Patients with valve disease have a new alternative to open-heart surgery. Chest pain that’s ruled out as a heart attack shouldn’t be ignored. Absorbable stents are the new interventional cardiology tool on the block. These were among the topics explored by 13 speakers before an audience of more than 100 health professionals at the 28th Annual Update in Cardiology, held March 3 in the John H. Ammon Medical Education Center at Christiana Hospital.
TAVR: Transcutaneous aortic valve replacement
Neil Wimmer, M.D., clinical cardiologist with Christiana Care Cardiology Consultants, introduced a procedure that has become widely available only in the past five years. Transcutaneous aortic valve replacement (TAVR) enables patients who aren’t good candidates for open heart surgery to receive a new heart valve inserted through a catheter.
TAVR is a product of “disruptive technology” and a noteworthy collaboration among several medical disciplines, Dr. Wimmer said in his presentation, which included the title “The Experimental Becomes Routine.” In its three iterations, the device has been made significantly smaller —in line with an average person’s artery size, he said.
“We’ve gotten better at the procedure, and the materials are better,” he said.
Open-heart surgery requires a sternotomy. This is an invasive operation and is accompanied by an average hospital stay of four to five days. TAVR may be performed using only conscious sedation, and 50 percent of TAVR patients return home the next day, Dr. Wimmer said. Initially, the TAVR procedure was targeted to patients who were too high-risk for open-heart surgery. Now it may be considered for those at intermediate risk.
Unexplained chest pain
Karin H. Humphries, MBA, DSc, scientific director at the British Columbia Centre for Improved Cardiovascular Health, presented on the perplexing issue of unexplained chest pain, the diagnosis of about 85 percent of those presenting for the complaint at the emergency department.
The cause could be coronary microvascular dysfunction, or CMD, which standard testing won’t detect, she said.
“It’s not a benign condition,” she added, noting that such patients have quite an impact on the health system, because they return to the emergency department at the same frequency as patients with known coronary artery disease. Her conclusion: “We need to optimize and standardize the assessment of CMD. A non-invasive cardiac MRI holds great promise.”
The most cutting-edge topic of the day was presented by Kirk N. Garratt, M.D., MSc, associate medical director for the Christiana Care Center for Heart and Vascular Health: “Bioresorbable Stents. The Next Best Thing in Interventional Cardiology, or Not Enough Backbone to Survive?”
It’s too early to tell if these biodegradable devices, approved for use in the U.S. just last July, will replace metal stents, Dr. Garratt said. But they hold promise in treating “repeat offenders” in the cath lab, removing the need to navigate around metal obstructions within a patient.
Heart disease in women
Sandra A. Weiss, M.D., FACC, clinical cardiologist with Christiana Care Cardiology Consultants, educated the audience about important differences in heart disease in men and women.
In younger adults, men are at higher risk for heart disease, but the risk “catches up with women after menopause,” Dr. Weiss said, noting that one in three women has some sort of cardiovascular disease, and the mortality rates are higher for women.
Premature onset of menstruation and early menopause also heighten a woman’s risk, she said. Women who have experienced hypertension, pre-eclampsia or gestational diabetes during pregnancy may be at higher risk, as well, but primary physicians don’t necessarily know to assess patients for such a profile. Dr. Weiss encouraged practitioners to keep this in mind, and she encouraged women to become educated advocates for their own health.
Keeping abreast of clinical research
Other speakers included Christiana Care’s William Weintraub, M.D., MACC, FAHA, FESC, who provided some tips on interpreting clinical research studies.
“You should follow major research broadly — and in detail in your area of practice,” Dr. Weintraub said, adding that the “methods” and “results” sections are most important, in that order. He cautioned against following non-peer-reviewed journals, mainstream media and Internet reports.
Other presenters from Christiana Care included: Ronald L. Lewis Jr., D.O., FACC, clinical cardiologist with Christiana Care Cardiology Consultants, who spoke on cardiac screening before exercise or athletic participation; cardiologist Roger Kerzner, M.D., FACC, clinical director for specialty services in the medical group, who presented “Stroke Without Obvious Cause. When — and How — Should We Search for ‘Occult’ Atrial Fibrillation?” as well as atrial fibrillation ablations; and Andrew J. Doorey, M.D., FACC, FACCP, chair of the conference, who discussed the pros and cons of interrupting anticoagulation therapies in preparation for surgical procedures.
Clinical cardiologist Henry L. Weiner, M.D., FACC, highlighted the dangers of driving for cardiac patients, and Sourin Banerji, M.D., director of Advanced Heart Failure and Transplant Cardiology, gave an overview of where Christiana Care stands in the landscape of advanced heart failure treatment.
Among the invited speakers were: Matthew R. Weir, M.D., from the University of Maryland School of Medicine, who shared practical tips for treating hyperkalemia; Deirdre E. Mylod, Ph.D., from Press Ganey Associates, who talked of the importance of capturing patient satisfaction; and Eric R. Bates, M.D., a cardiology professor from the University of Michigan, who advised that guidelines in clinical practice aren’t necessarily “carved in stone.”