At the Heart of the Matter

Although death rates from heart disease and stroke are falling in the United States, data provided by the American Heart Association shows that heart and coronary artery disease remains the leading cause of death. What progress has really been made? EHM asked Dr. Timothy Sanborn, Head of the Division of Cardiology at Evanston Northwestern Healthcare.

EHM. As many as two thirds of patients with heart attacks don’t arrive at the hospital for treatment until four or five hours after their symptoms started. What impact does this have on the patient’s condition?
TS. It’s important to recognize that when patients have a heart attack, two things can occur. First, the longer there is a delay, the more damage can occur to the heart muscle. Second, with a heart attack, people can have significant arrhythmias, which may lead to cardiac arrest. If the person is in a hospital, there’s obviously a much better chance that they can be treated as compared to being at home.

EHM. Remote EKG devices can reduce the time to treatment. What are the advantages of such devices?
TS. By doing an EKG remotely in the field, emergency medical technicians can record the heart rhythm, look for signs of a heart attack and then report to the hospital that is going to be receiving that patient.

A hospital then can activate the doctors and nurses that treat these patients with emergency angioplasty; so often, if we have a 10 or 15 minute lead time, we can get our team organized and together sooner. This makes the most sense after hours and on weekends, because daytime Monday through Friday, the team is already in the hospital and organized. It has been documented that door-to-balloon time is shorter during regular hours as compared to after hours. So shaving 10-15 minutes off of that door-to-balloon time can help increase the chances of successfully treating these patients.

EHM. What are recent innovations and developments in cardiac monitoring, and how do they help to improve patient care?
TS. There are some new developments where we monitor patients with implantable devices looking for irregular rhythms that may not be picked up on a traditional EKG or a Holter monitor, which is only in place for 24 hours.

Also, there are techniques for monitoring the various filling pressures in the heart. If somebody has congestive heart failure and it’s a delicate balance between treating them with diuretics, beta blockers and ace inhibitors, some of these new devices to look at the filling pressures can be very useful.

EHM. Each year about 1.1 million Americans suffer a heart attack. What have been recent advances in the actual treatment of heart attack patients?
TS. The sooner you can reestablish blood flow, the better the patient’s prognosis. So there is a lot of effort in decreasing door-to-balloon time. When we do open up arteries, we’ve now learned that if you keep them opened up with stents, there is a better chance that the blockage will not come back. We’re also now using drug coated stents to prevent restenosis. There is also a lot of research in the area of clot prevention and preventing some of the complications of additional clotting.

Once again, there’s a delicate balance between preventing clots and the risk of bleeding. So some of the recent literature indicates that if you do a procedure and there is significant bleeding, that may also be putting the patient at a high risk. So you don’t want to prevent clots excessively because that may lead to bleeding, which then leads to other complications.

EHM. Angioplasty with or without stent placement has become the first choice of treatment for heart attack if it can be performed in a timely manner. However, there is a 20-30 percent chance that the artery will re-narrow with the use of traditional stents. What has been done to improve the prevention of restenosis?
TS. The major improvement in the last few years has been the use of drug eluting stents, which can significantly decrease the risk of restenosis down to a single digit frequency: five to 10 percent.

Drug eluting stents prevent the need to come back for a second procedure. Also, patients are being treated more effectively with medicines to lower their cholesterol and prevent heart attacks through the use of statins and beta blockers. We’re getting much more efficient and effective in our treatment of these patients.

EHM. Glycoprotein IIb/IIIa inhibitors when used with heparin decrease ischemic complications. New data suggest that direct thrombin inhibitors such as bivalirudin are acceptable alternatives to heparin plus a IIb/IIIa inhibitor. Are patients who get stents being treated with either?
TS. Yes, most patients nowadays are treated with heparin plus the IIb/IIIa, or the newer direct thrombin inhibitors. The latter is growing in percentage. Often, there’s a lag between publication of evidence based medicine and incorporation into practice. As we provide more education to physicians, the incorporation of this evidence based medicine increases.

We’ve actually done some studies looking at some of our national databases. For example, the use of bivalirudin in angioplasty has increased significantly since publications of these randomized trials.

EHM. What are the major challenges that still stand in the way of making progress in the diagnosis, treatment and prevention of cardiovascular disease?
TS. Lifestyle changes. We still have a tremendous job ahead of us in smoking cessation, which is one of the major risk factors of poor heart as well as other diseases such as cancer. Also, we need to emphasize more that there’s a tremendous epidemic of obesity in the United States. This is because people simply don’t exercise as much and they are not as careful with their diet.

One of the other things we’re using are national registries and databases. In the United States, we have quality measures where we look at the percentage of patients that are treated with the recommended medications such as aspirin and beta blockers on hospital admission and at discharge.

There’s been some tremendous advances in technology and medications to treat patients with cardiovascular disease, but prevention should still be the primary focus; encouraging people to exercise regularly and watch their diet. So with every patient visit, I try to emphasize the importance of diet and exercise.

EHM. Where will you concentrate your efforts in the future?
TS. Currently, our main area of research is in the treatment of structural and valvular heart disease. We’re investigating new catheter based therapies to treat these problems to avoid the need for open heart surgery. Minimally invasive and non-invasive procedures will be the next major breakthrough that we’re going to see in the treatment of cardiovascular diseases.

Dr. Timothy Sanborn, an interventional cardiologist, is Head of the Division of Cardiology at Evanston Northwestern Healthcare and a professor of medicine at Northwestern University Feinberg School of Medicine.