And the Beat Goes On
By Cathy Cassinos-Carr
Posted on October 10, 2006
What's New in Heart Care
Photography by Jayson Carpenter
If there is one message for the 13.2 million Americans who are battling heart disease, it is this: There is hope.
Modern medicine has been waging a war on America’s No. 1 killer for decades, but never before have there been so many breakthroughs on so many levels. Major surgeries are becoming minor thanks to an ever-expanding arsenal of minimally invasive techniques. Imaging technology is so state-of-the-art that it takes less than a minute to get a clear picture of a beating heart. Cholesterol-lowering medicines and other preventive measures are being used more effectively than ever before. And doctors are working together more closely than ever before, too, taking an interdisciplinary team approach that provides the very best kind of patient care.
If it weren’t for stents, the term “minimally invasive” wouldn’t have much meaning in the cardiovascular world today. If your arteries have become blocked, that little piece of metal can mean the difference between having your chest cracked open and a few small incisions, making the stent a heart patient’s new best friend.
“There’s a big trend toward doing angioplasty and stenting instead of a traditional coronary bypass,” says Victor Rodriguez, M.D., a vascular surgeon for Kaiser Permanente in South Sacramento. Angioplasty, which uses a catheter to “rotor rooter” to the site of the heart’s blocked artery and a “balloon” that opens it up, is nothing new. But the more recent practice of combining angioplasty with drug-eluting stents (drug-coated stents that help to keep arteries open) is more effective than angioplasty alone, making it possible for a larger number of patients to avoid the more invasive bypass.
Stents also are revolutionizing other previously invasive surgeries. Last summer, Rodriguez became one of the first surgeons in the country to use a newly approved FDA stent to treat a patient with a thoracic aortic aneurysm, a potentially fatal condition that starts in the chest portion of the aorta. Traditional surgery required a foot-and-a-half long incision across the chest and down the abdomen—a highly invasive procedure that “most patients don’t tolerate very well,” according to Rodriguez. But the new technique requires only a small two-inch incision in the groin, reducing complications and accelerating recovery time. “The stent has opened up the door for us to fix these patients with minimal trauma,” says Rodriguez. Most of his patients are elderly people whose aortic walls have weakened with age.
UC Davis surgeons have recently expanded these patient parameters by using the thoracic aortic stent in trauma cases. “Trauma is the leading cause of death in the younger (40 and below) age group, and rupture of the aorta is second only to head trauma [as the cause of death],” notes Royce Calhoun, M.D., assistant professor of cardiothoracic surgery. Although most trauma patients with torn thoracic aortas die “in the field,” as Calhoun puts it, he and his partner, William Pevec, M.D., are there to help the 10 percent who make it to the hospital. Someday, Calhoun predicts, this cutting-edge technique will be the standard of care. But that day, he says, “is still down the road—maybe five to 10 years away.”
New applications for stents are constantly emerging, but minimally invasive heart care doesn’t end there. “We’re excited about all of it,” says Forrest Junod, M.D., medical director of the Sutter Heart Institute, who talked about new techniques for patients with virtually every imaginable kind of cardiovascular problem. For severe angina (chest pain), Sutter is refining a laser treatment (called TMR) so that it can be done with a much-smaller incision and without the patient being put on a pump. For atrial fibrillation (irregular heartbeat), Sutter has recently tried the “Mini-Maze,” a less-invasive alternative to the “Maze procedure,” which involves open-heart surgery. The Mini-Maze uses bipolar radiofrequency clamps on either side of the heart, creating a “conduction block” that forces electrical currents to go where they’re supposed to, regulating the heart’s rhythm. Only small incisions are needed.
UCD’s Calhoun, who also has recently performed the Mini-Maze with excellent short-term results, says the technique has the potential to help many patients, and the statistics back him up: As many as 2.2 million Americans are living with atrial fibrillation, according to the American Heart Association. “Atrial fibrillation is a huge problem, and most patients end up on [the anticoagulant] Coumadin, which is a disease unto itself,” says Calhoun, adding that early intervention is key. “If atrial fibrillation goes on too long, the heart starts to deteriorate, so the sooner you can take care of it, the better.”
It Takes a Village
The team approach is one of the most important emerging trends in cardiovascular care, says William Pevec, M.D., chief of vascular surgery and professor of surgery at UC Davis. For years, Pevec dreamed of finding a way to more closely coordinate the efforts of cardiologists, vascular surgeons, interventional radiologists and other specialists who treat patients with atherosclerosis (hardening of the arteries), the starting point for most heart and circulation problems. Last December, he got his wish when UC Davis established its first Vascular Center, with Pevec as interim director. Though patients are already being seen, the center remains a “work in progress,” says Pevec, who hopes the master center clinic will be open by May or June.
“The traditional model is that like physicians work with like physicians—cardiologists work with cardiologists, vascular surgeons work with vascular surgeons,” he says. But working in isolation is an inefficient way to treat illness, he says, especially with a systemic disease such as atherosclerosis. “The way it usually works is that a patient sees the cardiologist one day, spends another day seeing the surgeon, another day seeing the endocrinologist, and so on,” he says. “So the patient’s getting six or seven trips around town and probably not getting the best care they could because no one is taking ownership of a systemic disease with a whole myriad of manifestations.” Ideally, Pevec says, the Vascular Center will serve as a one-stop shop where patients can spend the day making the rounds among specialists. “If we can eliminate the need for patients to spend five to 10 days a month going to doctor’s appointments, we’ll be doing them a big favor.”
At Mercy General Hospital, Sue Kelman-Harr is developing a multidisciplinary team to better coordinate the efforts of cardiologists, interventional radiologists and vascular surgeons, whose roles are overlapping as never before. “Cardiologists are no longer limited to the cath lab or cardiac surgery,” says Kelman-Harr, RN, vice president of cardiovascular services. Thanks to new technologies, cardiologists and interventional radiologists now are performing below-the-heart (“peripheral”) blood-vessel surgeries that were once strictly the domain of the vascular surgeon. “Cardiologists are already trained to do cardiac catheterizations,” she explains. “So it’s natural for them to apply their skills and experience to using a catheter to pull a clot out of the leg.”
“We started thinking, ‘Those are arteries, these are arteries—let’s fix those, too,’” adds Jack Casas, M.D., a cardiologist at Mercy General who is especially excited about a new catheter-based “freezing” technique for removing leg clots. “But would I dare operate without a vascular surgeon at my side? No way. It has to be collaborative. The two together (cardiologists and vascular surgeons) make a natural combination.”
Every Picture Tells a Story: The Newest Imaging Tools
Doctors may argue the merits of MRIs versus CT scanners, but one thing’s for sure: With all the imaging tools they’ve got now, there’s really no excusing a wrong diagnosis.
“Imaging tools that allow us to see inside without slicing and dicing—that’s the revolutionary change that’s taken place,” says Rob Schott, M.D., director of the nuclear lab at Northern California Cardiology Associates in Sacramento and chief of Sutter Medical Center’s division of cardiovascular medicine. Instead of cardiac catheterization, an invasive test in which a catheter is placed in an artery in the arm or leg, the newest scanners provide critical information about heart structure and function using only an IV.
The latest and greatest is the 64-slice CT scanner, which is so new at Mercy General that they’re “still training docs to use it,” says Michael Chang, M.D., cardiologist and medical director of cardiovascular services. Its images provide a highly detailed map of the heart, revealing everything from blocked arteries to aortic aneurysms to congenital and structural anomalies. But its biggest advantage, says Chang, is that it’s fast—so fast that it can take a clear picture of a beating heart in all its 3-D glory. “The previous technology would provide a blurry picture,” he says. “But at 64-slice, it’s more accurate and can be done much more quickly.” He isn’t kidding: The test takes less than a minute.
And now that it’s been featured on “Oprah,” adds Sandra Meyers, a marketing communications manager at Mercy, “we’ve been getting phone calls asking, ‘How can I have this done?’” To that, Chang answers, “It’s not appropriate for every patient, and it is probably not the first test you would do on a patient.” For example, he says, if a patient with chest pain fares poorly on the exercise test, a doctor would probably opt for cardiac catheterization—which, Chang notes, is still considered the gold standard. “But if you think the arteries are probably OK, the 64-slice scanner would be an ideal test to do, because a negative test is very helpful and because it allows you to avoid a more invasive [cardiac catheterization] test.”
The new generation of imaging tools is a boon to preventive cardiology, adds Schott.
“The idea is to recognize heart disease before you end up with a heart attack—before you end up with what we euphemistically call ‘an event,’ he says. “An event is a bad thing.”
But not all the new tools are high tech. One of the most exciting new additions to the cardiology arsenal also is one of the simplest: A blood test called cardio-CRP (C-reactive protein). “It’s actually an old test,” notes Schott, “but it’s being used in new ways.” Elevated C-reactive protein levels indicate the presence of inflammation, a known risk factor in heart disease. So how do we reduce inflammation? Schott counts the ways. “Inflammation is driven in part by obesity, so staying lean and exercising regularly can help,” he says. Lipid-lowering medicines (statins) such as Lipitor and Zocor also can help to reduce both inflammation and “bad” cholesterol (LDL).
The Holistic Way
But conventional medicine is not necessarily the only answer. New research has revealed a host of alternative therapies that also can reduce inflammation, notes Maxine Barish-Wreden, M.D., an internist and medical director of Sutter Health’s Downtown Integrative Medicine program.
“The hot topic these days is looking at inflammation and its connection not only to heart disease, but other chronic diseases, such as diabetes, arthritis and some cancers,” she says. Fish oil (omega 3) supplements, green tea, pomegranate juice and other dark-red/purple fruits and vegetables, and the herbs turmeric and curcumin (the active ingredient in turmeric) have all been identified as anti-inflammatory agents.
But we first need to pay attention to our lifestyles, emphasizes Barish-Wreden, especially the kinds of fats we eat. “Since the Industrial Revolution, we have markedly increased our intake of animal fat as well as hydrogenated omega 6 [such as margarine and Crisco] instead of omega 3 oils, which are found not only in fish, but also flaxseed, walnuts, soy and green leafy vegetables. We also have reduced our consumption of whole grains, fruits and vegetables; combine this with our obesity epidemic and sedentary lifestyles, and you’ve got a recipe for chronic disease. We need to turn that around.”
“I think obesity is the No. 1 environmental risk factor in the people I treat,” concurs Schott. “The obesity epidemic is driving cardiovascular disease.”
All of which seems to suggest that the most important trend in cardiac care also is the oldest: prevention.
“Heart disease is preventable if we take care of ourselves,” says Barish-Wreden. “Over and over, it goes back to the simple things we’ve known all along: Don’t smoke, exercise, maintain a healthy weight, and eat less meat and more fruits and vegetables.”
But getting the message out to those who need it most can be a challenge, says Schott.
“How do we reach the patients who potentially have disease and get them to do the right things so they don’t end up having a heart attack or stroke?” he asks. “How do we get them to believe the story—to go to a doctor and get assessed, and potentially change habits or lifestyle to reduce the risks of all sorts of diseases? Most of the diseases that kill us are related to lifestyle.”
Education is key, he says, but getting people to follow the rules is much easier said than done.
“It’s very hard and unsuccessful to counsel people to be more active, drink less soda, eat less fast food and lose weight,” says Schott, a lean machine who practices what he preaches, typically putting in 200 miles a week on his bike. “But there are lots of things you can do to help yourself.”