Update in Cardiology: 2012

James A. Coman MD, FACC

President and Founder,Heart Rhythm Institute of Oklahoma

Tulsa, Oklahoma

Disclosures

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

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

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

Valvular Heart Disease

Prevalence of valve disease in the population

The Next Cardiac Epidemic

Nikomo et al, Lancet 2006; 368: 1005

Pre

vela

nce

of m

ode

rate

or

seve

re v

alv

e d

ise

ase

(%

)

Severe Aortic Stenosis Without Surgery:

Worse Than Most Metastatic Cancers

5-Year Survival

Su

rviv

al,

%

* 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.

†

Transcatheter Aortic Valve Implantation (TAVI)

Smith CR et al. N Engl J Med 2011;364:2187-2198.

All Cause Mortality (ITT)Landmark Analysis

All

Ca

use

Mo

rta

lity

(%)

Months

Mortality 0-1 yr Mortality 1-2yr

Standard Rx TAVR

HR [95% CI] =0.57 [0.44, 0.75]

p (log rank) < 0.0001

HR [95% CI] =0.58 [0.37, 0.92]

p (log rank) = 0.019450.7%

30.7%

35.1%

18.2%

Numbers at Risk

TAVR 179 138 124 110 83 Standard Rx 179 121 85 62 42

44.2

10.2 10.9 10.610.6

0.64

1.55 1.61 1.58 1.68

0.0

0.5

1.0

1.5

2.0

2.5

0

10

20

30

40

50

60

70

Baseline 30 Day 1 Year 2 Year 3 Year

Me

an

Gra

die

nt (

mm

Hg

)

Error bars = ± 1 Std Dev

EOA

Mean Gradient

N = 158

N = 162

N = 137

N = 143

N = 84

N = 89

N = 65

N = 65

N = 9

N = 9

AV

A (cm

²)Mean Gradient &

Valve Area

Transcatheter valves provide excellent hemodynamics and appear very durable to 3 years

Months

348 289 252 143 65

351 247 232 138 63

No. at Risk

TAVR

AVR

28.0

26.5

HR [95% CI] =0.95 [0.73, 1.23]

P (log rank) = 0.70

PARTNER COHORT A (high risk)All-Cause Mortality or Stroke (ITT)

All Patients (N=699)

Complications• Device embolization

• Aortic insufficiency

• Coronary occlusion

• Root rupture

• Stroke

• AV block – pacemaker

• Vascular complications – bleeding

• Acute Renal Failure

Device Embolization

Para-valvular Regurgitation

Iliac Avulsion

Embolic Materialafter TAVR

Embolic Material

Embolic Material

Day 6 Post-implant

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

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%

Radiofrequency Ablation

• Targeted RhythmsAVNRTAccessory Pathway RhythmsAtrial FlutterEctopic Atrial RhythmsPost Congenital Repair RhythmsNormal Heart VT

AF

Radiofrequency Ablation

• Success rates of 95-100% for all but atrial fibrillation

• Complication rates approaching zero

• Home after 4 hours

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

Atrial Fibrillation RFA• Success rate from 40 to 80%

• Complication rate: 1% chance of CVA1% 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

Cryoballoon

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

Atrial Fibrillation• Drug treatment

• Dofetilide

• Amiodarone

• Sotalol

• Flecainide

• Dronedarone

CHF

Courtesy of Dr. Auricchio, University of Magdeburg, Germany.

The Implanted LV Lead

LAO View Lateral Coronary Vein Placement

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”

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

ANNUAL DEATHS IN U.S.

0

50,000

100,000

150,000

200,000

250,000

300,000

SCD CVA Lung CA BreastCA

AutoAcc.

AIDS Fires1NASPE, May 20002American Heart Association 20003National Cancer Institute 20014National Transportation Safety Board, 20005Center for Disease Control 20016NFPA, US Facts & Figures, 2000

CAST-I and other AAD Trials

80

85

90

95

100

0 91 182 273 364 455

Days After Randomization

Pat

ien

ts W

ith

ou

t E

ven

t (%

)

Placebo (n = 743)

Encainide or Flecainide

SWORD – D sotolol

CASH -propafenone

EMIAT - amiodarone

Primary Prevention ICD Trials1.0

0.8

0.6

0.4

0.2

0.0

0 1 2 3 4 5Year

Pro

ba

bili

ty o

f s

urv

iva

l

MADIT I - Conv Tx

MADIT I - ICD

MADIT II - ICD MUSTT - ICD

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

Cost Analysis

050

100150200250300350400

1,00

0

Cost/YOLS

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

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

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