,116 nurses were studied. They were originally between the ages of 45 and 64 years old. Over this period of time, there were 580 cases of angina or myocardial infarctions. In addition, there were 73 cases of “other” ischemic events but they were not otherwise characterized. When adjusted, the nurses who felt that work pressure was “much too high” had a 1.4 fold increased risk of developing symptomatic heart disease.
The London-based study began in 1985 and looked at participants who were 39 to 61 years old. The study follow up was completed in 2004. Adjusting for all factors, working three to four hours of overtime per day was associated with a 60% higher rate of fatal and nonfatal myocardial infarction or angina.
Although interesting, the reasons for these findings are pure speculation. One could postulate that it is all “stress” and that this is manifested in unhealthy lifestyle choices and high blood pressure. Is there more stress working at a job or not having one? Is it more stressful losing your insurance or working to keep it? Similar findings have occurred when life events such as death of a spouse or child, or divorce have been studied.
It all relates back to keeping your blood pressure under control and trying to reduce stress in your life in anyway that it applies to you. Everyone is different. Some people exercise, some read, some listen to music. Whatever it is, just do it to relieve stress and possibly stay disease-free.
Vote for the Blog of the Year
Did Dr. Niederman post a blog in 2009 that you found particularly helpful? Was there a blog that you could not wait to share with someone else? We’d love to receive your feedback.
Please comment on what you think was Dr. Niederman’s best blog in 2009.
Different Paths Lead to the Cath Lab
It might seem that using angiography to determine whether a coronary lesion is significant would be easy. Sometimes it is; sometimes it is not.
Patients arrive in the cath lab by different routes. Some come from the hospital because of unstable angina or myocardial infarctions. Some come because of classic symptoms of angina and multiple risk factors. Some come because of a positive stress test, stress echo test, or nuclear stress test.
The problem occurs because coronary arteries are three dimensional and they are being represented in two dimensions. To get around this, multiple views are obtained during the exam by rotating the camera around during the catheterization to obtain multiple angles. Heavy calcification and overlap often obscure vessels.
Confounding this problem further if you take a cath film to multiple doctors there is significant inter-observer variation in reporting of the severity of a stenosis in an artery. In fact if you ask the same doctor at different times the reports can vary.
This is a critical problem. The stenting of a coronary artery that is not significant can produce long lasting poor consequences for a patient. As I have written about in other blogs, medical management is an excellent way to treat much of what we find in the cath lab. Regardless of the extent of disease in one’s coronary arteries, management of the illness is medical and life long. Angioplasty is for those patients that have failed medical management and had life limiting angina. Surgery is for patients that can not have angioplasty or have poor heart function.
There is a way to discriminate coronary lesions that are considered “indeterminate.” Sometimes, even lesions that correspond to nuclear stress test results do not appear significant.
Next…what’s a doctor to do?
Determining Your Risk Level for Developing Heart Disease
Primum non nocere…first do no harm.
The concept as it applies to medicine was first introduced by Hippocrates in his oath of medicine. He wrote “to abstain from doing harm.” Physicians take this oath when we graduate medical school. In modern times it is attributed in the Latin to Thomas Inman in 1860. In general, physicians attempt to apply treatment and procedures that have an overall beneficial effect on patients.
The diagnosis of atherosclerotic heart disease can be quite difficult in patients. Sometimes patients have and express relatively classic signs of exertion angina such as chest pressure that waxes and wanes, sometimes peculiar shortness of breath. Other times it is very difficult to place the symptoms in context.
The Framingham risk score is a system that was developed from the Framingham study (which will be several blogs in the future). Assembling the data allows us to determine the 10-year risk of someone developing symptomatic coronary disease. Those of you who read my blog know our goal as physicians is to reduce the symptoms of coronary disease as we treat the underlying condition with aspirin, statins and medication to control the blood pressure and heart rate.
The score consists of seven questions:
• Age
• Gender
• Total Cholesterol
• HDL Cholesterol
• Smoker
• Systolic Blood Pressure
• Currently on medication for high blood pressure
The higher your Framingham risk scores the higher the risk. You can go online to do it yourself at hp2010.nhlbihin.net/atpiii/calculator.asp
It is those patients who have no symptoms and high risk (> 20%) that demand other techniques to determine the status of their atherosclerotic burden; those in the middle present the largest quandary.
Those techniques are the question, and in my next blog I will discuss the risk of identifying those with coronary disease.
Ask the Cardiologist
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Posts are published by Holy Cross Hospital to provide general health information. They are not intended to provide personal medical advice, which should be obtained directly from your physician.
NOGA and Protein Combine to Beat Angina
Our team has begun enrolling participants in our third stem cell therapy trial. This trial is unique in many ways.
First and foremost, we will be utilizing the NOGA machine to restudy patients at the study’s conclusion. At this time, we will obtain some very unique data not usually collected on participants. Most of the “success” of trials for heart failure and angina depends on a decrease in the symptoms that the patient had at the study’s start. Treadmill and walking tests are also used. However, the NOGA enables us to revisit the exact sites of injections so those areas of heart muscle can be analyzed for improvement in blood supply and movement.
The second unique part of this study is it does not use cells but rather a manufactured human protein which has been altered slightly. This protein is understood to provide stimulation of the growth of new blood vessels and of new muscle. This may allow those patients that need this type of therapy to not have to endure the arduous and expensive process of harvesting the cells from each donor. The manufactured protein can go in any patient without concern for rejection.
Like the BAXTER study before it (see blogs on 06-25-09 and 06-29-09), this study is enrolling patients who are limited by their angina and have failed medical management and are not angioplasty or coronary bypass candidates.
Candidates must walk on the treadmill and qualify, then undergo catheterization and nuclear stress testing. If they pass all the qualifying tests, they are then injected by NOGA mapping with either active protein or placebo. This is a safety study and does not have the statistical power to determine whether the treatment works or not. We know from other work that patients can have marked benefit. You will soon be able to hear some of these patient success via video on our website toward the end of the summer.
If you have angina and would like to discuss treatment options with us further, we can be reached at 954-229-8400.
Adult Stem Cell Therapy Offers Options
In my blog on June 04, 2009, I discussed angina. In spite of all physicians have to offer patients who suffer from coronary atherosclerotic heart disease, some individuals end up with no further treatment options. They often have had coronary artery bypass surgery and multiple angioplasties. They are on maximal medical therapy and still they have disabling angina. Coronary bypass requires an adequate vessel to bypass into. Often the heart arteries are 1 mm or less at these sites and cannot accept the bypass grafts. Similarly, angioplasty requires adequate vessel size to be possible.
Humans are the only species on earth who develop collaterals. Collaterals are natural connections from one heart artery to another that develop because of restricted blood flow. Sometimes these collaterals are quite robust. Sometimes they are not. When they are present, heart damage can be very limited in a heart attack situation because the heart still gets blood in spite of the upstream artery blockage. When they are not present, the damage can be profound and often death or severe disability occurs. The mechanisms for the creation of collaterals are not known. It is not well understood how to improve them.
Over the past years it has become possible to promote the collateral blood flow by various treatments. One such treatment is stem cell therapy in the form of CD34+ cells. We participated in the Baxter Phase II ACT34-CMI study to document the safety of stem cell injections. This study involved 26 study sites. We were the 7th highest enrollers. There were a total of 167 patients, and we enrolled 10.
The study enrolled patients with no options. There were three treatment groups, placebo, low dose and high dose. This was a safety study and not powered to show effect. In spite of this, the study proved that it was safe to perform and did provide a significant benefit to the patients. In fact, it is the first time that this patient population showed a significant improvement in treadmill walking times. A third phase is scheduled to begin early next year.
Next: How it’s done.
Adult Stem Cell Research
NOGA mapping image
One of the primary purposes for the creation of the JMHVRI was to have Holy Cross Hospital involved with cutting-edge research. This has allowed us to participate in the most exciting research development in years.
In my 20 years of research at the clinical level, my team and I have had the privilege of being involved with important breakthroughs in the clinical and drug treatment of cardiac disease. We have participated in the development and approval process of most of the drugs I now use for the treatment of heart disease. Much of our work continues in this mode. Our work with adult stem cells portends an improved future for cardiac patients.
To date, we have been involved with two stem cell projects and one project utilizing a stem cell protein. We are the only site in south Florida and one of three sites in Florida.
Adult stem cells are undifferentiated cells that multiply by cell division to replenish dying cells and regenerate damaged tissue. They are derived from adult tissue samples. Although the process is unique, it is not strong enough to repair all the cells that die naturally or by accident. If you have a heart attack, the few adult cardiac stem cells in your heart are not numerous enough to repair the damage. The reasons are unknown and an active area of research. We have no way of obtaining adult cardiac stem cells because we cannot biopsy the heart adequately to obtain them.
Therefore, the studies utilize other stem cells to obtain the results we are clinically trying to obtain. These cells or protein material are then injected directly into the heart from the leg in a manner similar to angiography and angioplasty using an additional special machine known as NOGA. NOGA technology is similar to the technology used in electrophysiology studies to isolate and identify areas of the heart of interest; in our case, those areas of the heart which are scarred or lacking adequate blood supply. After identification, special catheters are used for the injections.
Next… The Baxter CD34+ stem cell study for the treatment of angina.
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