Holy Cross Cardiovascular Blog

Minimally Invasive Heart Therapy to Treat Aortic Stenosis

  • Posted Mar 14, 2012
  • Vicente Font, MD, FACP, FCCP, FACC

A new release of a consensus document to help guide the use of a new minimally invasive therapy for aortic stenosis was recently published. With the U.S. Food and Drug Administration’s recent approval of transcatheter aortic valve replacement (TAVR) for patients with aortic valvular stenosis, the American College of Cardiology Foundation (ACCF), along with the American Association for Thoracic Surgery (AATS), the Society for Cardiovascular Angiography and Interventions (SCAI) and the Society of Thoracic Surgeons (STS), released an expert consensus document to provide important guidance on its use.

What is Aortic Stenosis?

Aortic valvular stenosis – or aortic stenosis (AS) – occurs when the heart’s aortic valve narrows, making it difficult for the heart to pump blood through the body. Until recently, some patients with severe AS who were at very high risk for conventional surgical aortic valve replacement had few, if any, options for treatment to help prevent serious heart problems, including heart failure and death. TAVR, an innovative procedure that uses minimally invasive catheter-based technology to replace the aortic valve, represents a new therapeutic option for these severe AS patients who are either extremely high-risk candidates or are inoperable for surgical aortic valve replacement due to associated comorbidities.

Transcatheter Aortic Valve Replacement (TAVR)

“This is a new, transformational technology for our patients; we have never had this type of an approach before. It’s not like another balloon catheter,” said David R. Holmes, Jr., M.D., president of ACC and chair of the writing committee. “As this technology is introduced into practice, detailed and agreed upon protocols are needed to ensure we achieve optimal clinical results. This consensus document provides the field with clear recommendations and guidance for its use.”

The new report – a detailed follow-up to the joint position statement from ACC and STS released in late 2011 – examines the current state of the evidence; offers steps to facilitate integration of TAVR into the mix of available therapeutic options for select patients; outlines how it should best be used and how to appropriately select patients to optimize clinical outcomes and encourage responsible application of this promising technology.

TAVR, which was approved by the FDA in November 2011, represents a fundamental change in the management of aortic valvular heart disease by offering an alternative to traditional surgical aortic valve replacement in carefully selected patients, according to the writing committee. Its implementation into the flow of patient care is complex and involves consideration of several key factors, such as clinical site selection; operator and team training and experience; patient selection and evaluation; procedural performance and complication management; and post-procedural care. Therefore, guidance is urgently needed to ensure it is smoothly integrated into clinical practice and followed to achieve real-world benefits and minimize risks to patients.

"Our goal in crafting this expert consensus document is to provide a clear roadmap for the use of TAVR as it reaches patients across the United States," said Michael J. Mack M.D., president of STS and vice chair of the writing committee. "TAVR innovation is a major advance in treating aortic stenosis, and sick, elderly patients should have access to this new treatment so they can resume normal, active lives. These guidelines are a coordinated effort from the cardiovascular community to help ensure the appropriate use of TAVR therapy for optimum patient safety."

The consensus document, which is endorsed by a dozen leading medical groups, outlines key recommendations for the successful roll out of this therapy. Among others, these recommendations provide detailed criteria on:

• Careful patient selection.
• Team-based approach given the complexity of the procedure, coupled with the high-risk profile of suitable patients, many of whom have extensive comorbid conditions that require ongoing management.
• Specialized heart centers and physician expertise in treating valve disorders. This includes the use of proctors, as needed, to serve on the heart care team during the first few cases, as well as proper facilities (hybrid operating rooms, like the one we have here at Holy Cross Hospital, or modified cath labs).
• TAVR screening tests to make informed treatment decisions
• Enhanced patient and family education in the risk and benefits of this procedure
• Ongoing evaluation and participation in national TAVR registry to assess real world outcomes.

An estimated 45,000 patients have received TAVR worldwide. Multiple single and multicenter registries, and a single randomized trial, have documented favorable outcomes using a wide spectrum of endpoints including survival, symptom status, quality of life, and need for repeat hospitalization. Clinical use of TAVR, its continued evolution and outcomes will be evaluated in the new STS/ACC TVT registry, which will further inform future recommendations on application of this transformational technology. 

“We have tried to collate the evidence into a coherent road map for judicious use, rational dispersion and careful post-marketing scrutiny of this promising technology,” said Sanjay Kaul, MD, a cardiologist at Cedars-Sinai Heart Institute in Los Angeles and vice chair of the writing committee. "It is now the collective responsibility of all the stakeholders to optimize its full potential for improving the duration as well as the quality of survival in patients with severe symptomatic aortic valvular stenosis."

Which Patients Benefit from this Treatment?

While this technology has the potential to benefit many patients with AS, authors caution that it is not for everyone and stress that more data is needed to ascertain the risk-benefit ratio prior to using this approach in certain groups. At present, and as outlined in the consensus document, TAVR is not recommended in adults who have:

• An acceptable surgical risk for conventional surgical AVR
• Known bicuspid aortic valve.
• Severe mitral annular calcification or severe MR.
• Moderate AS
• Other (e.g., severe AR and subaortic stenosis)

The other professional medical and consumer groups represented on the writing committee and that endorse this document include: the American Heart Association, American Society of Echocardiography, European Association for Cardio-Thoracic Surgery, Heart Failure Society of America, Society of Cardiovascular Computed Tomography, Society of Cardiac Magnetic Resonance, Society of Cardiovascular Anesthesiologists, and Mended Hearts.

Warning Signs of a Heart Attack (Spanish)

  • Posted Mar 07, 2012
  • Vicente Font, MD, FACP, FCCP, FACC

Photo from nhlbi.nih.gov

In general, Hispanic American adults are 10% less likely to have coronary heart disease than non-Hispanic white adults. They are also less likely to die from heart disease than non-Hispanic white adults.

• In 2009, Hispanics were 10% less likely to have heart disease, compared to non-Hispanic whites.
• In 2007, Hispanic men and women were 30% less likely to die from heart disease, compared to non-Hispanic whites.
• Mexican American women are 20% more likely to have high blood pressure than non-Hispanic White women.

While heart disease is the number one cause of death for all of us – Hispanics, non-Hispanics, Latinos, and Latinas - there are things we can do to prevent it as we have discussed previously on this blog.

Having such a vast Hispanic population in South Florida, I would like to diverge a little this time and switch to Spanish in an attempt to raise awareness to a broader audience. So here it goes…

¿Cuáles son las señales de aviso del ataque al corazón?

La enfermedad vascular y del corazón son la principal causa de muerte en el país. Aproximadamente la mitad de las muertes de enfermedades del corazón y vasculares son causadas por enfermedades coronarias, incluyendo el ataque al corazón.
Aproximadamente 309,000 personas mueren por año a causa de enfermedades coronarias fuera del hospital o en la sala de emergencia. Pero muchas de esas muertes se pueden prevenir, ¡actuando rápido!

Algunos ataques al corazón son repentinos e intensos. Pero la mayoría comienza lentamente, con dolor o incomodidad leves. Estas son algunas de las señales que pueden indicar que se está en presencia de un ataque al corazón:

• Molestia en el pecho. La mayoría de los ataques al corazón se presentan con una molestia en el centro del pecho que dura más de algunos minutos o que desaparece y reaparece. Puede sentirse como una presión incómoda, opresión, llenura o dolor.

• Molestia en otras zonas de la parte superior del cuerpo. Los síntomas pueden incluir dolor o malestar en un brazo o en ambos, en la espalda, el cuello, la mandíbula o el estómago.

• Falta de aire. Puede ocurrir con o sin malestar en el pecho.

• Otras señales: podría comenzar a sentir sudor frío, náuseas o mareo.

Al igual que en los hombres, el síntoma más común de ataque al corazón en las mujeres es el dolor o la molestia en el pecho. Sin embargo, las mujeres son algo más propensas que los hombres a experimentar algunos de los otros síntomas comunes, sobre todo falta de aire, náuseas y vómitos, y dolor en la espalda o la mandíbula.

¿Qué debo hacer si sospecho que tengo un ataque al corazón?
• No espere más de cinco minutos antes de pedir ayuda. Llame al 9-1-1 o a los servicios médicos de emergencia (EMS) como el departamento de bomberos o la ambulancia.
Vaya al hospital de inmediato.

• Si es usted quien tiene los síntomas y no puede acceder al EMS, pida que alguien lo lleve de inmediato al hospital. No conduzca a menos que sea la única alternativa.

¿Qué más puedo hacer?
• Si usted está bien capacitado y es necesario, puede brindar RCP (respiración de rescate y compresiones torácicas, mejor conocido en este país como CPR) a la víctima hasta que llegue la asistencia.

• Antes de que ocurra una emergencia, es una buena idea conocer qué hospitales en su área tienen cuidados coronarios de emergencia las 24 horas. Además, por las dudas, tenga una lista de números de teléfonos de emergencia al lado de su teléfono y consigo en todo momento. Tome estas medidas AHORA:

¿Por qué las personas no actúan con suficiente rapidez?
Muchas personas que tienen un ataque al corazón esperan más de dos horas antes de pedir ayuda.

Algunas personas se sentirían avergonzadas de dar una "falsa alarma." Otros tienen tanto miedo de sufrir un ataque al corazón que se dicen a sí mismos que no lo están teniendo. Estos sentimientos son fáciles de entender, pero también son muy peligrosos.
Si usted o alguien cerca suyo muestra señales de ataque al corazón, ¡llame al 9-1-1 y pida ayuda enseguida!

¿Qué puedo hacer para evitar un ataque al corazón?
• No fume y evite el humo de tabaco de otras personas.
• Si tiene presión arterial alta, contrólela.
• Ingiera alimentos bajos en grasas saturadas, grasas trans, colesterol y sal.
• Sea físicamente activo.
• Mantenga su peso bajo control.
• Realice chequeos médicos en forma regular.
• Tome sus medicamentos como se le haya recetado.
• Controle el azúcar en la sangre si tiene diabetes.

En Holy Cross Hospital, tenemos un grupo de médicos especialistas incluyendo cardiólogos que le pueden ayudar en su propio idioma. No espere y haga su cita con su doctor para una evaluación cardiovascular.


Aspirin for Primary Prevention of Vascular Events in Women

  • Posted Feb 29, 2012
  • Vicente Font, MD, FACP, FCCP, FACC

Another article has popped up discussing the usefulness in taking aspirin for primary prevention in women. The study question was “do individual patient characteristics identify women who would benefit from aspirin 100 mg every other day for primary prevention of vascular events?”

To clarify the terms, primary prevention deals with delaying or preventing the onset of cardiovascular disease. Secondary prevention relies on early detection of disease process and application of interventions to prevent progression of disease (i.e. disease is already there).

Going back to the article published in the European Heart Journal Nov 2011, data from the Women’s Health Study (WHS), a randomized controlled trial of aspirin for primary prevention of vascular events, were used in the present analysis. The WHS evaluated the effect of 100 mg of aspirin on alternate days when compared with placebo on the occurrence of major cardiovascular events (i.e., nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes) among 39,876 initially healthy women 45 years of age or older. They were followed for 10 years. Aspirin treatment was associated with increased risk for gastrointestinal and urinary bleeding, as well as nosebleeds.

A total of 27,939 women were included in this analysis. On average, women were at low baseline risk for cardiovascular disease, with a mean 10-year risk for cardiovascular events of 2.9%. The predicted reduction in 10-year absolute risk for major cardiovascular events was 1% in the majority of women.

The investigators concluded that aspirin was ineffective or harmful in the majority of women. Age (> 65) was positively related to treatment effect, whereas current smoking and baseline risk for cardiovascular events were not.

This current analysis allows clinicians to provide a more detailed discussion of the risks and benefits of aspirin in women for primary prevention, and supports current prevention guidelines, which recommend aspirin (75-325 mg per day) for women at high risk for cardiovascular events, including those with a prior history of coronary heart disease, unless contraindicated. Aspirin is also reasonable for women with diabetes mellitus (unless contraindicated). Current guidelines also suggest that aspirin may be beneficial for women 65 years or older (either 80 mg/day or 100 mg every other day) if risk of ischemic stroke or myocardial infarction is greater than risk of hemorrhagic stroke or gastrointestinal bleeding, unless contraindications including uncontrolled hypertension are present.

Vicente Font, MD, FACP, FCCP, FACC: My Journey into the Field of Medicine

  • Posted Feb 22, 2012
  • By Holy Cross Administrator

Get to know Dr. Vicente Font, Cardiologist with the Holy Cross Medical Group. Dr. Font currently practices in Fort Lauderdale, but his video webisode below tells the story of how his journey began in healthcare and in the field of medicine:


You Have an Enlarged Heart? (Part 2)

  • Posted Feb 15, 2012
  • Vicente Font, MD, FACP, FCCP, FACC

Last week we discussed the definition and the diagnosis of an “enlarged heart,” and specifically, we talked about dilated cardiomyopathy (DCM). Today we focus on treatment options.

What Is the Treatment for DCM?
Treatment of DCM is aimed at correcting the cause of the condition wherever possible. Another major goal is to decrease the heart size and decrease the substances (hormones) in the bloodstream that enlarge the heart and ultimately lead to worsened symptoms. Patients usually take several medications to treat the heart failure. Doctors also recommend a variety of lifestyle changes.

What Drugs Are Used to Treat DCM?
To manage heart failure, most people improve by taking drugs, such as a beta-blocker, ACE inhibitors or an ARB, and/or diuretics. If you have an arrhythmia, your doctor may give you a medication to control your heart rate or lessen the occurrence of arrhythmias. Blood thinners may be used to prevent blood clots from occurring. We will discuss what medications are best for you.

What Lifestyle Changes Are Recommended With DCM?
Lifestyle change can make a big difference in DCM and your heart health. Changes which are recommended include:

• Diet: If heart failure is a problem, sodium (salt) should be restricted to 2,000 mg per day or less. This diet should be continued even once the symptoms abate.
• Exercise: We will tell you if you may exercise or not. Most people with cardiomyopathy are encouraged to do non-competitive aerobic exercise. Heavy weight lifting is not recommended.

What Surgeries Are Used to Treat DCM?
People with severe DCM may need one of the following surgeries:
• Cardiac resynchronization (CRT) by biventricular pacemaker: For some individuals, stimulating (pacing) both the right and left ventricles improves the heart's ability to contract with more force, thereby improving symptoms and increasing the length of time you are able to exercise. You may be a candidate for this special pacemaker if your electrocardiogram (ECG) and echocardiogram reveal specific characteristics, and you are still having symptoms of heart failure although you're receiving optimal medical therapy. This pacemaker also will help people with heart block or some bradycardias (slow heart rates).
• Implantable cardioverter defibrillators (ICD): ICDs are suggested for people at risk for life-threatening arrhythmias or sudden cardiac death. The ICD constantly monitors the heart rhythm. When it detects a very fast, abnormal heart rhythm, it delivers energy to the heart muscle to cause the heart to beat in a normal rhythm again.
• Surgery: conventional surgeries used to treat coronary artery disease or valve disease may be used. Some individuals may be eligible for surgical repair of the left ventricle or other devices.
• Heart transplant is always an option for a few selected patients. There are pretty strict criteria to become eligible for a transplant, and we would discuss the options available with the patient at the time of the office visit.

Learn more about the Holy Cross heart team by visiting www.holycrossheart.com.

You Have an Enlarged Heart? (Part 1)

  • Posted Feb 08, 2012
  • Vicente Font, MD, FACP, FCCP, FACC

Photo from http://nlm.nih.gov

A common term used too frequently, an enlarged heart, is a term that is sometimes misleading and requires clarification. This condition is usually caused by a disorder referred to as dilated cardiomyopathy. What Is Dilated Cardiomyopathy? Dilated cardiomyopathy (DCM) is a condition in which the heart's ability to pump blood is decreased because the heart's main pumping chamber, the left ventricle, is enlarged and weakened; this causes a decreased ejection fraction, or EF (the amount of blood pumped out with each heart beat). In some cases, it prevents the heart from relaxing and filling with blood as it should. Over time, it can affect the other heart chambers as well. What Are the Symptoms of DCM? Many people with DCM have no symptoms or only minor symptoms, and live a normal life. Other people develop symptoms, which may progress and worsen as heart function worsens. Symptoms of DCM can occur at any age and may include: •    Heart failure symptoms (shortness of breath and fatigue). •    Swelling of the lower extremities. •    Fatigue (feeling overly tired). •    Weight gain. •    Fainting (caused by conditions such as irregular heart rhythms, abnormal responses of the blood vessels during exercise, or no cause may be found). •    Palpitations (fluttering in the chest due to abnormal heart rhythms). •    Dizziness or lightheadedness. •    Blood clots due to blood flowing more slowly through the body; if a blood clot breaks off, it can be carried to the lungs (pulmonary emboli), kidney (renal emboli), brain (cerebral emboli or stroke), or limbs (peripheral emboli). •    Chest pain or pressure (occurs usually with exercise or physical activity, but can also occur with rest or after meals). What Causes DCM? DCM can be inherited (familial DCM), but it is primarily caused by a variety of other factors, including: •    Severe coronary artery disease •    Alcoholism •    Thyroid disease •    Diabetes •    Viral infections of the heart •    Heart valve abnormalities •    Drugs that are toxic (or cause damage) to the heart It can also occur in women after childbirth (postpartum cardiomyopathy). Most cases of DCM are idiopathic (an exact cause is not known). When that's the case, the condition is called idiopathic dilated cardiomyopathy or dilated nonischemic cardiomyopathy. How Is DCM Diagnosed? DCM is diagnosed based on medical history (your symptoms and family history), physical exam and tests: such as blood tests, electrocardiogram, chest X-ray, echocardiogram, exercise stress test, cardiac catheterization, CT scan and MRI. Another test rarely done to determine the cause of a cardiomyopathy is a myocardial biopsy, or heart biopsy, where a tissue sample is taken from the heart and examined under a microscope to determine the cause of the symptoms. Relatives of those with familial DCM should be screened for DCM. Testing would be the same as mentioned above (medical history, physical exam, ECG, echocardiogram, etc.). Genetic testing may also be available to identify abnormal genes. Next Week We will discuss the treatment options and conclude this topic.

Holy Cross Heart Failure Clinic in Fort Lauderdale, Florida

  • Posted Jan 18, 2012
  • By Holy Cross Administrator

We recently announced that Holy Cross Hospital opened its new Congestive Heart Failure Clinic to help patients in South Florida manage their disease and stay out of the hospital. In this video, Dr. Joshua Larned (Medical Director, Heart Failure Clinic) and Kristine Raimondo, MSN, ARNP (Heart Failure Clinic Coordinator) provide more information on the services offered at our clinic and our ultimate goals for this disease management program: http://youtu.be/EE9bMvKvodw For more information, visit the Holy Cross Heart Failure Clinic website or call 954-229-7974.


Does Niacin Protect?

  • Posted Jan 04, 2012
  • Vicente Font, MD, FACP, FCCP, FACC

For quite awhile, physicians at times have been prescribing niacin for statin-treated patients to raise HDL cholesterol levels or to manipulate lipid subfractions detected by more elaborate lipid testing. The clinical effect of this practice has been unclear until now. An NIH- sponsored study called AIM-HIGH found that niacin plus simvastatin was no better than simvastatin alone. In this study, 3414 patients with established cardiovascular disease (CVD) were randomized to receive simvastatin plus either extended-release niacin or placebo. To be in the study, patients needed to have HDL cholesterol levels <40 mg/dL for men and <50 mg/dL for women and triglyceride levels between 150 and 400 mg/dL. In addition, patients were selected for randomization only after completing an open-label run-in phase, during which they demonstrated that they could tolerate high niacin doses (1500–2000 mg daily). During the trial, most patients took 40-mg or 80-mg simvastatin daily; the LDL cholesterol target was <80 mg/dL. Most patients also received aspirin, β-blockers, and angiotensin-converting–enzyme inhibitors.

Compared with placebo, niacin therapy induced significant changes in LDL cholesterol, HDL cholesterol and triglyceride levels. Nevertheless, the trial was stopped after average follow-up of 3 years when no hint of cardiovascular benefits and a trend toward more strokes with niacin were reported. The primary outcome (a composite of adverse coronary events, strokes and revascularization) occurred in 16% of patients in each group; the incidence of stroke was 1.7% with niacin and 1.1% with placebo (statistically, not a significant difference).

So, for now, extended-release niacin doesn't seem to benefit patients with known cardiovascular disease who achieve low LDL cholesterol levels with statin monotherapy. Note that this study was purely a secondary prevention trial (patients had to have established CVD to participate); we also have no evidence that niacin improves outcomes in contemporary primary prevention.


This blog was archived on June 14, 2016. New blogs are being posted to The Medical Insider Blog

About the Center

The Jim Moran Heart and Vascular Center at Holy Cross offers the latest in high-tech cardiac care. Holy Cross was the first in Broward County to offer Induced Hypothermia, which has shown to increase the odds of surviving cardiac arrest, and has been shown to improve neurological outcomes after such an event. We were also the first in Florida to use the Prime ECG Vest which, in select patients, may give physicians additional data beyond a traditional electrocardiogram. Our outstanding cardiovascular team, utilizing cutting-edge technology, can treat any heart and vascular situation especially in an emergency.

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