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Holy Cross Cardiovascular Blog

Karan Munuswamy, MD: Why I Chose Cardiology

  • Posted Dec 28, 2011
  • By Holy Cross Administrator

Hear directly from Dr. Karan Munuswamy on how the burden of heart disease on our health and the economy inspired him to pursue a career in the field of cardiology: http://youtu.be/vl9yDbaKbPU

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New 3T MRI at Holy Cross Hospital

  • Posted Dec 14, 2011
  • By Holy Cross Administrator

Holy Cross Hospital is one of the first facilities in South Florida to utilize the MAGNETOM Skyra 3T MRI scanner from Siemens Medical Solutions which offers enhanced ability to customize patient scans, improved imaging and user capabilities that reduce exam times. Having received FDA clearance one year ago, the state-of-the-art scanner features 204 coil elements and 128 radio frequency channels to deliver a signal to noise ratio increase of up to 20 percent for clearer, more detailed images. The MRI's 70 cm open bore design offers many patient benefits by accommodating a large variety of patient sizes, shapes and conditions and enabling more scans in which a patient's head remains outside the equipment. Watch our video for more information regarding the benefits to our patients and physicians that this machine offers, and hear what our physicians, radiologist (Dr. Hugh Jones) and Cardiac Electrophysiologist (Dr. Rishi Anand), have to say about how the 3T MRI helps them care for patients: http://youtu.be/TfApQueSitM "I am amazed at the quality images this new technology delivers," said Holy Cross Hospital President and CEO, Patrick Taylor, M.D. "Patients’ medical treatments are so often dictated by the results of tests like these, and I am very proud that by investing in technology and employing dedicated technologists and Board Certified radiologists, Holy Cross is committed to offering patients the best images, held to exacting standards of accuracy, training, patient safety and quality."

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Asymptomatic Carotid Stenosis: Medical or Surgical Management?

  • Posted Dec 07, 2011
  • Vicente Font, MD, FACP, FCCP, FACC

Aggressive medical management could be better for now.
A tough problem we face daily is the increasing numbers of patients with abnormal carotid ultrasounds showing high grade stenosis (narrowing) and no history or symptoms of strokes or mini-strokes (a.k.a. TIAs). To make things worse, there are no standard recommendations to screen patients for carotid disease when they have no symptoms. Typical one encounters a carotid bruit on physical exam, or a carotid ultrasound is performed as part of the workup for a few conditions including syncope. Let’s take a look at some of the current ideas regarding this topic.

Carotid endarterectomy (CEA) was compared with medical therapy in asymptomatic carotid stenosis (ACS) patients in two large randomized trials — a North American study published in 1995 (JW Gen Med May 16 1995) and a European trial published in 2004 (JW Gen Med May 21 2004). In both trials, the 5-year risk for stroke (including perioperative stroke or death) was significantly lower with CEA than with medical therapy, but the difference was only about 5 percentage points (5%–6% vs. 11%–12%), and no benefit was seen in women. Given the 2%–3% rate of perioperative stroke or death, it took several years for the benefit of CEA to clearly surpass that of medical therapy.

Because medical therapy has improved since these trials were conducted, researchers have examined whether stroke rates in patients with ACS have declined during the past decade. In fact, rates have fallen to around 1% annually in medically treated patients. Thus, we must ask whether CEA has any role in patients with ACS. Recently, researchers have proposed several imaging findings that might identify high-risk subgroups — plaque echolucency, plaque ulceration, and embolic signals on transcranial Doppler ultrasound of the ipsilateral middle cerebral artery.

In one study of 435 patients with ACS (>70% stenosis by ultrasound), only 10 patients (2%) had strokes during average follow-up of 2 years. However, four of these strokes occurred among the 27 patients with both echolucent plaque and embolic signals (15% stroke rate). In contrast, only 1.5% of patients without these two findings had strokes.

In another study of 253 patients with ACS (>60% stenosis by ultrasound), only 6 patients (2.4%) had strokes during average follow-up of 3 years. Three of these strokes occurred in the 42 patients with at least two carotid ulcerations (7%); in contrast, the stroke rate was only 1.4% in the 211 patients with one or no ulcers. Additionally, the stroke rate was 13% in patients with embolic signals (2 of 15 patients) but only 1.7% in those without embolic signals (4 of 238 patients).

The most striking aspect of these two studies is their confirmation of a very low overall incidence of stroke — about 1% annually. Thus, many asymptomatic patients who now undergo CEA (or carotid stenting, which is not safer than CEA) are likely risking harm without commensurate benefit. Use of embolic signals and plaque characteristics to identify candidates for CEA is promising but requires larger studies and assurance that the techniques are reliable in community settings. For now, many experts are favoring an aggressive/intensified medical management rather than revascularization procedures in patients with ACS, until strategies to identify high-risk patients have been thoroughly investigated. Their position seems compelling.

To learn more about the Holy Cross heart team, visit www.holycrossheart.com or call (866) 988-DOCS for a Holy Cross Medical Group physician referral.


Congestive Heart Failure Disease Management: Reorganizing Healthcare Delivery

  • Posted Nov 30, 2011
  • Joshua Larned, MD

It should come as no real surprise that the Centers for Medicare and Medicaid services (CMS) is targeting congestive heart failure (CHF) re-admissions as an area of potential cost savings to our country’s overburdened healthcare system.  CHF accounts for over $8 billion in Medicare expenditures annually and is expected to grow in a linear fashion.  This projection can be explained by our aging “baby boomer “population and the simple fact that more patients are surviving their initial cardiac event, whether it is myocardial infarction or a life-saving but potentially cardiac-damaging cancer treatment. People are living longer with chronic diseases such as diabetes, kidney disease and hypertension.  Yet, the trade-off for patients who live with these diseases is an increased risk of developing CHF.  Congestive heart failure is defined as a condition where the heart is unable to supply the physiologic demands of the body. The end results of this problem are significant hormonal imbalances that lead to systemic illness. Fluid retention is the obvious manifestation, but is often the last symptom to develop. Multiple organ systems are driven into disarray secondary to the heart’s inability to circulate blood. Nutritional deficiencies, respiratory dysfunction, renal insufficiency are three simple examples.  Because CHF is a systemic illness, people are different, and people will respond differently to illness. Caregivers generally agree that it is a difficult illness to treat. The counter-point of this sentiment is that patients who have treated CHF (optimal evidence-based treatments), patients who are carefully monitored, patients with the ability to self-manage and patients with a structured support system may live functional lives with greater longevity.  Financial incentivization (or disincentivation) aside, this rapidly changing healthcare environment presents an opportunity for all caregivers to restructure the way that they manage chronic illness. All caregivers generally acknowledge the fact that many CHF patients are difficult to manage in a 15 minute office encounter and with four office visits per year.  CHF disease management programs represent a paradigm shift in healthcare delivery.   The concept of the disease management program is simple: the patient with chronic disease has access to multiple potential points-of-care (physician, specialty physician, mid-level practitioners, nutritionists, social workers, educators, support groups, home health care and telemonitoring). Clinical evidence demonstrates consistently that the primary benefits of CHF disease management programs are fewer hospitalizations, improved mortality, improved morbidity and an increased likelihood of achieving target evidence-based therapies. Secondary (and perhaps far more profound) benefits are greater patient understanding of their chronic illness, greater patient adherence to lifestyle and greater patient feelings of self-perception/self-worth. Many successful CHF disease management programs utilize a mid-level caregiver, such as a nurse practitioner or physician assistant, to liaison patient care. It is important for skeptical physicians to realize that physician extenders, when utilized in this fashion, do not replace the need for physician input/interaction with the patient. An example to this effect is vital role that physician extenders play in the delivery of cancer management in successful oncology programs. Physician extenders are often able to spend more time with the finer points of chronic disease management such as education, identify social support for the patient and provide off-site support for the patient (telemedicine).  Therefore, the role of the physician extender is often critical to the success of a CHF disease management program. A blunt way of justifying this point is the fact that poorly managed and poorly treated CHF not only increases the risk of patient hospitalization, but also carries a risk of death greater than many forms of cancer. Successful CHF disease management programs also expose the patient to different therapies and technologies. For example, high-level functioning CHF programs allow patients to participate in clinical research trials that may become tomorrow’s standard of care. Additionally, patients that have advanced CHF may gain the ability to receive life-changing therapies such as ventricular assist devices (VAD). There is no way that a patient can potentially gain exposure to these advanced technologies in a system that does not have a successful disease management program. Finally, high-level functioning CHF disease management programs network with other regional and national CHF programs in order to provide care for the patient beyond geographic boundaries. Patients, therefore, are no longer geographically confined to certain areas (example: urban areas with academic centers) and can, therefore, receive advanced care at the community level. The Accreditation Council for Graduate Medical Education (ACGME) recognized the need for specialty physicians who can practice advanced CHF medicine and who can develop medical systems to provide CHF disease management. The end result has been the development of accredited fellowship programs that subspecialty train cardiologists in CHF medicine.  Therefore, look for a growing group of physicians that have spent additional training in accredited subspecialty fellowship programs dedicated to understanding and treating CHF. Holy Cross Hospital in Fort Lauderdale, Florida is pleased to introduce its Comprehensive Congestive Heart Failure disease management program, which opened on November 28th. For questions regarding the Holy Cross Congestive Heart Failure Clinic, you may contact Kristine Raimondo at (954) 229-7974 or kristine.raimondo@holy-cross.com.   Sources: http://www.cms.gov 2 Wexler DJ, Chen J, Smith GL, Radford MJ, Yaari S, Bradford WD, Krumholz HM. Predictors of costs of caring     for elderly patients discharged with heart failure. Am Heart J. 2001;142:350 –357.3 3 Hershberger RE, Ni H, Nauman DJ, Burgess D, Toy W, Wise K, Dutton D, Crispell K, Vossler M, Everett J.     Prospective evaluation of an outpatient heart failure management program. J Card Fail. 2001;7:64 –74. 4 Krumholz HM, Amatruda J, Smith GL, Mattera JA, Roumanis SA, Radford MJ, Crombie P, Vaccarino V.     Randomized trial of an education and support intervention to prevent readmission of patients with heart     failure. J Am Coll Cardiol. 2002;39:83– 89. 5 Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland KE, Carney RM. A multidisciplinary intervention to     prevent the readmission of elderly patients with congestive heart failure. N Engl J Med. 1995;333:     1190–1195. 6 Fonarow GC, Stevenson LW, Walden JA, Livingston NA, Steimle AE, Hamilton MA, Moriguchi J, Tillisch JH,     Woo MA. Impact of a comprehensive heart failure management program on hospital readmission and     functional status of patients with advanced heart failure. J Am Coll Cardiol. 1997;30:725–732. 7 Kornowski R, Zeeli D, Averbuch M, Finkelstein A, Schwartz D, Moshkovitz M, Weinreb B, Hershkovitz R, Eyal     D, Miller M. Intensive home-care surveillance prevents hospitalization and improves morbidity     rates among elderly patients with severe congestive heart failure. Am Heart J. 1995;129:762–766. 8  http://www.acgme.org/


Atrial Fibrillation and the Risk for Dementia

  • Posted Nov 16, 2011
  • Vicente Font, MD, FACP, FCCP, FACC

By 2030, nearly one in five Americans (71.5 million) will be aged 65 and older. Evidence has been emerging that atrial fibrillation (AF), considered a common heart arrhythmia, may contribute to dementia risk. We know that AF affects 3 million people in the United States, including more than 10% of people aged 80 and older. AF also increases the risk of stroke, which is known to increase dementia risk. Beyond its effect on clinically recognized stroke, the question is whether AF could increase dementia risk through other mechanisms, such as poorer cerebral perfusion or thromboembolism, causing silent cerebral infarction. Prior studies of AF and dementia have yielded conflicting results. Of eight longitudinal studies, three found that AF was associated with greater risk of dementia, whereas five found no association. Most of these studies were small, with fewer than 700 participants, and the length of follow-up was short, limiting their power.

A recent prospective study published in the Journal of the American Geriatrics Society in September 2011 addressed the relationship between AF and the risk of dementia, or Alzheimer's disease (AD), beyond its effect on stroke. A population-based sample of 3,045 community-dwelling adults aged 65 and older without dementia or clinical stroke followed from 1994 to 2008. AF was identified from health plan electronic data codes from inpatient and outpatient encounters. Participants were screened every 2 years using the Cognitive Abilities Screening Instrument (range 0–100), with detailed neuropsychological and clinical assessment of those scoring less than 86. A multidisciplinary consensus committee determined diagnoses of all-cause dementia and possible or probable AD using standard research criteria. AF was present in 132 (4.3%) participants at baseline and was diagnosed in 370 (12.2%) more over a mean of 6.8 years of follow-up; 572 participants (18.8%) developed dementia (449 with AD). AF was associated with higher risk of developing AD and dementia. In this population-based study of older adults, AF was associated with a 40% to 50% higher risk of AD and all-cause dementia, independent of stroke. This higher risk persisted after adjustment for many cardiovascular risk factors and diseases and in numerous sensitivity analyses.

In the United States, the estimated costs of Alzheimer's disease (AD) are $172 billion each year. Most of the known risk factors for dementia are not modifiable, including the most robust risk factor currently known, apolipoprotein E (APOE) genotype. The potential association between AF and dementia has important implications because the best approach to treating AF is not known. If there were a causal relationship between AF and the development of dementia, then different treatment strategies for AF might have differing effects on dementia risk. Future studies should examine whether specific treatments, including optimal anticoagulation, can decrease this risk.


Deciding Between Mechanical or Biological Heart Valve Replacement

  • Posted Nov 09, 2011
  • Vicente Font, MD, FACP, FCCP, FACC

Image from www.nlm.nih.gov

Sometimes a natural heart valve that is not working properly needs to be replaced surgically with a prosthetic valve. Some surgeons will first recommend repairing the valve instead of replacement, but if the patient is not a good candidate for repair, then the valve should be replaced. A prosthetic valve is a synthetic or tissue substitute for the natural valve. It is designed to imitate the normal opening and closing motions of a natural valve. About 15 million people in the US suffer from either mitral or aortic valve disease. Many of those with severe valve disease will need replacement surgery to improve their outcomes. Currently, 70,000 to 90,000 heart valve replacements are done each year in this country. Types of Valves There are two primary types of artificial valves—a metal or mechanical valve and a tissue valve or biological valve. The mechanical valves are made entirely from metal and pyrolytic carbon and tend to last a lifetime. The two common types of mechanical valves, tilting-disc and bileaflet valves, have comparable durability and both require life-long anticoagulation therapy due to their associated thrombotic risk. Biological valves can be made of either human or animal tissue. Options include: autograft valves (the replacement valve is made from another valve within the patient's own heart, like the removal of the pulmonary valve to fix the aortic valve), homograft valves (taken from a deceased human donor), heterograft valves (comes from an animal donor, either a pig or a cow). Advantages and Disadvantages Both types of valves have advantages and disadvantages. One of the important advantages of mechanical valves is their greater durability (could last between 20-30 yrs to a lifetime) compared to the tissue bioprosthetic valves (10–15 years). Clearly, the greater durability of mechanical valves translates into lower reoperation rates among these patients. One study compared the durability of the bioprosthetic valve and mechanical valve and concluded that the lifetime risk of reoperation is 25% for a bioprosthetic valve compared with 3% for a mechanical valve. Although mechanical valves are more durable than bioprosthetic valves, the former also has several disadvantages that the physician and patient must consider. Because the blood flow around the mechanical valve results in high sheer stresses, our own clotting defense mechanisms can contribute to a higher risk for thrombosis on the valve surface and a subsequent risk for embolism. Because of this high risk, all recipients of mechanical heart valves require lifelong anticoagulation, most commonly with a vitamin K antagonist such as warfarin. Of course, this also comes with its own price tag, namely the higher risk of bleeding complications associated with anticoagulants. This bleeding risk increases with age. For example, a 60-year-old male with a mechanical valve replacement has a lifetime risk of bleeding of 41% compared with a 12% risk in a similar patient with a bioprosthetic valve replacement. Anticoagulation Therapy The need for anticoagulation therapy, usually with warfarin, introduces a variety of additional considerations for both providers and patients. Those who already take warfarin (for whatever indication) already know about the difficulties of maintaining therapeutic levels of warfarin. This is a problem frequently related to both adherence issues, as well as the variety of interactions that warfarin has with other medications and diet. A recent study underscored this difficulty by demonstrating that only 62% of those patients with a mechanical valve on anticoagulation medication are found within the appropriate international normalized ratio (INR) range, even in the setting of adequate medication adherence. Which to Choose The choice of which type to use should be made by the patient and his doctor taking the following into consideration: patient's age, medical condition, preferences with medication and lifestyle. Although many caveats exist, the general recommendation is for patients younger than 60 to 65 years to receive mechanical valves due to the valve’s longer durability and for patients older than 60 to 65 years to receive a bioprosthetic or biological valve to avoid complications with anticoagulants. There are always situations that warrant special consideration including patient co-morbidities, the need for anticoagulation and the potential for pregnancy. In regards to pregnancy, warfarin is contraindicated with pregnancy, and as such, the physician and patient need to consider the implantation of a bioprosthetic valve in a woman with the potential to become pregnant; this is always a very delicate discussion that we need to have with our childbearing-age female patients. In summary, the process of deciding which prosthetic valve type is best for an individual patient is complex. Optimal valve selection results when the patient and provider carefully consider the advantages and disadvantages of each valve type in the context of the individual patient’s age, clinical conditions, values and lifestyle desires.


The Heart-Diabetes Connection

  • Posted Nov 02, 2011
  • By Holy Cross Administrator

Diabetes is a growing epidemic in this country. It affects nearly 24 million Americans, and some ethnic groups are more prone to having diabetes.  Karan Munuswamy, MD, cardiologist with the Holy Cross Medical Group and president of the American Diabetes Association of Broward County, explains the connection between heart disease and diabetes:

http://youtu.be/5XiOOgnFYMc To learn more about the Holy Cross heart team, visit www.holycrossheart.com.


Heart Failure Clinic at Holy Cross Hospital

  • Posted Oct 26, 2011
  • Vicente Font, MD, FACP, FCCP, FACC

Holy Cross Hospital will be offering a new service that will help patients manage one of the most common medical problems affecting millions of Americans: congestive heart failure (CHF). Congestive heart failure is a major and escalating health problem in industrialized societies and contributes to nearly 250,000 deaths annually in the United States, affecting more than 4 million people. The number of hospital discharges in which CHF was the first listed diagnosis in 1993 (more than 875,000 admissions) was almost five times greater than it was 25 years earlier. Annually, 400,000 new cases are diagnosed. As you can imagine, there are considerable costs associated with the diagnosis and treatment of heart failure (HF), and better systems need to be designed to improve the quality of medical care in order to improve outcomes. The Heart Failure Clinic will be an education and treatment program designed to assist patients with advanced stages control their disease. Treatment options available to patients include cardiac resynchronization therapy, conventional surgery, cardiac transplantation evaluations and follow-ups. With our cardiologists and surgeons, we will work closely with heart transplant medical centers to enure that appropriate candidates get properly screened and referred. Stay tuned for more information on this promising new service. Click here to view a video from the Holy Cross online Health Library explaining heart failure:  Understanding Heart Failure.


Metabolic Syndrome and Atrial Fibrillation

  • Posted Oct 12, 2011
  • Vicente Font, MD, FACP, FCCP, FACC

The metabolic syndrome is characterized by a group of metabolic risk factors in one person. These include abdominal obesity, dyslipidemia (blood fat disorders like high triglycerides, low HDL cholesterol and high LDL cholesterol), elevated blood pressure, abnormal blood sugar metabolism (insulin resistance or glucose intolerance),  a prothrombotic state (abnormal blood clotting mechanisms), as well as a proinflammatory state.

The American Heart Association and the National Heart, Lung and Blood Institute recommend that the diagnostic criteria for metabolic syndrome include the presence of three or more of these components:

•    Elevated waist circumference:
 Men — Equal to or greater than 40 inches (102 cm)
; Women — Equal to or greater than 35
inches (88 cm)
•    Elevated triglycerides:
 Equal to or greater than 150 mg/dL
•    Reduced HDL (“good”) cholesterol:
Men — Less than 40 mg/dL
Women — Less than 50 mg/dL
•    Elevated blood pressure:
 Equal to or greater than 130/85 mm Hg
•    Elevated fasting glucose:
 Equal to or greater than 100 mg/dL

For quite some time, we have known that the various components of metabolic syndrome are risk factors for atrial fibrillation. A new study called the REGARDS study was published in the American Journal of Cardiology and showed that metabolic syndrome increases the risk of atrial fibrillation by as much as 20%. This report follows a report from Reuters Health in May that diabetes increases the risk of atrial fibrillation by 30-40%.

REGARDS evaluated the associations among 23,650 study participants, including 9,421 (39.8%) with metabolic syndrome. On multivariate analysis, each metabolic syndrome component except high triglycerides was significantly associated with an increased risk of atrial fibrillation, and the risk for atrial fibrillation increased as the number of metabolic syndrome components increased. The association of each metabolic syndrome component and the number of metabolic syndrome components with atrial fibrillation was similar for whites and African Americans in the study.


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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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