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Update in Cardiology: 2012

Update in Cardiology: 2012. James A. Coman MD, FACC President and Founder, Heart Rhythm Institute of Oklahoma Tulsa, Oklahoma. Disclosures. Ischemic Heart Disease.

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Update in Cardiology: 2012

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  1. Update in Cardiology: 2012 James A. Coman MD, FACC President and Founder,Heart Rhythm Institute of Oklahoma Tulsa, Oklahoma

  2. Disclosures

  3. Ischemic Heart Disease • Ranolazine (Ranexa) – indicated for reduction of anginaDose 500 mg BID and increase to 1000 mg BIDAvoid concomitant CYP3 inhibitors • Fish Oil nonhelpful

  4. Ischemic Heart Disease • Post Cardiac Arrest CoolingLowers mortality and improves neurologic outcomes32º C for 24 hoursWatch for infection and coagulopathyCan’t be used in patients with head trauma, CVA, or preexisting coagulopathy

  5. Acute MI • Drug Eluting Stentsaccount for 75% of all stentslower restenosis ratesrequire one year of ASA, andplavix, prasugrel, or ticagrelor • IABP placement found non helpful in AMI shock

  6. Valvular Heart Disease

  7. Prevalence of valve disease in the populationThe Next Cardiac Epidemic Prevelance of moderate or severe valve disease (%) Nikomo et al, Lancet 2006; 368: 1005

  8. Severe Aortic Stenosis Without Surgery:Worse Than Most Metastatic Cancers 5-Year Survival Survival, % † * National Institutes of Health. National Cancer Institute. Surveillance Epidemiology and End Results. Cancer Stat Fact Sheets.http://seer.cancer.gov/statfacts/. Accessed November 16, 2010. † Using constant hazard ratio. Data on file, Edwards Lifesciences LLC.

  9. Transcatheter Aortic Valve Implantation (TAVI) Smith CR et al. N Engl J Med 2011;364:2187-2198.

  10. Standard Rx TAVR All Cause Mortality (ITT)Landmark Analysis Mortality 0-1 yr Mortality 1-2yr • HR [95% CI] =0.58 [0.37, 0.92] • p (log rank) = 0.0194 • HR [95% CI] =0.57 [0.44, 0.75] • p (log rank) < 0.0001 50.7% All Cause Mortality (%) 35.1% 30.7% 18.2% Months

  11. EOA Mean Gradient Mean Gradient & Valve Area Mean Gradient (mm Hg) AVA (cm²) N = 84 N = 89 N = 158 N = 162 N = 137 N = 143 N = 65 N = 65 N = 9 N = 9 Transcatheter valves provide excellent hemodynamics and appear very durable to 3 years • Error bars = ± 1 Std Dev

  12. PARTNER COHORT A (high risk)All-Cause Mortality or Stroke (ITT)All Patients (N=699) • HR [95% CI] =0.95 [0.73, 1.23] • P (log rank) = 0.70 28.0 26.5 No. at Risk Months TAVR AVR

  13. Complications • Device embolization • Aortic insufficiency • Coronary occlusion • Root rupture • Stroke • AV block – pacemaker • Vascular complications – bleeding • Acute Renal Failure

  14. Device Embolization

  15. Para-valvular Regurgitation

  16. Iliac Avulsion

  17. Embolic Material after TAVR Embolic Material Embolic Material

  18. Day 6 Post-implant

  19. Who Might Be a Candidate for TAVR? • Severe aortic stenosis – AVA < 0.8 • Symptomatic • Chest pain, CHF, syncope • Inoperable • Opinion of two surgeons • Porcelain aorta • Multiple sternotomies • Chest radiation • COPD • General frailty

  20. What the Patient Should Know • Survival (inoperable cohort) – 70% one year and 60% two year survival. Late deaths mostly noncardiac • Stroke – 5% • Pacemaker – 3.5%

  21. Radiofrequency Ablation • Targeted Rhythms AVNRT Accessory Pathway Rhythms Atrial Flutter Ectopic Atrial Rhythms Post Congenital Repair Rhythms Normal Heart VT AF

  22. Radiofrequency Ablation • Success rates of 95-100% for all but atrial fibrillation • Complication rates approaching zero • Home after 4 hours

  23. Atrial Fibrillation • Mechanism: starts from high frequency impulses from the pulmonary veins and continues from vortices of re-entry within the atria • Treatment with membrane active drugs carries risk, making treatment appropriate only for the young OR symptomatic patients

  24. Atrial Fibrillation RFA • Success rate from 40 to 80% • Complication rate: 1% chance of CVA 1% chance of pulmonary vein stenosis • Long procedure time • High doses of radiation for patient and physician • Ideal patient has highly symptomatic AF, failed multiple drugs, and has PAF with a normal heart

  25. Cryoballoon

  26. Atrial Fibrillation • CVA risk can ONLY be addressed by warfarin long term (INR 2-3), dabigatran, or rivaroxaban • Risk factors necessitating anticoagulation include: HTN, DM, CHF, h/o thrombus formation elsewhere, age > 65-75, vascular disease, or female gender • CHADS2-Vasc Score: CHF, HTN, Age>65 (1) >75 (2), DM, CVA or Thromboembolism (2), Vascular Disease, and female gender Scores of 0 and 1 need ASA, others anticoagulation

  27. Atrial Fibrillation • Drug treatment • Dofetilide • Amiodarone • Sotalol • Flecainide • Dronedarone

  28. CHF

  29. The Implanted LV Lead LAO View Lateral Coronary Vein Placement Courtesy of Dr. Auricchio, University of Magdeburg, Germany.

  30. Patient Selection • Any Class of CHF on appropriate medical therapy with IVCD (QRS > 120ms) and LVEF <35% • Patients post AV nodal ablation • “Candidates for living” • Be cautious of choosing only the “healthy”

  31. Sudden Cardiac Death • 350,000 to 550,000 people die each year in the US from SCD • 97% of people die from their first episode of SCD

  32. ANNUAL DEATHS IN U.S. 1NASPE, May 2000 2American Heart Association 2000 3National Cancer Institute 2001 4National Transportation Safety Board, 2000 5Center for Disease Control 2001 6NFPA, US Facts & Figures, 2000

  33. Placebo (n = 743) EMIAT - amiodarone SWORD – D sotolol Encainide or Flecainide CASH -propafenone CAST-I and other AAD Trials 100 95 90 Patients Without Event (%) 85 80 0 91 182 273 364 455 Days After Randomization

  34. Primary Prevention ICD Trials 1.0 0.8 MADIT I - ICD MADIT II - ICD MUSTT - ICD 0.6 Probability of survival 0.4 MADIT I - Conv Tx 0.2 0.0 5 0 1 2 3 4 Year

  35. Sudden Cardiac Death • One patient dies each minute in the US from SCD • 1440 patients died yesterday • Statistically, 600 saw a health care provider in the past year

  36. Cost Analysis

  37. Conclusions • Cooling post cardiac arrest is beneficial • Angina can be treated even when revascularization can no longer be performed • AS can be treated easily percutaneously for inoperable patients

  38. Conclusions • Most abnormal rhythms can be ablated • Atrial fibrillation is potentially ablatable • Many patients with AF need anticoagulation. Risk assessment with CHADS2-Vasc should be done • Cardiac Resynchronization Therapy (BiV pacing) is the treatment of choice for CHF after appropriate medications in patients with a wide QRS

  39. Conclusions • ICD’s are the best protection against SCD – America’s number one killer • Patients with LVEF < 35% likely need an ICD • Patients with LVEF <35% and QRS >120ms need CRT-D

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