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AHA wrap up

Sun, 16 Nov 2008 16:33:00 -0500

So, after a long and eventful week at this year's AHA meeting, we have all returned home to settle into another long and eventful week in our practice lives. Here's a brief look backward:

Steve Stiles, one of our very own heartwire journalists took home the Howard L Lewis award which honors those who have made outstanding journalistic contributions in the realm of heart disease and stroke. We are proud of Steve and his very meticulous reporting on these topics. No doubt, his writings have changed what goes on in hospitals and offices around the world for the good of all of our patients.

The internet outage at the Morial Convention was of almost catastrophic proportions. I have NO doubt that many news outlets experienced delays of a few minutes, to hours or greater in reporting some stories because of these problems. Before we go back there, I hope that whomever is reponsible for containing those Gremlins will get a grip on them post haste.

Folks were buzzing about Jupiter and how it would increase the number of Crestor prescriptions written, but my bet is that it will increase the number of HsCRP's written even more.

I-Preserve will rightly discourage the use of Irbesartan in dyspneic patients with normal EF's but will wrongly propagate the mislabeling of many of these patients as having "CHF" when in truth, many may not even have it to begin with. I hope the many discussions surrounding this study will instead stimulate a complete work up in patients who are in as much need of a real diagnosis as they are a real treatment.

The oral hypoglycemic agents Rosi and Pio glitazone have played a significant role in the number of peripheral edema patients masquerading into my practice as "CHF". I have never felt these drugs were worth the extra birthe of echos and consults driven by them and I don't see where they are making much difference with regard to wall physiology. I stop them in every patient with edema and shortness of breath, especially when their symptoms are temporally related to their implementation. However, much like "Jason" of Friday the 13th fame, I'll bet we'll continue to witness multiple attempts at resurrection much like Folate and Vitamins C and E over at least the next decade. Meanwhile, we'll just keep upping the arb/ace doseages to treat more side effects of more side effects.

Our NYH Class II -IV patients should not only be "encouraged" to exercise, they should be placed into a situation early into their diagnosis that begats a 30 min/day-3day/wk program, so says HF-ACTION. Cardiac Rehab centers should flourish, but we will see if they can overcome a failing economy that often leaves behind the frailest of patients first. Not only will our CHF patients feel better, they will be happier according to a life quality survey administered. After all, if you aren't happy, no matter how sick or well an individual may be, it still spells misery. So, no longer should we "fear" daily exercise in this population. We should embrace it.

If only we could study what actually goes on in the world of anticoagulation in America. Not only do we not use enough coumadin, we obviously don't monitor it very well either and we know this from experience, not the THINNRs' trial. If we had compared real world care in America with point of testing and another arm of home monitoring, there is NO doubt that we would be insisting upon home "point of care" or office "point of care" monitoring. I insist that if we are going to prescribe this medication, we should invest in a point of care testing unit as well. Delays in INR reporting can = death for many patients. Also, it doesn't take an accountant to see that one bleed or one stroke costs hundreds of thousands of dollars that would be better spent in other areas of health care. An even greater mystery is why on earth those who control reimbursement in this country haven't yet figured it out. Another Bill Cosby " COME ON PEOPLE!" moment. So COME ON PEOPLE.

Dr. Oz was a welcome delight and departure from the world of p -values and meeting jargon. His practical approach to prevention is admirable. Although I didn't question him about it specifically, I would caution anyone with established disease to not rely soley upon "nature" to drive change. I think after disease has been established, nature needs a little help. If more of us were medical evangelists like Dr. Oz , the world would be a better place for our patients. Dr. Oz you rock. I think I might even buy your book "You , being beautiful". I think at this meeting, we got an opporunity to see "you" being beautiful as a human being and a physician.

New Orleans is still a beautiful and magical city. Artists hopeful to sell a piece of their talent display their hard work on the black iron fence that surrounds Jackson square every morning. From sidewalk portraits to grandiose Rodanian pieces, we saw some very important work on the morning before the meeting. At first, I thought I was seeing everyday scenes from New Orleans, but on a closer look, a water line is seen in every piece, depicting the beauty of a waterlogged post -Katrina New Orleans. From etouffe' to Benet's (which I did not eat!), there is something for everyone. The chefs' create savory dishes in every restaurant and the people are friendly and accommodating. The Starbucks line at the convention center , only slightly longer than a line of ticket hopefuls the night before a Final four UK Basketball game , drove us outdoors and across the street in beautiful Louisianna Sunshine . The weather was perfect until the very last day of the meeting. I confess that rain in the Big Easy still makes visitors like me a bit Un-Easy as my mind drifts toward the same Levys that our tour guide described as "unstable and prone to break" just 2 years before the great flood.

Even though the city is still fighting back from a near drowning, I was a bit sad when my family and I attended church on Sunday. When I turned to ask where all the members had gone, a lady behind me sadly said, "they left after Katrina and just never came back", thus echoing what has happened all over the southern Louisianna Coast. Large buildings and meeting places ring hollow , a sign of shifting priorities in a civilization grown tired of fighting the forces of nature.

Just as with the close of any meeting, we look forward to the next. For me, I hope to be able to attend the ACC 2009 which from a blogger's perspective is a veritable candy store of provocative data. More than that, we at theheart.org have happily managed a 6:30 am - 11 pm schedule many days to bring you the best meeting information possible. Our hope is that each and everyone of you found something interesting and most of all, helpful in your daily walk as a cardiovascular health care provider. We respect your challenges and celebrate your victories as we continue with you on your journey to the bedside of your next cardiac patient.

Melissa

THINRS--- Study of HOME INR monitoring MISSES the POINT : the need for UNIVERSAL "point of care" INR monitoring

Wed, 12 Nov 2008 12:16:00 -0500

First of all, I want to congratulate Drs. Matchar and Jacobson for a very important trial and one that will eventually help those of us who are proponents of home INR testing to drive the change so desperately needed in our country's very costly difficulties with warfarin monitoring. It's an almost insurmountable task to reign in a drug that is often prescribed and monitored in a rogue and disorganized fashion. Even though INR levels can produce catastrophic disability from stroke or can produce devastating morbidity and drive up mortality from bleeding, we have made no efforts at formally standarizing our monitoring methods in this country. 'And it could be SOOooooo simple.

Simply put: If one is going to prescribe warfarin, one needs to have point of care testing available either in the office or in the patient's home. PERIOD.

Even though I respect the efforts made in this study, THIS STUDY DOES NOT REPRESENT REAL WORLD EXPERIENCE WITH COUMADIN.

Let's test that hypothesis. How many physicians, non cardiologists or cardiologists have point of care testing available in their own office? We run a protime clinic in our office every Mon. Tues, Thurs. and Fri. from 8 am-10 am. No appointment necessary. But many physicians who prescribe coumadin do not.

For our clinic you just Bring your finger, we will stick it and we will tell you in 120 seconds what your protime is and in the same breathe, tell you whether to hold your dose, double it, halve it, etc. or just keep on doing what you are doing. "See ya next month" is very common way to say goodbye in our protime clinic unless a change has been made in the dose or dosing regimen.

Compare the above practice to the real world of INR testing for many patients.

Let's follow Ms. Jones on coumadin for a prosthetic valve in the mitral position with an EF of 32%. She travels 18 miles into town, to the lab with a protime slip. She leaves a blood sample at the free standing lab or at the lab in the hospital at 2 pm. The lab runs the blood and mails or faxes it to the doctor's office. The staff closes up and goes home at 5 pm. The result is still on the fax machine at 8 am when the office closes. It's Tuesday, the staff collects all the overnight faxes the next morning. With about 65 lab slips in hand, it's handed to the filing person. The filing person then tries to locate all those charts, some of which can't be located. Ms. Jones chart is one of them. She then puts Ms. Jones lab slip on Dr. Martin's desk, with no chart. 4 other staff persons pile more work on top of Dr. Martin's desk. Dr. Martin, about to go over his desk at the end of the day is called to the hospital. He does not return to his desk until Thursday because Wednesday is Dr. Martin's half day at the hospital, then has the afternoon off. Thursday, Dr.Martin has a very hectic day. Finally at 5 pm on Thursday, he sees Ms. Jones INR of 1.2. drawn on Monday. He panicks a little tries to call Ms.Jones, only to find that Ms. Jones is not home. Unknown to him, she has traveled to her sister's house in the next town to spend the weekend,. Ms. Jones thinks everything is great because she has been told "if you don't hear from us, everything is OK". Ms. Jones wakes up at her sister's home Saturday morning and can't speak and is taken to a local hospital where she is admitted for stroke. Monday, Dr. Martin's office staff reaches her daughter to tell her that her INR is subtherapeutic that was drawn a week ago. Her daughter is distraught, the patient is harmed,the physician is also devastated to hear of this turn of events.

This scenario is a horrible tragedy for the patient and a terrible outcome for the doctor who cares about their patients but is trapped by an inefficient system designed to increase morbidity and mortality in warfarin dependant patients. THis tragedy could be diverted multiple times daily in this country......with a common sense approach.

Transform the above scenario in this way: Ms. Jones travels 18 miles to Dr. Martin's office, gets her finger stuck and in 120 seconds learns she needs to go into the hospital for heparin therapy until her INR is therapeutic. Cost of three days of heparin vs. a lifetime of after- stroke care? NO COMPARISON. You can do the same thing for bleeding. What if her INR had been 4? One week later, she's had her IC or GI bleed entirely preventable by just instructing the patient to hold her coumadin and recheck.

Even better yet,thanks to THINRS we now know it's SAFE for her to get out of bed, start her morning decaf, sit at her kitchen table and stick her finger. "Wow, my protime is up today, better call the office". She gets her instruction and proceeds on in whatever is best for her and her anticoagualtion needs.

REIMBURSEMENT for MEDICARE AND MEDICAID should be tied to having point of care testing available in every single physician's office and clinic in this country.

It's a hard line, but coumadin is a hard pill to swallow.

Melisa

I-PRESERVE trial: I-PROTEST!! DOE and large ankles : A "normal EF" in wolves' clothing?

Tue, 11 Nov 2008 12:10:00 -0500

Ibersartan didn't work in patients with normal EF with "symptoms" of "CHF". REALLY?

I can't help it that I found the design of this trial slightly annoying. All that was required was that the patient had "heart failure symptoms", and LVEF of at least 45% and "COULD" include an abnormal CXR, LVH or LAE on echo OR LVH OR LBBB on ECG. If my residents gave a permanent diagnosis of "CHF" to a patient based only on the above criteria of shortness of breathe and LVH by ECG , I would NOT give them a very good review at the end of their rotation. The design of this trial took me back to one of the most rudimentary pieces of advice that I ever give to any medical student: "Just because someone tells you it's CHF, don't ever EVER believe it until you have proof ", or at least until you have exluded ALL OTHER possiblities."

The reason? Simple. It's because we already know in clinical practice that nothing much works for these patients. You know them because you see them every week: They have hypertension, an EF of 50%, large ankles, fatigue and they keep coming into the ER for more and more doses of diuretic that works for about 3 days, then they are back with the same symptoms. I feel very badly for these patients because they are patients who are desparately seeking a diagnosis. I feel even worse when we give them one just to try and make them feel better.

Basically, I teach my students that in the patient with normal EF and dyspnea we start with assessing valvular regurgitation, then if that's not the issue, we look first and foremost at their (a) medication regimen, assessing for those that make them take on fluid like the great Titanic: ACTOS, NIFEDIPINE, STEROIDS. 40% of these study patients were on calcium channel blockers, and the removal of such should be the first order of business whenever possible in someone with fluid management issues. I tell them about my patient who once had a 40 pound weight gain with nifedipine. Removing that along with a gastric lap band procedure "CURED" her "normal EF heart failure". Perhaps just being on a calcium channel blocker should be in the exlucsion criteria for entry into one of these normal EF studies.

(B) we look at the U/A: ?proteinuric? and if yes, we do a 24 hour urine both for Cr.clearance and protein. Occasionally we are suprised to find nephrotic syndrome, BUT OFTEN we find the GFr is lower than we estimated which spells trouble with salt eaters who are drinking a lot of water because they are desperate to replace what we're stealing with our diuretics.

(c) we look for sleep apnea which can turn the delicate small ankles of any school girl into large uncomfortable pitting tree trunks in a 70 something year old. It might be worth it just to asked if anyone ever complained that she snores.

(d) we look at albumin, assess for issues with cirrhosis (something I spent years trying to figure out in a patient who actually responded beautifully to natrecor....yes natrecor worked for a normal EF patient who was drowning in fluid , and we asess for hypoxemia from pulmonary fibrosis/COPD, even adult onset asthma can have strange presentations. Perhaps consider doing a six minute walk and a PFT and see where you land.

(e) on the first minute of our evaluation, we must always keep in mind the chronic thromboembolic patient with near normal PA pressures, a hint of resting tachycardia, but subtle RV dysfunction that might not have been immediately obvious. This patient gets a CTA and sometimes a diagnosis of chronic recurrent PE.

(F) finally, we address the weight issue. In this study the average BMI was 30 +/- 5, so I'm not certain what percentage were actually overweight, but if they are overweight, they have a substantial reason to retain fluid from that issue alone, not to mention lack of conditioning as an etiology of shortness of breath.

But the BNP was a median of 320 -360 you say? It's not like the BNP was a 1000 in all of these patients as if it's often not, because guess what, that is BECAUSE it's NOT always congestive HEART failure when the BNP is midly elevated. Some Humans make BNP for unexplained reasons, but a fairly common reason for elevated BNP and big ankles is renal insufficiency inherent to being 75.

So, after it 's all said and done, if my patient just keeps coming in for "CHF" with very little to make their case, it's worth it just to do a "left heart cath" to check for recurrent ischemia, measure their LVEDP and get another look at their MR jet. So many of my "heart failure" patients just get better with addressing at least one or more of the above issues. I get more information there than from just slipping in a swan. At least I come out with an EDP and their coronary anatomy.

Which brings me to why I made the annoying point today that perhaps before we continue to be "bewildered" by the normal EF patient with "CHF" and their lack of response to a heart failure treatment, we should perhaps establish the diagnosis FIRST, and as definitively as possible, THEN study entities like Irbesartan to see how they will respond. Blaming a normal EF heart whose being taxed by fluid overload combined with renal insufficiency in someone eating salt and drinking 2 liters per day with severe sleep apnea on nifedipine seems hardly fair. I'd like to declare the diagnosis of CHF as both prejudicial and unjust in many cases.

If every single one of these patients had undergone a quick LVEDP measurement (we certainly do more horrific things than that to study cohorts in clincal trials so it wasn't that far -fetched) we may have found the magic subset that actually would respond to therapy. For the rest of those patients, it's a matter of a great amount of detective work, weight loss, fluid restriction and removing any offending agent from their regimen.

As Dr. Milton Packer put it "We don't really know what we are studying here. In many instances the heart is an innocent by-stander and the problem is in the periphery".

Yeah,............what he said.

Melissa

TIMACS-another reason to be on time to the office.

Tue, 11 Nov 2008 00:54:00 -0500

A typical scenario in the day in the life of a busy cardiologist:

You arrive to the hospital with plenty of time to see everyone on your rounding list. You are fairly refreshed because you weren't on call last night. You rush at first, but then seeing you have about thirty minutes before you have to be at the office, you take a little extra time to talk to Mrs. Jones about her husband because you just didn't have the time yesterday. She really appreciates it, gives you a hug and just as you are about to turn the handle on the exit door to dash over to the office, a pesky nurse says (sorry Becky), "don't forget to see Mrs. Peters, she was admitted to you at 3 am this morning with ST's down, troponin I of 0.7. "No one called me " I say, trying to explain why Elvis is about to leave the building. " The nurse never misses a beat and says "She's OK now,....ST's back to baseline on a heparin drip, beta blocker and aspirin. Here's her chart", and pulls me into her room where her family has been anxiously awaiting my arrival.

"GREAT", I think to myself. I took extra time to try and do a good thing for one patient only to realize I've done a bad thing for another by not allowing myself enough time to take this patient to the cath lab. The ER called my partner who is already doing a case in the lab and either forgot to call me just hasn't had time. None the less, I check the cath lab and we are booked until late evening. My office doesn't wind down until after the first open time slot. The patient doesn't want to be NPO all day and quite frankly, no one looks forward to doing a cath late in the evening.

Now, with TIMACS, we have good news for our patients with ST''s down since there is no advantage or disadvantage of going to the cath lab late or early (EXCEPT in those with GRACE scores > 140) and good news for our office patients that we can actually plan on being to the office on time, well at least sometimes. However, early invasive strategy had a large impact on reducing the rate of refractory ischemia by 70% which prompted the "take me early" direction given by Dr Bhat.

Though Dr. Bhat, the commentator said if he were the patient, he would want us to "take him early" to the lab, it's not always practical and in those circumstances patients can safely wait. I fear the only losers in the "waiting" strategy are the insurance companies who expect us to serve 24/7, even though a quick phone call to their office on the weekend will certainly verify that they do not.

Melissa

MASS-PAC Registry

Tue, 11 Nov 2008 00:38:00 -0500

Just a short blurb here on the continued issue of stent selection.

Though encouraging that this study looked at 67 different propensity matched variables along with Mortality,myocardial infarction and TVR at 3 years in the subgroup of diabetics, classically the toughest audience of all, and found decreased incidences of all the primary endpoints with DES vs. BMS, this wasn't the real story. The real story is that these patients could even be studied at all, and in most places, their data would just be relegated to the patient's medical record and taken deep into some warehouse for storage.

Since this is a registry and not a randomized trial, these patients come to us through inherent selection bias. Someone already determined which patients could safely get a DES and gave it to them. But of those who passed the necessary screening of obvious bleeding, upcoming surgery, compliance issues, etc. etc. in order to get a DES, this study suggests they will bode well.

Our hats are off to the State of Massachusetts for their required reporting of ALL PCI DATA. We could definitely take a lesson from them, and perhaps we should just all follow their example without having to be made to.

Melissa

AHA Day 2-Atlas ACS TIMI

Tue, 11 Nov 2008 00:01:00 -0500

We are now at TIMI something to the 6th power ( I exaggerate of course), but we are grateful for every one of those studies, including this one, with no CURRENT practical application, but lots of hope for the future, and no less important in our quest to lower inhospital and long term mortality with a pharmaceutical cocktail. Dr. Michael Gibson gave an excellent but very basic and rudimentary explanation of the goals of this new compound "Rivaroxaban", a potent and selective Xa inhibitor. "It treats the fluid part of the blood stream by inhibiting thrombin formation" he said.

This is merely a phase II study whose purpose is to pin down exactly which dose is both safe and most efficacious. Though we are left to merely trust the investigators that this drug will have an indication some day, we are left wondering just how many of these medications our patients can afford and would be willing to take.

The commentator gave an excellent review of definitions of bleeding, comparing and contrasting TIMI bleeding vs. other bleeding definitions, a point well taken and should be the first consideration in any study in which blood loss is an issue. We absolutely must understand these differnces in order to fully appreciate outcomes . For instance, the TIMI group's 5- gram Hb drop requirement before "bleeding" can be declared leaves patients as anemic as a vampire victim in an Anne Rice novel. (Sorry, I couldn't resist. We are in NOLA after all). Where as other definitions acknowledge bleeding if the Hb falls 2 gms or if the HCT falls 6%. A point well taken from the commentary on this drug is that we really REALLY need to standardize our defintion of bleeding so we can discuss it more intelligently.

The final commentary on this compound was that "it yields irrefutable trends in reduction in CV events, but it does come at a cost of risk of increased bleeding" according to Dr.Hylek, here -to- fore undefined until the ideal dose is studied in a later Phase III trial.

Thanks Dr. Gibson for your diligent efforts in this area.

We'll be waiting.

Melissa

Interview with Dr. Mehmet Oz-Prevention and Change-Living it and Loving it!

Mon, 10 Nov 2008 17:50:00 -0500

My sister- in -law Lori Walton saved me a seat in Louisiana Ballroom C at 12:30 so I might get to hear Dr. Mehmet Oz speak. Though, I'm tempted to say "yes, THE doctor OZ of Oprah fame", more importantly, I should say "yes, THE doctor Oz, a blueberry eating, yoga practicing, full-time cardiothoracic surgeon and author of hundreds of publications who holds multiple patents and has been haled as a "healer of the Millenium". After I got to kiss my husband and my daughter good bye who are leaving me to fly back to Kentucky, I dashed in for a listen.

From his first word, he draws in his audience, speaking to them "like you would at a cocktail party" because we should behave as if we know that everything we say is important. His first slide shows us that he identifies with our manic days and hectic schedules. It's a toilet that he calls "his office", a joke, but we get it. On either side of the commode are shelves lined with stress producing icons of productivity such as fax machines, keyboards, computer screens and a telephone. He then shows slides of great advancements in medicine that have occurred during his practice life.....LVAD's, catheter- based valve replacement and robotics. But obviously, these things weren't enough for him. He said he felt that " instead of driving change", he was "a cog stuck in the wheel of change".

And change he did. He found Dr. Mike Roizen, an internist with a background in anesthesiology and co-authored the "You" book series. Their first and second became instant best sellers. They couched medical terms in analogies that the lay- public can easily understand by describing illness as the "crime", the symptoms as "the witness", the doctor as the "detective", and the medical tests as the "interrogation". He then pointed out that "America has never gotten the message because we have never given it to them". He shows a picture of a man with all of his weight thrown into PUSHingon a closed door with the HUGE sign on it that says "PULL". Our patients are pushing with bad information when they should be pulling,, he indicated. He then insists that the "secret" is NOT about rationale, it's about emotion. "90% of all change is about emotion" he said.

"Ok, you have our attention, we're listening. Tell us more," I thought.

"We have to make health fun" and "we must be transformational. We have to engage factually and we must make it news- you -can- use". "Telling a patient that smoking is bad is meaningless. It turns on the insulata. We are just (subconsciously) telling them to smoke more! (the crowd laughs) What we must say to them is "all I want you to do is to care about yourself as much as I care about you". He shows his patients live animations that would make even Walt Disney envious. There is a cartoon of a placque building and rupturing and he mentions Tim Russert's name because we can all identify with the tragedy of his untimely death. More importantly, the message is that WE DO NOT WANT TO BE Tim Russert. He uses his example that people want to "test themselves into safety", but insists "you have to LIVE safety". There is another animation of an African Cheetah chasing a poor Roebuck running for its life, then out of nowhere a man runs past the Cheetah, grabs the Roebuck and disappears. The audience gasps because it's so unexpected.

We now believe we can be that man because we have sat in a lecture with one of the greatest motivators in medical history, but more importantly, he is an innovator who can marry a message with action.

Then he shows a slide of Michael Angelo's David. He is standing there, stately, proudly, his oversized left hand dangling at his side, but 50 pounds overweight and completely oblivous to the paunch that hangs from his waist. The message here is that we have become complacent and worse than that, we are in denial. The audience identifies with a nervous snicker as the slides advance. "We must understand the biology of blubber" he says as he displays the outline of a bulging waist with intestines covered with a large abdominal fat pad. He explains the "secret" that I discovered a few years ago when I attended a lecture by Dr. Gabrielle Stegg. The "secret" kept from both patient and many physicians is that this fat pad is an organ in and of itself, ........an organ that produces deadly hormones and transmitters that make us diabetic, hypertensive and changes our lipid profile. He gives us practical advice like "your waist should be less than 1/2 your height" and "in order to avoid sleep apnea, your neck should be less than 17 inches as a male and less than 16 inches as a female. " Measure your waist at your belly button, pull it tight because you know you are going to suck it in". He then steps out from around the podium and pulls his belt down below his own belly button and says "men never buy a new belt, they just merely pull it down". The women sitting next to me laughed out loud and said "that's exactly right".

Practical points were then given about what we should eat including "fiber for breakfast, nuts 30 minutes before breakfast and whole grains". If we eat nuts 30 minutes before breakfast, we'll be less hungry and the omega three's are good for us. He then displayed another astounding animation which morphed his likeness over the next few years demonstrating what he would look like if he follows healthy habits and disturbingly, what he projects his appearance to be after following unhealthy habits. The healthy morph yielded less belly fat and a more upright posture. It was definitely thought provoking.

He next points out that "if we can't walk a mile in 5 minutes, we are 3 x more likely to die", a sad end for so many of our young people today. Adding to his armamentarium of practical advice, He wants us to get plenty of sleep because it increases the amount of" youth preserving" growth hormone needed and asks us to use his "sleep kit" which consists of "dimming the lights, wearing loose clothing, reducing noise, cooling the room to 67 degrees and investing in a mattress. (Hope my tempurpedic will do). He then says that "success is forgetting you are on a program". It takes 2 weeks to place yourself on "autopilot" and directs us to behave like a GPS system that doesn't ever shut down after a mistake, but rather just redirects the next move. "You can't get rid of bad habits, you must replace them" he offers.

He doesn't just give us advice to give to our patients, he give us advice on how to be better physicians too. "Patients first, advance the body of knowledge, police each other, and engage in our Civic responsiblity to speak up". "Bring value back to the US Health care system" he says. Easier said than done, but he's advocating both saying it and doing it and unless we are engaging in either, we have no room to complain about the way things are going.

In my one- on -one interview with him, I asked him to describe his day, a living testament that he practices what he preaches. He arises at 5:45 am, does 7 minutes of yoga, showers and drives to work at 6:20 am. He rounds, eats a high fiber cereal with blueberries, goes to the OR, eats a lunch of salmon or nuts, goes back to the OR, does adminstrative work, eats with his wife and kids around 8 pm something lite, like rice and broccoli ("my wife is vegan but it tastes really good" he said), then he works out for 40 minutes. He doesn't take statins and might drink one glass of red wine per week. "Oh yeah, and I take a multivitamin". "But didn't you see the study yester.......", I started. "Yeah I did" he said with a frown.

Finally, he encourages us to drive change into our own neighborhoods by joining HEALTHCORP. (Think job corp he says). "Use college kids who listen to the same music and are of the same culture as our high school kids to teach them about their bodies and about health. They will make what has previously been thought of as uncool.......cool. " He pointed out that this practice would be "both good policy and good politics" because "it's cheap and it works". Already, 7 states are engaging in this program.

Along those lines, in my private interview time with him I asked "What would you tell me to say to our own Glasgow , Ky. city council who just could not bring themselves to vote on the side of protecting our public from second hand smoke?". "How many total (council people) do you have?" he asked. "12" I answered, "but some of them are new. At least if we can get it to a tie, maybe our mayor will have the courage to stand up for protection", I said. "Tell them it's not about hating the smoker, it's about loving the smoker. It's about protecting the workers in the bars and the restaurants. When Michael Bloomberg asked me to help him with the ban, I was all for it because for every 4 cigarettes smoked in our environment, we are smoking one. I was so worried about the workers. Now it's no longer a big deal, they just take it outside." See, he really does dream of better health for America and he drives change. You must dream it before you can do it," I thought.

At the end of his public presentation, he invited us to check out his newest book "You, being Beautiful".

Ok, Dr. Oz......now that we've listened to you, we have even more courage to try.....being beautiful, both as patient and physician that is.

Melissa

AHA DAY 1-continued: Physicians Health Study II AND SEARCH

Mon, 10 Nov 2008 12:18:00 -0500

Jason never dies in the Halloween Movie series. He always raises up from behind the couch or after he jumps out the window, the ground where he landed is mysteriously devoid of a body, so you know that a year or two from now, you are going to have to deal with the masked serial offender again. Same for Folic Acid, Vitamin E and Vitamin C.

I'm not going to give much space to yet another obituary for these entities except to say that at least they are safe because though folic acid isn't in the water, it's in just about everything else we eat in America. So who really knows how much more a supplement can do on top of how much we are already supplemented. However, taking more of any of these "vitamins" won't save our lives and won't prevent cardiovascular events. Perhaps next we can spend more money to see if they might grow hair, make us thinner or make us better looking. This billion dollar supplement industry needs to find a real reason to exist because so far, it's hasn't ( except of course for the possible placebo effect of empowering our patients to go to the local Walmart pharmacy, be able to pick a drug, purchase it and take it with complete control over how much they are going to spend and how long they are going to wait.) The sad part is that in our prior economy, feeling good from a placebo effect like that was much more affordable. The bottom line now is that our "bottom line" has changed and Americans on a tight budget can no longer afford such nonsense.

Simvastatin 80 vs. Simvastatin 20 in the SEARCH trial did yield a reduction in events by 6% though NOT statistically significant, however , predictably myopathies increased. So, though we KNOW we can lower LDL MORE with a higher dose, it's worth our patient's time to have a conversation with them about side effects.

Back to vitamins: If we threw a good billion dollars into smoking cessation classes, exercise equipment, purchased high quality foods instead of junk and spent that wasted money spent on Vitamin C, E or Folate on other worthy primary prevention measures, we would reap tens of billions in reducing the cost of health care in America plus save millions of lives. Instead, when we finish our next bottle of Vitamin C, all we have is an empty bottle and empty promises to show for it.

More from AHA Day 1-JPAD: Aspirin fails in primary prevention trial for elderly Japanese diabetics

Mon, 10 Nov 2008 11:40:00 -0500

Like a movie from the horror genre, journalists and bloggers alike felt as if we were trapped behind a mirror most of the day in the Morial Convention center. We were talking, even yelling behind the glass but not even a handprint was left to prove that we were ever here at some points during the day. Wireless gliches and server outages have stolen some of our best work. Suffice it to say, we are all saving and backing up everything, but even sometimes that has't worked. So, here goes. I'm blogging live now so forgive the lack of spell checking because I'm in a hurry to post for you.

JPAD: A primary prevention trial with ASA 100 mg and 81 mg in elderly Japanese diabetics. The bottom line: It really didn't reduce events.

I overheard a couple of commentors say that we should now look at our guidelines for aspirin therapy, but I hope they meant that only for Japanese patients still residing in Japan. Before we change anything, we should look at just how we differ from the Japanese with regard to exercise and dietary habits, both of which have been viewed as the holy grail by anthropologists and culturists alike for decades. Do we practice "Hara Hachi bi" in America? (the practice of stopping eating when our belly is 80% full-a common Okinawa reminder for a population of patients who has the longest disability- free life expectancy in the world). Do we serve ourselves first, put the food away and THEN eat? Do we routinely utilize small plates? Do we actually sit down to consume our food? Do we have 2 oz snacks of nuts or do we eat mounds of chips and soft drinks? Do we move naturally and take a literal daily "walk of life" as most 100 year old Japanese citizens do or do we hop in a cab, take the elevator or just sit on the couch at every opportunity?

The bottom line is that we should practice caution with regard to applying JPAD results to the typical elderly American population because when we Supersize Japanese citizens who relocate to America with Big Macs and fries, they die of cardiovascular disease at the same rates that we do.

We may be comparing apples with oranges, or perhaps more appropriately we are comparing a traditional smoke house breakfast with a nice plate of Natto (fermented soy).

Melissa

Space---the final frontier? Likely just the beginning with JUPITER

Sun, 09 Nov 2008 18:50:00 -0500

JUPITER - With the potential to reduce the number of myocardial infarctions by "250,000 world-wide" this study is perhaps the most widely anticipated and discussed study of this meeting and certainly the one with the greatest potential to impact what goes on behind exam room doors. 17,802 patients from 26 countries are now our template for treating patients with normal LDL but elevated hsCRP. With 38% of the study population being women ( a total of 7000 in all) and 25% black or hispanic, we get a real world experience with this study, rather than the usual white male cohort. A 47% reduction in the grouped components of the primary endpoint of MI, stroke or CV death was to say the least, incredible. The safety data was also reassuring with only one reported patient suffering rhabdo which was a 90 - year -old with trauma and pneumonia. Only Nineteen myopathic events wre reported in 10 subjects receiving therapy and in 9 in the placebo arm.

The only unexplained rings around the JUPITER trial were the slightly increased Hba1c's which included a small but possibly significant number of patients, a signal we've seen before in other trials. Also, post menopausal women on hormone replacement therapy were excluded. Additionally, this study as any other "primary prevention trial" begs the question "what exactly is primary prevention". Are we preventing events by preventing the development of atheroma, or are we stabilizing atheroma and preventing events or both? Finally, real world practice never yields a compliance rate of 75% with any directed activity except perhaps breathing or sex , so this final frontier is still insurmountable as of today in most clinics and private physicians' offices.

When asked the invariable "cancer signal" question in regard to statin use the reply was that "we have a modest area under the exposure curve" as it was stopped at 1.9 years and that "it takes 5-20 years for solid organ cancers" to show up, however, we have a "large amount of exposure data for the safety of statins as a class" pointing to overall safety.

The youngest female enrolled in this trial was "60 years and one day" which reconfirms our lack of data for women who are premenopausal with normal LDL's and high hsCRP's. I asked the presenter regarding his recommendation with this type of patient, a question which seemed to annoy more than stimulate. Rather, I thought he should be flattered that we would be interested in his opinion on the subject, after all, he must have one with his level of experience and expertise. Alas, he merely replied "you are asking me to comment on a patient who was not enrolled in this study". ---- I know. That is why I asked it and still would like to know the answer.

So what I know today is that when a post menopausal female over the age of 60 or a male 50 years old or older with a normal LDL asks me whether they will benefit from statin therapy, I can reach for an answer ....with a simple hsCRP. With a 47% reduction in events, the sky and even outerspace are no longer the limit thanks to JUPITER.

Melissa

JUPITER: How will it change your practice?

Sun, 09 Nov 2008 15:50:00 -0500

How do you interpret this landmark trial? Will you do CRPs in all patients? Or will you stick to the current guidelines? Will the trial results change your use of statins? Which statins will you use?

See:

JUPITER hits New Orleans: Landmark study shows statins benefit healthy individuals with high CRP levels

AHA 2008 New Orleans-Will Change Come?

Wed, 05 Nov 2008 07:44:00 -0500

Will a nation sleepy from the long celebration of a newly elected president pay much attention to our upcoming American Heart Association meeting developments? I do believe that in this troubled economic environment, as American physicians, we are more willing than ever to listen to what our colleagues in other countries have been telling us for years : "An organized approach to AMI therapy is effective and necessary" and "a new focus on personal responsiblity" from the patient perspective will be required to balance the strain of a country whose medical budget is bust, against the needs of an aging population writhe with obesity, tobacco use and a sedentary lifestyle. We can no longer "rob Peter to pay Paul" because Peter is bankrupt and uninsured. Peter probably smokes if he's from the deep south and he's obese just about anywhere else we look in America. For some, the Peter they know, through no fault of their own is saddled with medical bills that can never be paid and face the daily decision of either purchasing food or medication. Change is long overdue and maybe, just maybe, some of the results of the late breaking clinical trials will be implemented in such a way that both "Peter and Paul " can have a brighter and healthier future.

One would hope that the long anticipated birth of "change" in America will reach into our offices, our homes and the lives of our patients. Perhaps after this year's AHA meeting, we can look forward to a better understanding of why women aren't responsive to certain primary prevention measures and why for the first time in a long time we just might have real hope with regard to that issue. Are we studying women too early or too late? Might we look forward to finally implementing home INR monitoring that when placed in the hands of certain individuals might save billions in the cost of bleeding and thrombotic complications? Will CRP enjoy a resurgence in popularity on the wings of JUPITER or remain an orphaned lab parameter with no real feel for its best application? Will the FIT trial change our family mechanics such that we no longer spend our evenings in front of the television or computer screens munching on carbs and instead spend a few quality moments trying to insure that we can meet our grandchildren? Will new drugs with new applications make their way into our daily prescribing regimens? Will Ibersartan really help those with normal EF's but the lable of "heart failure"? So many questions will be answered this week and most certainly will give rise to even more questions to be answered in future meetings. Anyway you slice it, this year's AHA seems to be lining up to be an exciting week indeed.

The most important question is "Will change really come to this nation?" or will it be more empty rhetoric? My daughter, with just a tinge of excitement in her voice called us after the election last evening. She and her boyfriend rushed down to Grant park just to see if she could hear Obama's victory speech. If she made it onto the grounds, she heard him say "there are many who won't agree with every decision or policy I make as president, and we know the government can't solve every problem. But I will always be honest with you about the challenges we face".

Mr. President-elect Obama, I'm being honest with YOU about the challenges we face. I hope that in this week in all the aftermath and hustle and bustle of your victory schedule that you will take the time to hear about the problems we face in America with the delivery of optimal Cardiac care to our citizens. Perhaps you will hear our voices all the way from New Orleans and all across the nation from this year's AHA where we will surely outline some of those issues. But our own organizations, the AHA and the ACC will have to acknowledge the specifics of the challenges that we face in order to make real progress. First and fore most, we must be honest with ourselves. Only then will "change" finally come.

Melissa

Thinking about an academic career? Listen to our audio interview with Dr C William Balke

Tue, 04 Nov 2008 09:25:00 -0500

What should be the primary concerns as you set out in your academic career? Should publishing take precedence over securing grants? Dr Larry Allen, recent ex-fellow and assistant professor (University of Colorado Health Sciences Center, Denver), interviews the national authority on funding opportunities and career development, Dr C William Balke (senior associate dean for clinical research, University of Kentucky, Lexington), on career hurdles and watershed events and why now is a stimulating time to be embarking on an academic career.

Sources of support:

National Institutes of Health (NIH)
National Heart, Lung and Blood Institute (NHLBI)
NIH Extramural Research Training Programs
NIH Loan Repayment Programs
NIH New Investigators Program
NIH Extramural Fellowship (F) Programs
NIH Extramural Career Development (K) Awards
Veterans Affairs Career Development Awards
American Heart Association
American College of Cardiology

TCT Wrap up

Fri, 31 Oct 2008 06:40:00 -0400

In closing, I'd like to encourage anyone who has any interest in Intevention, whether it be from the perspective of interventionalist, angiographer, nurse or technician. Treat yourself and make this meeting a priority next year. It's more compact that the other American meetings and OHhhhhh, the live cases,......it's like going to the Mall of America of procedures!!! There is something for everyone. Gregg Stone directs them with the same efficiency of a Nextel commercial and easily navigates between foreman, spectator and participant. If you go, you will come away with a better appreciation of what actually goes on in other labs and have a marvelous opportunity to glean a few pointers and tips that you just might incorporate into your technique. I liked the focus on anticoagulation and the mix of opinions and protocols presented. The transfusion issue was also challenging and stimulating. I sat in on a review course where many guys and gals were gunning for their boards. During the 2 hours I observed there, it seems to be an excellent review and discussion.

Everyone from the press room, to the speaker ready room to the faculty lounge were accommodating, personable and efficient. I am eternally grateful for the invitation from Dr. Stone to speak on a topic that is near and dear to my heart. Already, I've been contacted by several systems across the US who have asked for a discussion or assistance in setting up their own PCI programs in areas where they must swim upstream to deliver adequate AMI care. I've also been contacted by those who have already established their own programs but just wish to share their experiences or just offer encouragement as we make our way here in Kentucky. I know this year's TCT meeting will be the gift that just keeps on giving.

Here's YOUR chance for a GREAT clinical and academic experience : TCT 2009 San Francisco September 21-26 . Be there!

Melissa

The only frustration I felt during the TCT was during the Town Hall Meeting.

Mon, 27 Oct 2008 07:37:00 -0400

Meant to give insight into the function of the FDA/NIH/CMS and a preview of things on the horizon, the town hall meeting seemed to be the best place I could ask my question, the grand-daddy of all questions to the one person in this world that might be able to wave the magic "do something" wand and make things happen. Dr. Marcel Salive, Director of the Division of Medicare and Surgical Services within the Coverage and analysis Group of the Center for Medicare and Medicaid Services (CMS) in the US Department of Health and Human Services spoke for about 15 minutes on generalities. He was gracious to fill in for Dr. Phurrough and amply qualified having held leadership positions with the NIH and the FDA and has led, developed and served on research teams for outcomes data and is a fellow of the American college of preventive medicine and the AHA. So, who better to answer my question, or at least point me in the right direction?

Before I reveal what exactly the "question" was, I'll give a little insight into my thinking. The TCT meeting seems the best meeting possible to discuss and explore new gadgets, widgits, wires, guides, stents, etc. To make a Golfing comparison, It's like the PGA in that its business is promoting the best ideas from the brightest minds in the field. In the case of our country's approach to Coronary intervention, with regard to how far we've come , it seems that we have access to all the right golfing equipment but maybe don't have the basic rules of the game down quite yet. To make a comparison, it would be like our having the best gloves, the best clubs, the nicest shoes, nifty range finders, extravagant club houses but we don't quite understand where the next hole is and the best route to get there. We are all dressed up in our fancy polos and pants, but we don't understand yet where to hit the ball, how to stand, how to follow through, etc. Simply put, we aren't organized in the US in such a manner that allows us to do our best for the patients who need it most.....our acute MI's.

Now for one simple question, as asked to Dr. Salive: "Why do we NOT tie reimbursement to AMI strategy? Why not make it manditory that every single hospital in this country, in order to receive medicaid and medicare funding HAVE A PLAN to treat AMI's? I can tell you there are piles of cash to solve Dr. Shurin's problem of funding at the NIH just by organizing our approach to AMI care , which would reduce CHF spending" (our most expensive DRG, which I've said 1 billion times, but should say 25 billion times because that's how much it costs us every single year in America"), which would yield enormous pay- offs in human life and health care dollars.

The answer? Well, even after listening for a couple of minutes, I couldn't understand it. I can't even blogg it. It was something like,......we're looking into........? Sorry, I can't even tell you what it meant. But in all fairness, I've been obsessed with this question for 2 years and Dr. Salive heard it for the first time. So, maybe after this meeting, he might think about it more and even see that it's a fair question and a good question and he just might help us.

The answer I had hoped for? "Excellent question. (it's my fantasy, so I get to put in whatever dialogue I want) Since places in the world like the Czech Republic, Poland, Denmark have made huge dents in pump failure due to organized AMI care, we should definitely make it a goal by 2011that every single hospital in America have a plan for transporting AMI's to PCI capable hospitals. Every single EMS system should have prehospital ECG in place unless it's geographically impossible. MISSION LIFE LINE shouldn't be an experiment, it should be a requirement. It's about as logical as doing a study on asystole vs. sinus rhythm just to see which one is associated with the longest longevity. Every single hospital in America without a cath lab should DIVERT AMI's to hospitals with cath labs. Every single hospital in AMerica should have chest pain center accreditation, which teaches us that it's not the specifics of the plan that matter so much as just having a plan and honing it to our best capability. Every single hospital who performs PCI should be mandated to report outcomes and D2B times in order to continue to receive medicare funding. The Joint Commission, famous for making you quake in your boots if you haven't recorded a family history on your consult form, that's already on the chart 4 times from other consultants and on the initial history, should ask you about the time it takes to recognize an AMI, or that same joint commision that causes great consternation over whether or not your hospital's basement pipes can pass the "white-glove" inspection, should spend their time on more lofty goals, like "what are you going to do for your patient if their ST's are up? " Yes, it's an excellent question and far more important that knowing which stent goes where and so basic that all other issues should take a back seat to this one question". (Yes, dreaming now).

I know it's a major fantasy, but with a little effort, optimal AMI care could become a reality in this country and soon. Until folks like Dr. Salive get behind this notion, we are going to continue to boast the best equipment and anticoagulation protocols, the biggest hospitals and some of the brightest folks in the field, but still continue to allow our AMI's to languish for lack of an organized approach to AMI care. We need to stop saying how difficult it is and start putting in the necessary time it takes to solve it and put folks like Dr. Salive with all of his talent and genius onto it.

Back to the golf analogy: If I can putt, chip and birdie every time, but can't find my way to the next hole, there will be a lot of folks who won't be able to play very efficiently with me. Folks will be backed up at their tee's for ever. Some will quit out of frustration. Others won't get home until midnight. Some golfers will die of old age just for their chance to Tee off. Right now, our American AMI's are still waiting for us to learn to play our best game and there are plenty of Tiger Wood caliber players out there in other countries who can give us a few pointers about organization .

We just need to listen and roll up our polo sleeves and go to work on it.

Melissa

To Transfuse or Not to Transfuse.......Tis the Question

Wed, 22 Oct 2008 07:17:00 -0400

My apologies for my late entry. The responsibilities of private practice must often trump the time I'd like to spend writing. I returned home early Thursday morning and have been on call most days since. Despite multiple ACS admits and STEMI patients this weekend, I had a nice discussion with Dr. Gregg Stone about his reflections on this year's TCT meeting Friday afternoon. I'd like to offer some brief excerpts of that conversation with a few concluding remarks.

The TRANFUSION discussion crept into many presentations at this meeting. We all know that bleeding increases mortality , but transfusing the patient seems to be worse, at least for some patients. I recall Figures of Hct's less than 27% as a requirement for transfusion in one presentation and even less, at 24% were mentioned as a threshold in another. Images of pale, weak and winded patients came to mind being discharged on gut busting iron tablets facing weeks, even months of rehab back from the world of anemia. Being a naysayer on the topic, I asked Dr. Stone his opinion stating that I can recall many patients with ST's down and chest pain who responded beautifully to a couple of units of packed cells. ST's normalized, chest pain went away, etc.. Having said that, Dr. Stone pointed out that in those patients, where anemia is obviously driving tachycardia and instability, it's appropriate, but in the stable patient, it is not just inpatient mortality that is a concern, but 30 day mortality is also an issue. He added that the key to the entire transfusion issue is to prevent bleeding to begin with. "Horizons-AMI established Bivalirudin as the anticoagulant of choice for PCI ", he said, which demonstrated a "greater reduction in mortality than statins". This fact is sobering and I wondered why everyone in the world doesn't just switch immediately to this anticoagulation regimen. It's not like it's the first time we've ever heard this. A couple of years ago at the ESC, we learned more about BiValirudin data and even prior to this in Atlanta at the AHA , another siren song for Bivalirudin was sung but fell on skeptical ears. The combined bleeding/transfusion mortality data combined with the BiValirudin Horizons AMI data should finally turn the tide for the interventional world.

Yet, I couldn't let go of the thought that there must be regional variations in the transfusion experience. What could account for such diverse opinions on the topic? I decided to call my own blood bank at our local hospital and asked if there could be differences. "Absolutely" replied my blood bank director. Apparently, most of the country does not transfuse with Leukocyte Reduced blood products. We apparently went to LR PRBC's in 2003 because of our director's concerns regarding leukotriene release and other entities released by dying rbc's that can mediate inflammation . Also, we get relatively fresh blood and transfuse it long before a 2 week expiration date. We then offload the unexpired but older prbc's to other hospitals because they cannot be returned to our regional bank in Louisville Kentucky. So, intuitively, if we stick to this older blood theory, other hospitals that receive our blood may see more difficulties, but weigh that against the bleeding and shocky trauma patient who has no other option but utilize our rejected blood products.

Our director pointed out that not only are there regional variations, but there are individual patient variations. The Amish and Mennonite populations in our region are fairly large and almost all are RH (-), which begets more inflammatory issues with transfusion. Furthermore, one could assume that individual disease processes might account for differences, i.e. the febrile, infected patient or the patients suffering from malignancy might be more prone to inflammatory issues with transfusion. Whether or not blood is irradiated could make a difference which is why many oncologists order irradiated products.

So, what to do about this complex and varied transfusion issue? Start with PREVENTION. Let's NOT overdose elderly/frail/renally insufficient patients with anticoagulants. We must stop clinging to the "normal" creatinine in an 88 pound patient as a guide for dosing anything. GI prophylax those patients who are under the gun with ACS on anticoagulants. Utilize BiValirudin........despite the fact that it's a long 5 syllable name with a funny spelling. We can get around that. I contacted our cath lab director today and asked that our interventionalist and angiographers all sit down and just have a discussion about Bivalirudin. Perhaps if we say it out loud enough, we'll all get more comfortable with the notion of using it.

We need a Randomized Controlled Trial with Leukocyte reduced PRBC's vs Non LR PRBC's to see if that might impact mortality perhaps. Shouldn't someone be studying whether or not "aged" blood is really the culprit? Let's stop hypothesizing and get some answers.

"To transfuse or Not to transfuse" is an enormous question and its answer will have a broad sweeping impact on morbidity, mortality and spending. The issue brings to mind another Shakespearean quote from Hamlet, "That one may smile, and smile, and be a villain".

Is a simple transfusion such a wolf in sheep's clothing? Only a good solid RCT will tell.

Melissa

Geoffrey Hartzler-my hand is over my heart in hommage to your work. Thank you! Thank you!!! Thank You!!!!!

Wed, 15 Oct 2008 15:18:00 -0400

Entertaining and informative, this witty look back at the early genius and ridiculously rudimentary pci techniques made me feel as if the first ptca's were done in an era when we were still rubbing two sticks together to start a fire. I fully expected to leave this presentation only to see Rachael Welch running from a dinosaur in her bear skin two- piece.

I gained a whole new respect for intervention today but still marveled at How on earth we ever got here from the dark but genius age of Gruentzig and colleagues? Let me just navigate you through the typical day in the cath lab" way back when"as described by Geoffrey Hartzler as told with Jackie Gleason style humor.

A typical PTA case: (That's Peripheral transluminal angioplasty, for you babes born long after the first procedure was performed)

The year is 1980 BC, ....I mean AD. You were handed an .063 guide wire. ( No, you weren't going to fence with it you were going to navigate a trek from the femoral artery to the aorta with it.) Too bad we didn't recycle back then, After the cath, one could have used it to do a nice artsy wire sculpture. Once the coronaries were visualized, you requested the "steam kettle". No joke, a "steam kettle" to help warm the guide and sculpt it into the shape needed. After it was determined that the patient was to have a PTA, you took a stiff tipped balloon with a distal spring wire , (kind of reminded me of the size and shape of a tonsil tipped suction apparatus) and reamed the heck out of the vessel. There was only one balloon, the advantage of which was that you didn't have to waste all that time sizing, etc.) When you did your 5-6 atm. inflations, "the balloon always , ALWAYS broke". There was NO HEMOSTATIC valve which meant you had soggy sox and shoes, dripping with the patient's blood through out the entire procedure. 2 unit transfusions were not uncommon at the close of a routine procedure.

No time was wasted on a Pharmacology decision making process as the patient received isordil po, dextran, heparin and at the end of every case, they were reversed with protamine. ASA and Dipyridamole were all they had back then in the way of oral angicoagulants, but they were FORBIDDEN because the surgeon refused to operate on the patient if they had taken an aspirin.

Then, at the end of the day, everyone was so relieved and grateful to have an open vessel. But really, what did they have to worry about? After all, their procedural success rate was 72%!!!

Dr. Hartzler then described his first successful PTA case for STEMI . He asked for his case to be placed on the table to which the nurse replied that the cath had been canceled because he had developed chest pain with ST elevation and bradycardia.(That's about as ridiculous as saying I'm not going to dinner because I'm hungry). He evaluated the ECG and sure enough, inferior injury pattern was full blown. (This was July 1980). Unfortuanately, the film was lost forever but he did show one that looked as if Charlie Chaplin would walk by, twirling his cane, at about 1 frame per second it seemed, that demonstrated the opening of an artery with a GIGANTIC banana shaped balloon. The patient however became completely pain free and ST's were normal. The LV gram normalized completely at a recath some weeks to months later. By Joe, Dr. Hartzler, I do believe you were on to something!!

Thus PCI for STEMI was born. And to think, we quibble today over such ridiculous things as surgical back up. The way I look at it, if we aren't using a steam kettle to shape the guiding catheter, I think the patient is probably pretty safe.

Needless to say, I'll never view the interventional world in the same light again. In the now famous words of the infamous GARTH and Wayne of Wayne's world, every time I see Dr. Hartzler from now on.......I'm going to bow and say "We're not worthy, WE'RE NOT WORTHY!!"

Because you know what.??.....we're not. Nothing can compare with the story of the birth of PCI and the courageous and genius antics of the first cardiologists who invented PTA. NOTHING.

SKIRBALL Center for CV RESEARCH

Wed, 15 Oct 2008 14:59:00 -0400

This is just a brief collection of observations. from this case. This was a unique animal model who was receiving stem cell injection into the border zone of a huge antero-apical MI. GE INNOVA equipment was being utilized for 3D imaging of the LV gram. A 3 needle scaffold configuration was employed. Patient movement is an issue no matter what the system. With this Silver point catheter, it was felt that it was a safer and more stable injection which reduced the number of injections required. The system is spring loaded. One commentator stated that "even the NOGA system has this limitation of still having trouble if the patient moves" after the LV has been tagged.

"Do you get tactile feed back from this system,or are you just watching for PVC's" someone asked. "PVC's" was the answer.

These folks are a translational science lab. We don't say it enough, but we owe them a lot.

Their hard work there today makes us all have a better tommorrow.

Thanks guys.

MULTI-VESSEL PCI CORONARY--- GRAND SYNTAX STYLE-TRUE GRIT AWARD

Wed, 15 Oct 2008 14:32:00 -0400

site: St. Paul Hospital Vancouver

Case: 48 y.o. male prior smoker, stable angina, NYH II, +stress for ischemia anteroapical position, EF 48%, with exercise decreases to 41%. Coronary anatomy: 40% left main, 100% LAD, Severe diffuse RCA with 100% occlusion. Collaterals from Cx and LAD to the RCA.

In some views, I thought the left main seemed more than 40%. Dr. Stone also verbalized that observation/concern. Another panelist said "This is the 1st time I've moderated a case in which I'm saying 'this is a surgical case'. For added drama and further insight, the cardiologist had asked the surgeon to scrub in who added that if he could have done this case, he would have been a good RIMA/LIMA candidate. He's obviously a good sport but standing by on a case like this has to be as frustrating to a surgeon as it is to my husband when I turn on the TV but hide the channel changer.

Technique: Double injection with R and L judkins catheters -2 hydrophilic wires in the RVside branch and RCA, PTCA then IVUS--3.5x38mm DES post dilated with 4.0 balloon with absolutely BEAUTIFUL RCA TIMI wonderful flow .

Next, 2 wires in the ramus and cx, the CTO wire to theLAD. Much difficulty trying to get across. We leave the case and go to another case. When we come back, the wire is obviously Sub-intimal. Patient is fine without symptoms. Surgeon is hovering probably thinking I would be done by now and having supper if I could have done this case .

Discussion: Stone: " Could we go retrograde from the RCA and kiss the wires?" Another panelist commented: " You know, an arterial graft might not have matured on this small LAD, maybe this wasn't such a bad case after all for PCI:. The operator: " Let's IVUS it to see where we are. Did we go subintimal at the proximal or mid LAD?"

Dr. STone then added "in the context of SYNTAX, you know that we CAN do these lesions but in some cases there is still a bridge too far". Then a question for Dr. Abel (seems to be a very patient and very nice surgeon, unless of course he too was just premedicated for this case)," will you do the RCA since it's open if you operate this patient? "Reply: maybe I'll do a RIMA too. Dr. Stone: "has he been loaded with clopedigrel?" reply:" No ,just maintained on it and asa, I won't load until the LAD wire is distal." Dr. STone: "How did you decide to do the RCA first?" Reply: "It's just a matter of taste".

I can't tell you how this came out. Time got away from us. If anyone knows, please feel free to add a comment. I happen to agree with Dr. Stone on this one, but I admitt that the RCA result was such a beautiful thing to behold and the operator was so confident, I would not be suprised if the patient isn't being discharged tomorrow. If that's the case, this operator gets the TRUE GRIT award for this afternoon.

POPLITEAL PCI in a dismally poor candidate for revascularization

Wed, 15 Oct 2008 13:39:00 -0400

Site: Riverside Methodist Hospital Columbus Ohio -MCConnell Heart Hospital

Patient: 36 yr old diabetic type II, smoker, +FH, prosthetic AV and CABG 2001 (doing the math: CABG age 28, sure this isn't Kentucky?) Left foot ischemia, 1st digit compromise, prior ABI 0.36 but suspected to be less due to the arterial wave form amplitude during the procedure. The right popliteal was totally occluded.

Technique : contralateral access with 8F sheath with planned popliteal and PTA of anterior tibial vessel. He utilized an 18 hydrophilic gold tipped guide wire. The device diameter was 2.1 mm but expands to a 3.0 mm diameter with blades and then one has to take into account the "wobble" which expands the diameter yet a bit more. The operator utilized a "hunt and peck" technique and cautioned others not to" go too fast"and "not to force it" He then suggested an 014 Miracle Bro wire. He advised that it cannot be a coated or a braided wire. Someone asked about the particulate size here but there did not seem to be much concern about that.

After 5 minutes of intermittant but fairly consistent work, there wasn't much progress and the point where we were stuck (*yes, we all felt as if we were in this thing together at that point)and we were still proximal to the heavily calcified point that we were all dreading.

"any other technology available for this procedure?" Reply : "Fox Hollow" was the reply (I know that's what is used in our lab at TJ Samson Community Hospital in Glasgow---tobacco capital of the world).

"Anyone ever do rotational atherectomy", someone replied, "yes, back in the old days we did it, off label of course, but there were concerns about particulate matter, however 2b3a's really helped with this and it actually did pretty well for cases like these".

COMPLICATION: it was time to take a look with some contrast. The operator asked for a balloon and they quickly identified a fairly large mouth'd perf with brisk flow. Everyone understands this is not immedately life threatening but a compartment syndrome will ruin everyone's day, especially this type of patient with poor wound healing and diabetes to begin with.

"Do you ever just reach underneath the table (I think he meant to say drape) and just grab the leg and occlude the bleeding?"asked a panelist.

"Yes, every now and then we do. " "Get me a Graftmaster" , he requested but placed it on standby. After a 2 minute inflation , no better. Another two minute inflation.,no better. 1cc protamine to reverse the 4000U bolus of heparin at the beginning of the procedure.....a 4 minute inflation ......., no better. Multiple 3-4 atm. inflations after the protamine finally stopped the leak and no stent was required . He added that his plan would have been to place a 16mm short stent but fortunately didn't need it.

We ran out oftime, but he planned to downsize to a 3.0 size device and use a cutting balloon distal, I suppose in the point of heavy calcification that we were all still dreading.

Conclusion: Every smoker needs to see this guy's arteriogram.