Getting to the heart of the disease

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By Kathy Ruff

As the underlying cause of death, cardiovascular disease accounts for nearly one of every three deaths in the United States, according to the American Heart Association. In that respect, it claims more lives each year than all forms of cancer and chronic lower respiratory disease combined.

However, advances in treatment and prevention continue.

Over the past decade, statins have helped to reduce LDL, the “bad” cholesterol that collects on the walls of blood vessels where it can cause blockages. Yet some people could not tolerate statins or they did not work well enough.

“We are now a year or two into lipid-lowering drugs, the PCSK9 inhibitors,” said Martin E. Matsumura, M.D., chief of cardiology at Geisinger Wyoming Valley, Wilkes-Barre. “It had a very, very significant impact on cholesterol lowering and less side effects. There was excitement around them. Now, recently, we have had the first study that says they appear to reduce (cardiac) events.”

So what’s new or in the pipeline for the near future in cardiac care and prevention?

“There is not a lot in development that is exciting,” Matsumura said. “It’s not a particularly robust time for cardiology drugs. But there’s a drug in development that is a new class of medicines that directly targets inflammation and has now been shown to prevent recurrent events in people who have had heart attacks. We have known for years and years that inflammation plays a key role in heart events and overall survival. For the first time a drug shows that targeting that specific aspect may keep a patient alive and healthy.”

Ilaris, a drug created by Novartis, a Swiss-based pharmaceutical company, currently treats periodic fever syndromes and system juvenile idiopathic arthritis. Given just four times a year for cardiac use, Ilaris trial evidence shows it can prevent heart attacks not by lowering cholesterol or blood pressure or preventing blood clots but by reducing inflammation. 

Despite the drug’s preliminary stage of development, potential increase in deadly infections and current $200,000 annual cost, Matsumura holds hope the drug will pan out.

“I see concepts come along that sound exciting that don’t pan out,” he said. “There’s not a lot out there in development other than Ilaris. That’s something that may work and I would start creating hype about it. This is exciting.”

Though the drug therapy focuses only on high-risk patients, one can only wonder if reducing or blocking inflammation can prevent heart disease. Matsumura finds the concept of targeting inflammation to prevent heart events intriguing for potential behavioral and natural therapies.

NEW DEVICES

In addition to cardiovascular drugs, new devices to combat heart disease have come into use today.

Geisinger electro physiologist Wilson Young, M.D., placed the first leadless pacemaker in the Northeast region in August 2017.

“We put a lot of pacemakers in people who have rhythmic disturbances,” Matsumura said. “The traditional is a battery that goes in the chest and one or more – sometimes three or four – wires that go through the vasculature that goes into the heart.”

While pacemakers have obvious benefits, the traditional units have two downsides: an inclination toward cracks in those wires and increased infections, especially for those who have had multiple pacemakers.

“The more foreign bodies you put in, the more you are prone to complications,” Matsumura said. “The theory of the leadless pacemakers is it’s a tiny little battery. It has no wires that come out of it. It paces the heart without the need for any of the wires creating the issues. They put it right in the heart. It’s a big breakthrough.”

Another device, the Watchman device, helps to prevent blood clots in patients who cannot tolerate or use blood thinners such as warfarin or coumadin.

Geisinger cardiologists Pugazhendhi Vijayaraman, M.D., and Kishore Harjai, M.D., have been placing the Watchman device for about a year at Geisinger Wyoming Valley Medical Center and Geisinger Medical Center. They are the only physicians in the Northeast region to perform this procedure.

“This is really exciting for patients,” Matsumura said. “This has been a really nice breakthrough. The Watchman device is a left atrial appendage device that’s put in through a patient’s heart which is a little pouch off the left atrium which is the left upper chamber.”

Complications of patients with atrial fibrillation, a common rhythm disturbance, can result in blood clots, which can cause strokes and other vascular events. The Watchman device can help when treatment with well-established blood thinners cannot be used or pose a high risk.

“For years and years the only option really was to not have those people on something that doesn’t work nearly as well,” he said. “Those patients were obviously at risk for stroke. Along comes the Watchman device. The trials suggest that it works just as well as blood thinners, again, for a certain population of patients who have aren’t eligible for long-term anti-coagulants.

“We have been putting a lot of those in and accumulated a lot of data at Danville. This is a nice option and it seems to be working for patients.”

ABSORBABLE STENTS

Another device that generated a lot of excitement in the cardiac arena was absorbable stents. Geisinger does not use absorbable stents.

“The thought was you could eliminate the problem with stent clotting if you got rid of the stent,” Matsumura said. “They’re made of a new polymer and disappear. Data was accumulating that they aren’t as good as the traditional metal stents. It’s a nice example of sometimes the hype is out of proportion to the reality of what you’re going to get with new technology and new drugs.”

VALVE REPLACEMENT

Jon Resar, M.D., director of Johns Hopkins Hospital’s Adult Cardiac Catheterization Laboratory, director of the Interventional Cardiology Proram and Medical Director of the Structural Heart Disease Program, performs cutting-edge transcatheter mitral valve replacements, a procedure developed at Johns Hopkins.

According to the American College of Cardiology, transcatheter mitral valve replacement (MVR) recently emerged as an exciting new frontier in the field of cardiac structural interventions.

“The most common method to replace the mitral valve is with open heart surgery that requires cardiopulmonary bypass,” said Resar. “Indeed, this remains the gold standard in patients who are good candidates for open heart surgery. However, many patients with mitral valve disease are high-risk candidates for open cardiac surgery. It is in these patients that transcatheter mitral valve replacement (TMVR) is being studied.”

Johns Hopkins works with Medtronic Inc. on the Apollo Study which is studying the Intrepid valve system for replacing mitral valves that are leaking in patients who are at high risk for conventional cardiac surgery.

“The procedure is done through a small incision in the chest wall and does not require that the patient be placed on cardiopulmonary bypass,” Resar said. “It is performed on the beating heart. The native valve is not removed but is pushed aside by the new valve that fits inside the old valve.”

TMVR is also done on mitral valves previously placed with surgery that have degenerated and are either leaking or stenotic (narrowed), a higher-risk procedure.

“This procedure to place a new mitral valve inside of an old bioprosthetic surgical valve can even be performed without a chest incision and can be done from the vein in the leg.”

Patients benefit through a less invasive procedure and typically have much quicker recoveries.

Hari Tandri, M.B.B.S, M.D., associate professor of medicine and co-director of Arrhythmogenic Right Ventricular Dysplasia (ARVD) Program at Johns’ Hopkins, also performs sympathectomies, a cutting of the sympathetic nerve to treat certain heart conditions.

SIDEBAR:

HEART STATISTICS

• About 92.1 million American adults are living with some form of cardiovascular disease or the after-effects of stroke. Direct and indirect costs of cardiovascular diseases and stroke are estimated to total more than $316 billion; that includes both health expenditures and lost productivity.

• Coronary heart disease is the leading cause (45.1 percent) of deaths attributable to cardiovascular disease in the U.S., followed by stroke (16.5 percent), heart failure (8.5 percent), High blood pressure (9.1 percent), diseases of the arteries (3.2 percent), and other cardiovascular diseases.

• Heart disease accounts for 1 in 7 deaths in the U.S.

• Cardiovascular disease is the leading global cause of death, accounting for more than 17.3 million deaths per year in 2013, a number that is expected to grow to more than 23.6 million by 2030.

• In 2013, cardiovascular deaths represented 31 percent of all global deaths.

• In 2010, the estimated global cost of cardiovascular disease was $863 billion, and it is estimated to rise to $1044 billion by 2030.

Source: American Heart Association

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