Search for tag: "cardiology"

Interviewer: We are here with Dr. Jared Bunch, Professor of Medicine and Section Chief for Electrophysiology at University of Utah Health. Now, Dr. Bunch, when it comes to atrial fibrillation or AFib, what exactly is happening with the patient, and what are they experiencing?

Dr. Bunch: That's a great question. Atrial fibrillation is the most common abnormal heart rhythm that's sustained or maintained that we see in practice. I suspect most people who are listening to this know somebody that has atrial fibrillation. One in three of us to one in four of us will develop it. In fact, we live long enough, we live over 80, 40% of us will develop atrial fibrillation. And what it is is it's an abnormal electrical rhythm in the upper heart chambers, and these upper heart chambers normally beat in a really ordinary synchronized manner at 60 to 70 beats per minute. Atrial fibrillation replaces that maybe to 300, 350 beats a minute, the upper heart chambers. And that can cause stroke, it can cause heart failure, and it can cause a lot of symptoms such as chest pains, shortness of breath, dizziness, exercise intolerance, anxiety, fatigue. You may know somebody that has atrial fibrillation that called 911 the first time they developed it. In some people, the symptoms are more mild. So it's a symptomatic abnormal rhythm that's quite common amongst us.

Interviewer: And the potential for stroke, that sounds pretty serious.

Dr. Bunch: That's our biggest worry is stroke, because these upper heart chambers aren't squeezing and pushing the blood forward. So the clots that form can be larger than other sources of stroke and cause more disability and higher risk of death. So we really focus on trying to prevent stroke as an upfront treatment strategy.

Interviewer: Now, you said that some people live with AFib their whole life, and maybe it shows up at a physical or another kind of doctor visit. And other people, they feel it, and then they call 911, and they come in. Once a patient knows that they have some sort of AFib, what is the next step, and what are some of the treatments that can help kind of alleviate those symptoms or treat the disorder?

Dr. Bunch: So we look at this in three primary pillars, three primary treatment approaches. First, we want to prevent stroke, and our best way of doing that is early use and appropriate use of anticoagulants. They're often sometimes called blood thinners, but really they don't thin the blood. They make it slower to form a clot. So they're less likely to form a clot in the heart. And they can reduce the risk of stroke less than 1% a year, or it can be as high as 5% to 10% a year.

Our second concern is the heart is just a muscle. If the heart's going too fast or too long, it can begin to dilate, weaken, just like any of our muscles. And so we use medications to slow the heart down if needed. We want the average heart rate less than 100 beats per minute on average at rest. Sometimes we need to control it with exercise as well.

And then, finally, we focus on symptoms. Some people aren't aware that the symptoms they're experiencing is related to atrial fibrillation. They don't put that correlation together till we make the diagnosis. Other people know right away. So then we begin treatments to restore the heart rhythm really to help you feel better and do better and enjoy your quality of life at a higher degree.

Interviewer: Are there any kind of treatments that could potentially fix the kind of problems that they might be seeing that goes beyond, say, medications or some of these other things you've talked about?

Dr. Bunch: There's three primary ways that we treat this. First, we work on risk factor modification. What causes atrial fibrillation? The most common causes in the community, the most common we can't do anything about, we get older. It's a disorder of aging. But the other things we can do a lot about and that is high blood pressure, getting our blood pressure well-controlled, screening for sleep apnea when we hold our breath at night and treating that, decreasing alcohol intake, treating diabetes better, losing weight, and being more active. We want people to be active 30 to 60 minutes a day, that's the dedicated time towards activity, whether that's walking, jogging, running, swimming, yoga, whichever you like. It's important to have that time where we exercise our bodies.

So that is one part that we do to help lower the risk of atrial fibrillation. In fact, if we do those things really well, it will lower atrial fibrillation by 30%. We have medications that help force the heart to beat normal, what we call antiarrhythmic drugs. And there's a number that are currently available, and we can use them depending on the health of your heart. So sometimes we can use a lot if your heart's healthy. If your heart's weak or you've had heart attacks or surgeries, then there's only a few we can use.

Then, finally, there's approaches to do this without medication. So the most common is called catheter ablation, and that's a procedure where . . . it's a minimally invasive procedure where we advance little specialized tools that are flexible and move in your heart called catheters through the veins in your leg up into your heart and cauterize around the sources of fibrillation and block them. These electrical sources are like throwing a rock into a pond. The waves carry from outside from where the rock enters throughout the whole leg. We want to block these signals at their origin. And then sometimes also, if needed, the same procedure can be done by our surgical colleagues through open-heart surgery in patients with really advanced heart disease or disease that we can't get to from within the vessels.

Interviewer: So what kind of patient is best served by the cardiac ablation procedure? Is it the sickest of the sick or anyone with atrial fibrillation?

Dr. Bunch: Well, we've learned a lot just over this past year. A large trial came out that said, "When should we do it? Should we do it early?" And they took patients that developed atrial fibrillation within one year of diagnosis. We found that if we're going to get the most bang for your buck, the most efficacy for the procedure, we really should start looking at either using a medicine that helps the heart beat normal or an ablation within that first year. But that doesn't mean if you had atrial fibrillation longer that you wouldn't benefit from something like an ablation. Ablation is twice as effective as our medications.

And our patients that are the most sick really need their heart to be very efficient and those upper chambers to contract and squeeze just like the lower chambers. Sometimes they benefit from ablation as well and more so than medicines. And the best example of that is our patients with atrial fibrillation and heart failure. Ablation clearly is a better approach and actually can impact how long you live. If we can restore the rhythm effectively and get you off these medicines, it helps you live longer.

Interviewer: Now, one of the things I think we really need to talk about is that cardiac ablation is not necessarily a cure-all for AFib. Is that correct?

Dr. Bunch: Yeah, very much so. And it goes right back to that first thing I said regarding risk factors. If you still have risk factors that aren't treated at all, then our treatment approaches decrease in their efficacy and their success rates by as much as 50%. If you have sleep apnea that's untreated, then our success rates go down by 50%. So that's why when you see specialists, like myself, they will ask you about sleeping even though you came in with a heart problem. So you have to be diligent about the risk factors that you can control.

And then, also, atrial fibrillation, just like other chronic diseases, it can progress beyond the initial focal sources that we treat. And as it progresses, new areas can develop, and you could need a repeat ablation, or you could need a medication with the ablation to control it long term. But the good news with that is, if I am a patient that has atrial fibrillation, there's a lot I can do personally to help myself have a better outcome and to help the physician who is ultimately performing the procedure have a better outcome as well with the procedure.

Interviewer: For a patient that has been dealing with AFib for a while or maybe they just barely got their diagnosis, what advice would you give them for the treatment options available to treat their condition?

Dr. Bunch: Again, we need to work and minimize risk of stroke first. We're going to focus on that, and we're going to minimize risk of any potential injury or weakening to the heart. And then my approach has changed in the past year. I say, if we're going to do something about this rhythm, we should do it earlier, within the first year if possible, to keep the heart normal. The heart rhythm is a lot like kids. I have teenagers, and one teenager learns from the other. And the heart rhythm learns from the beat before it. So the more it's in fibrillation, the more it wants to be in atrial fibrillation. So we want to set the heart on a trajectory to want to beat normal. And so that's what we aggressively do in patients that have symptoms and want to pursue that route. People that don't have any symptoms at all, they said, "I came in for a test, and you found atrial fibrillation. I don't know why I'm here." In those people, we spend more of our time just making sure we lower stroke rates and making sure that that heart rate is well controlled, and so the muscle isn't in jeopardy of weakening.

Interviewer: It's time for Seven Questions. It's time, seven questions for a cardiologist. We've got Dr. John Ryan here and I'm going to ask you seven questions. Just want your answers just as they come to you, okay?

Dr. Ryan: Sure thing.

Interviewer: Don't think about it too much, as quick as you can. What's the best thing that I can do for my heart to make sure it stays healthy?

Dr. Ryan: Probably exercise 30 minutes every day, something that gets your heart rate up, and just get it into your routine as something that is part of your daily schedule.

Interviewer: All right. What's the worst thing I can do for my heart?

Dr. Ryan: Probably not exercise at all.

Interviewer: Really?

Dr. Ryan: Yes.

Interviewer: Even worse than like smoking or something like that?

Dr. Ryan: It is. Yes. Well, that's fair. I mean, you're going to assume that folks know that they shouldn't smoke, but even when you have people who have a normal weight and who don't exercise, they actually are at a higher risk of having heart disease and a higher rate of mortality than people who are overweight who do exercise. The sedentary lifestyle is really hurting us.

Interviewer: What do you know about the heart that everybody else should know?

Dr. Ryan: You really can make a positive change to your risk of having a heart attack. Really, it is not something that you need to give up on. And even if you've had a historical lifestyle of smoking, not exercising, eating fatty foods, your destiny is not to have a heart attack. You can actually change your destiny and really reduce your risk of having a heart attack by stopping smoking, actively exercising, losing weight, etc. So I think that's really just key to be aware of.

Interviewer: Can you scare somebody to the extent that they have a heart attack?

Dr. Ryan: There's definitely a stress component to having a heart attack. There are people who, at football games have heart attacks, at roller coasters have heart attacks, downhill skiers occasionally have heart attacks.

Interviewer: What about, like a victim of an April Fools joke?

Dr. Ryan: I think that would be really unfortunate and would kind of make you have to rethink the whole tradition of April Fools' Day in general if mortality from cardiovascular disease goes up on April Fools' Day, I think we need to rethink why we have this holiday.

Interviewer: What is your favorite song that has the word "heart" in it?

Dr. Ryan: The favorite, probably "Total Eclipse of the Heart."

Interviewer: Okay.

Dr. Ryan: It's an incredible song.

Interviewer: Why did you specialize in cardiology?

Dr. Ryan: I think you can really do a lot in cardiology because you can take care of the individual person across the way from you, but there's also a large public health component to it, in so far as trying to get your community to be more active. And that's just a fascinating part in America because we're so heavily dependent on our cars and we don't walk, we don't cycle around our neighborhoods anymore, stuff like that.

And then there is also the nutritional components. So, as well as having that one-on-one relationship, you also have this public health issue from cardiovascular disease, which I think is really important for cardiologists to be at the forefront of.

And then also the basic science in cardiology is just fascinating and has really made a significant impact in cardiovascular disease over the last 30, 40 years. And when you look at how we have cared for people and the advances we've made in terms of reducing the rate of heart attack, reducing the mortality from heart attack and stroke over the last 40 years, those impacts have been made because we have done significant basic science advancements and because we've also made community awareness about heart disease and how to lower your heart risk.

Interviewer: What advancement in your field has you the most excited?

Dr. Ryan: I think we're getting at a point where the technology is becoming really personalized. It is really exciting that people come to us with the data that they've generated, either from their phones, from their smart phones, from what people have collected from wearables, and that their health literally is in their hands, and they are coming to us with what they've found.

Whereas traditionally, we do tests and we would say, "Well this is what we've found." Now they're coming to us with what they've found, and that's a really exciting thing because that really shifts the responsibility of cardiovascular care and risk reduction to where it should be, which is to the individual.

updated: January 27, 2021
originally published: June 14, 2017

Interviewer: Heart attack patients are not all the same and that's important to know. We'll talk about that next on The Scope.

Announcer: Examining the latest research and telling you about the latest breakthroughs. The Science and Research Show is on The Scope.

Interviewer: I'm talking to Dr. Rashmee Shah, Assistant Professor of Cardiovascular Medicine at the University of Utah. What did you find?

Dr. Shah: We looked at heart attack patients who had a specific complication called cardiogenic shock. Cardiogenic shock occurs in patients who have very big heart attacks, and the heart muscle becomes so weak that it can't pump blood to the rest of the body. These are the sickest of the heart attack patients. In the last decade, we've gotten a lot better at treating heart attacks using stents, interventions and stents, to open the blocked arteries.

A lot of these patients are now surviving the hospitalization. That means they get hospitalized, get treated for their heart attack and then make it out of the hospital. Since that's happening more frequently, we need to know what happens to these patients after they leave the hospital. Are they going home and resuming their usual life? Or are they disabled and still sick like they were when they were in the hospital?

Interviewer: What did you find amongst these patients? How are they doing when they leave the hospital?

Dr. Shah: In a publication that preceded this one, we found that two-thirds of patients like this will survive the hospitalization and get discharged. We took it up from there. So among these patients who survived the hospitalization, we found that, surprisingly, within a year over half . . . almost 60% of these patients will either die or be rehospitalized.

Interviewer: Oh gosh.

Dr. Shah: Yeah, so not great. The interesting finding was that this risk is really clustered in the immediate, post-hospital period. So within the first 60 days after discharge, this is when these cardiogenic shock patients are the most vulnerable to have an adverse outcome, meaning death or hospitalization.

One interesting finding was that actually all heart attack patients, over 50% die or were rehospitalized within a year. That's all heart attack patients. That was a bit surprising and I think we'll have to delve a little deeper to see what could be driving that and what we can do about it.

Interviewer: That's not common knowledge yet, right, until this paper?

Dr. Shah: Correct.

Interviewer: Do you have any ideas of what's happening within this 60-day period that might put these patients at risk for dying?

Dr. Shah: Yeah. So there are some theories out there about the post-hospital, discharge period. One interesting idea is there's so-called post-hospital syndrome, especially among critically ill patients. Patients with cardiogenic shock are often in intensive care units, they're very sick. What happens is they become debilitated because they don't have adequate nutrition during that period, they're lying in bed, their days and nights gets reversed.

Everything about their daily life has changed and they become really weak. Critically ill patients, not just limited to cardiogenic shock patients, when they get home or when they get discharged to wherever they go, they're still very debilitated. This post-hospital syndrome is one possibility and efforts related to rehabilitation, physical therapy, occupational therapy could address that issue.

The other issue is that cardiogenic shock is a condition in which there's not enough blood getting to other organs of the body so they might have renal failure. They might have had less blood going to their brain, some kind of neurological effect. All those things coming together make patients very debilitated so it could also be a multi-organ issue.

Interviewer: Among patients who have heart attacks, what percentage is represented by this population?

Dr. Shah: The dataset we used is called the Action Registry and it's from the American College of Cardiology. This is the largest registry of heart attack patients in the US. In this population, 5% of heart attack patients will have cardiogenic shock.

Interviewer: You would think that if they have those serious problems, that they would be under a close watch once they're discharged. Do we know if that's happening?

Dr. Shah: Yeah. There are guidelines that encourage one-week follow-up for patients after a heart attack. That happens fairly consistently and it's something we work on aggressively here at the University of Utah. Often, the patients . . . there are standard therapies following heart attacks and these patients might not be able to get some of those therapies because, for example, their kidneys aren't working as well so they can't have the drug that can sort of protect the heart. They could have a follow-up, but that doesn't necessarily mean they eligible or able to get those evidence-based therapies to help the heart heal.

Interviewer: What are the next steps? What do you think this information is telling you about what can be done or what should be done?

Dr. Shah: I think there are many things we can do from here. A couple of things I'm interested in are focusing on the so-called patient recorded outcomes. We measure these very quantitative metrics, "Did the patient die? Did they get hospitalized?" But there's much more to patient wellbeing than just that. We want to know, "Are they able to function? Do they feel like they're short of breath every day?" those sorts of symptoms.

We can only get that by asking the patients and asking every patient, every time. Especially in this population, it'll be interesting to know what their daily life is like because it could be very different than what these somewhat simple metrics imply. I think that's a really important part there for subsequent research.

The other issue I think is important is, "Can we find a way that, while these patients are in the hospital, that we could proactively identify them before they leave the hospital?" That's really useful information for planning subsequent treatments or helping the patients and families understand what to expect when they leave the hospital.

Announcer: Interesting, informative, and all in the name of better health. This is The Scope Health Sciences Radio.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope

Dr. Stehlik: How does advance imaging help improve the treatment of patients with heart failure? I am Dr. Josef Stehlik along with Dr. Stavros Drakos, and today we're talking with Dr. Jeroen Bax, a cardiologist from Holland and the president of the European Society of Cardiology, who is speaking at the Utah Cardiac Recovery Symposium, U-CARS, at the University of Utah.

Professor Bax, I would like to ask you how your field of cardiovascular imaging relates to a patient who presents to a doctor with a heart condition.

Dr. Bax: If we speak about imaging and how does it relate to the specific patient, I think one needs to realize the information one needs to have, so if we speak about such a patient, the first thing is that we need to diagnose specifically what's going on with this patient. Why is his heart not functioning? What is the problem underlying that? And based on the information that we get from our modern technologies such as modern CT scanners, MRI scanners, echocardiography, but also nuclear imaging, this information will help us then to select the therapies.

What are the therapies? Well, we could go for medical therapy, could go to surgery, we could have device therapies such as cardiac stenting, pacemakers, supporting hearts and transplantation. Once we have selected the therapy based on this imaging that we have acquired, then we could actually look into determining the prognosis for the individual patient. What is the prognosis after we have decided exactly what we are going to do? And that's the cornerstone, I think, the prognosis eventually for the patient.

Dr. Drakos: So Dr. Bax, my name is Stavros Drakos, as my colleague Josef Stehlik said. We are cardiologists here at the University of Utah, and we see all the time patients coming with more than one heart attack and their heart is weak. They don't feel well. They're tired. They're short of breath. So how would you approach a patient like this? How is advanced imaging going to help you?

Dr. Bax: Yeah, that's exactly sort of giving an example of what we just spoke about. In this case we actually need to know for this patient what do we need to do, what are the therapeutic options, and to understand the therapeutic options we actually need to image his heart. So we look in this specific heart, where are the infractions? We have all these modern technologies that I just indicated and the focus is where are the infarctions and how big are these infarctions? How much scar tissue is there in this heart, and if there is a lot of scar tissue then the likelihood that he will improve based on medical therapy or something is not that high. But if there is very little scar tissue we can just focus on giving medication. So the imaging is going to help us to choose the strategy for the patient.

A lot of scar tissue means that we have to look for different things than just medication. Then we need to think about devices such as pacemakers that can help improve the function of the heart, or maybe bypass surgery is needed, that we need better blood flow to this heart, or maybe in a worst case scenario, we need to think about transplantation. These decisions can be made by the modern imaging technologies that we have.

Dr. Stehlik: Let me now ask you about a different patient, actually not a patient, just a person who's at home and hears about her best friend about the same age, same lifestyle, having a big cardiac event, and now this person comes and says, "Well, wait a minute. Am I at risk? Should I have my heart imaged? Will that change my future?"

Dr. Bax: Yeah, that's a very important question. We're now shifting actually towards the topic of prevention and that is important. Actually we have techniques for that. We have, for example, the technique of CT scan that most of us know nowadays. With CT scan we can look, just with the scan, not from inside but from outside, at the patient's coronary arteries and we see if there is obstructive coronary artery disease. This is already affecting the coronary arteries. Is there already atherosclerosis? Do we need to think about something? If we see little bits of atherosclerosis we can actually then help this individual and improve his lifestyle.

What could we think about, then? Healthy lifestyles. That means exercise more, reduce taking too much food, control the blood pressure, quit smoking, and actually this can be done in collaboration with general practitioners. So this sort of screening imaging can really help to prevent. I think now we're talking about adults looking at these things, but eventually the future might be that we are going to look at the early youth when we need to intervene. More healthy lifestyles. Imaging can also play a role there, but then we don't talk about CT scanners. Then we speak about certain echocardiography techniques where we can look at the heart, how is the heart functioning, and based on that we can actually decide upon helping these individuals for a better lifestyle.

Announcer: We're your daily dose of science, conversation, medicine. This is The Scope, University of Utah Health Sciences Radio.

Dr. Miller: Your child has chest pain. Does he need to see a pediatric cardiologist? That's next on Scope Radio.

Announcer: Access to our experts with in depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: I'm here with Collin Cowley. He's a pediatrician and a cardiologist and he's a professor of pediatrics and he works over at Children's Primary Hospital. Collin, tell me a little bit about chest pain in kids. Do you see chest pain in kids very often?

Dr. Cowley: It is a very common symptom. We see well over a thousand patients a month in our clinic at Primary Children's Hospital alone. A significant number of those patients are coming in with symptoms of dizziness or fainting.

Dr. Miller: In addition to chest pain?

Dr. Cowley: In addition to chest pain.

Dr. Miller: So the families are worried that oh my gosh, this could be a heart attack because they hear so much about that on the adult side if you're having crushing substernal chest pain.

Dr. Cowley: Absolutely.

Dr. Miller: As an adult you probably should consider that this might be a heart attack and get to the emergency room. Is that right?

Dr. Cowley: Right and that is ingrained in our culture. Even smart, well trained physicians and pediatricians in the community, a kid comes into their office and the kid says, “I have chest pain,” they very quickly say you better go see a cardiologist.

Dr. Miller: And once they get to your doorstep, what do you find?

Dr. Cowley: A normal kid usually with chest wall pain. We will typically do an electrocardiogram as a safety measure. It's probably overkill in and of itself. There are a few providers who might step up the testing to other things that are far more expensive. But the incidence of underlying heart disease in otherwise healthy kids presenting with chest pain is close to zero.

Dr. Miller: It's much different than it is in adults, right?

Dr. Cowley: Absolutely, it's a paradigm shift essentially.

Dr. Miller: So the number one cause of chest pain in kids is something related to the musculo-skeleture of their chest wall, right?

Dr. Cowley: Yes, and especially in teenagers. These teenagers growing, your chest wall is actually a very dynamic part of your body.

Dr. Miller: There's nerves running through the . . .

Dr. Cowley: Exactly. Lots of cartilage and in the normal process of growth sometimes those nerves get . . .

Dr. Miller: Or if they're rough housing . . .

Dr. Cowley: Exactly. Or yeah, their dad sits on them, something along those lines. That's a source of crushing chest pain that we can't treat, when your Dad is sitting on your chest.

Dr. Miller: The bottom line is, if your child has chest pain, and when you say child you mean up to the age of what, 18, 16?

Dr. Cowley: Yeah, yeah 16 to 18. It's pretty common for us to see teenagers in this age group, but oftentimes school aged children as well.

Dr. Miller: The vast majority of the time it's not going to be anything related to heart.

Dr. Cowley: I've actually never seen it be related to the heart in the 20 years I've been working as a pediatric cardiologist.

Announcer: Thescoperadio.com is University of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at thescoperadio.com.