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An Update from the Physicians of the Emory
Heart Center
APRIL - JUNE 2003
Volume 3, Number 2
The Emory Heart Center:
Douglas C. Morris, MD, Medical Director
David G. Harrison, MD, Chief, Cardiology
Robert A. Guyton, MD, Chief, Cardiothoracic Surgery
Una H. Newman, Senior Director of Marketing
For more information on Emory Heart Center’s faculty
and staff, procedures and services or to refer patients to EMORY HEALTHCARE
cardiologists or cardiothoracic surgeons, please contact the Emory Physician
Consult Line at 404-778-5050 or 800-22-EMORY. To transfer a patient to
the Emory Heart Center, please call 800-43-HEART.
THE EMORY HEART CENTER INCLUDES Emory University Hospital, Carlyle Fraser
Heart Center at Emory Crawford Long Hospital, Emory-Adventist Hospital
at Smyrna, Wesley Woods Center and 18 clinics in Atlanta, western Georgia,
northern Georgia and North Carolina.
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Emory
Cardiothoracic Surgeon Discusses
Novel Method for Minimally
Invasive Surgical Biventricular Resynchronization
Emory researchers have successfully employed an innovative, alternative
technique for biventricular resynchronization that can be performed in
high-risk congestive heart failure (CHF) patients who have failed the
customary percutaneous route for insertion of a biventricular pacemaker.
 Considered
the first major therapeutic breakthrough for heart failure patients since
the development of specialized heart failure drugs, biventricular resynchronization
therapy uses a pacemaker to stimulate the heart’s ventricles to beat
at the same time. A small pulse generator (about the size of two stacked
silver dollars) is implanted beneath the skin in the shoulder region and
delivers synchronized electrical stimulation to three chambers of the
heart through leads, allowing more efficient pumping of blood throughout
the body.
The result for many patients is a dramatic improvement in exercise capacity,
quality of life and functional status, allowing those who previously had
limited ability to perform common tasks and resume a more normal daily
routine. Some patients who were waiting for heart transplants have been
taken off the transplant list due to their improvement.
“Percutaneous biventricular resynchronization therapy has become
an acceptable therapeutic regimen in patients with CHF and intraventricular
conduction delay exceeding 130 ms,” says Emory Crawford Long Hospital
(ECLH) cardiothoracic surgeon, Omar Lattouf, MD, PhD. “However, although
the percutaneous approach is successful in most patients, technical difficulties
preclude adequate left ventricular capture in some people because of the
difficulty in getting the pacing wire into the vein of the heart. We are
very excited about our new technique because it allows us to overcome
that problem.” Dr. Lattouf explains that one incision only 1/2-inch
long and two to three pencil-sized holes are made in the chest wall. Then,
a special camera and small grasping tool are inserted to allow visualization
and connection of a lead to the heart.
“The advantages to this approach include no exposure to ionizing
radiation and no exposure to dye – which can damage the kidneys,”
says Dr. Lattouf. “Currently, we offer this technique to patients
who failed the percutaneous route. However, some physicians are considering
this as a first option for their high-risk patients. It is minimally invasive
and takes a lot less time to do.”
 Emory
electrophysiologist Angel Leon, MD, implanted the first cardiac resynchronization
therapy system, the Medtronic InSync device, following FDA approval at
the ECLH Carlyle Fraser Heart Center in Atlanta in 2001. In all, more
than 800 of these devices have been implanted in patients with CHF at
Emory Hospitals – more than at any other medical center in the world.
For information on referring patients for minimally invasive surgical
biventricular resynchronization, contact Dr. Lattouf at 404-686-3353.
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Emory Researcher
Finds Young People with Heart Disease at High Risk of Death
Patients younger than 40 years of age who have been diagnosed
with coronary artery disease (CAD) have a dramatically increased risk
of death, according to an Emory study recently published in the Journal
of the American College of Cardiology (Volume 41, Issue 4).
 Study
author Joseph I. Miller III, MD, and colleagues analyzed the medical records
of 843 heart patients younger than 40, all of whom had at least one documented
coronary artery blockage between 1975 and 1985. The average age at diagnosis
was 35 for the women and 36 for men. The researchers noted prior myocardial
infarction (MI), diabetes, heart failure, angina class, number of diseased
vessels, ejection fraction and initial therapy. Of the subjects, 58 had
single vessel disease and ten percent were diabetic.
“We found a third were deceased by age 50 at the fifteen year follow
up. For those with diabetes, the death rate was almost two out of three.
The death rate was highest among those who had suffered a prior MI or
who had been diagnosed with heart failure,” says Dr. Miller, an Emory
Heart Center cardiologist and assistant professor of preventive cardiology
at Emory University School of Medicine. “We also found coronary
angioplasty and coronary artery bypass grafts were associated with lower
mortality than medical therapy.”
Although an actual diagnosis of blocked coronary arteries is fairly unusual
in people younger than 40, Dr. Miller says the Emory study should be a
wake-up call to physicians signaling that young patients with heart disease
should have controllable risk factors treated aggressively.
“Although genetics might play a role in early onset cardiovascular
disease, lifestyle factors are also important.
Overweight patients should be encouraged to lose weight, elevated cholesterol
should be reduced with diet and
medication, if needed, and an appropriate exercise program should be initiated,”
Dr. Miller notes. “It is also
crucial diabetes be controlled in these patients.”
The study reinforces what cardiologists have known for decades –
smoking is dangerous to cardiovascular health. “Patients who continued
to smoke had a six times greater risk of death than those who didn’t
smoke,” says Dr. Miller. “The good news is the risk for people
who quit smoking dropped to almost that of non-smokers. However, even
if diabetes, high cholesterol and hypertension are treated aggressively,
the
cardiovascular risk does not go down for people who continue to smoke.
Smoking cessation clearly can play an important role in helping reduce
the mortality rates in this population.”
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Emory
Healthcare Executives Join American Heart Association’s Board of
Directors
John T. Fox, CEO, and Una Hutton Newman, Senior Director
of Marketing, both of Emory Healthcare, have been named members of the
Board of Directors of the Atlanta Division of the American Heart Association.
The executives will initiate two-year terms on the Board beginning July
1, 2003. In 2002, Fox and Newman led a dramatically successful Heart Walk
fund-raising effort on behalf of Emory Healthcare, whose 9,000 employees
raised more than $250,000 for the American Heart Association, more than
any other health system in the country and second overall among all participating
companies nationally.
 Association
of Black Cardiologists Honors Emory Heart Center
The Association of Black Cardiologists (ABC) presented the
Emory University School of Medicine and David G. Harrison, MD, director
of Emory’s division of cardiology, with a special award for “Ongoing
Commitment to the Promotion of Diversity and Cultural Enrichment in Medical
Education” during the 52nd Annual Scientific Session of the American
College of Cardiology (ACC). Emory’s cardiology program has graduated
approximately 20 African-American heart specialists, while nearly half
of the cardiology training programs in the U.S. have never graduated an
African-American cardiologist.
“There is a noticeable lack of African-American medical students
being recommended for cardiology fellowships. It is invigorating to know
one of the top medical schools in the country is committed to diversity,”
commented Malcolm Taylor, MD, President of ABC, a not-for-profit volunteer
national organization of more than 800 African-American cardiologists
and medical professionals.
“We at Emory are honored to be recognized by the Association of
Black Cardiologists with this award,” says Dr. Harrison. “We
are committed to continuing our efforts to support and train African-American
cardiologists.”
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Research Points
to Need for Timely Diagnosis of AMI in Young Women
Younger women who undergo angioplasty after suffering an acute
myocardial infarction (AMI) are at a higher risk of dying while in the
hospital than their male counterparts, according to research conducted
by Viola Vaccarino, MD, PhD, of the Emory Department of Medicine’s
division of cardiology.
 Dr.
Vaccarino points out this finding is most likely related to delayed treatment,
which could be due to a lower suspicion of coronary disease in these women.
“Because they are female, and they are young, physicians – or
women themselves – might not be considering heart disease as a possible
cause of their symptoms as quickly as they should,” says Dr. Vaccarino.
The Emory team studied 59,792 cases with AMI who underwent angioplasty
in 223 hospitals participating in the ACC-National Cardiovascular Data
Registry between l998 and 2001 – about 32 percent of the cases were
women. Overall, women in the study had a 32 percent higher mortality risk
compared with the men. The researchers noted the younger women frequently
had additional health problems such as diabetes, renal failure, previous
stroke and peripheral vascular disease. Their clinical heart disease also
tended to be more severe than their male counterparts.
However, the women’s previous health status and heart disease severity
by themselves did not explain the association, according to Dr. Vaccarino.
Instead, the factors that explained the results were primarily the severity
and acuteness of presentation in these women. Many were in shock and needed
an urgent procedure when admitted to the hospital.
“It was mostly urgency and severity of presentation that was important,
such as being in shock. Perhaps these women wait too long to seek treatment
for heart attack, or are referred later than men for coronary revascularization
during a hospitalization for myocardial infarction,” Dr. Vaccarino
concludes. “This study underlines the fact that although symptoms
of AMI may be less typical in women than in men, which makes
the initial diagnosis more difficult, physicians need to consider the
possibility more quickly so there is not delayed treatment for this population.”
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Edited by Peter C. Block,
MD, and Sonya L. LeFevre, MD
 A
71-year-old man is status post 3 vessel CABG 15 years ago. He complains
of recurrent progressive angina with minimal exertion. His blood pressure
is 110/60 mmHg, and he is maximally beta-blocked with a resting heart
rate of 50 bpm. His antianginal/medication regimen includes Imdur 120mg
qd, Toprol XL 200mg qd, Altace 5mg qd, Norvasc 10mg qd, Baby ASA 81mg
qd, Zocor 40mg qd (LDL is 86) and Plavix 75mg qd. Coronary angiography
demonstrates proximal occlusions of his native vessels, 2/3 bypass grafts
patent and severe diffuse native coronary artery disease distal to graft
insertion. A representive thallium image is shown above. What are the
therapeutic options for this patient?
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Case Study Answer
(from Jan-March 2003 issue)
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The patient underwent implantation of a biventricular pacemaker
– commonly referred to as resynchronization therapy, by electrophysiologist
Jonathan Langberg, MD. LBBB in the presence of a DCM worsens
the EF, decreases diastolic filling time and worsens MR. Biventricular
pacing has been shown to improve hemodynamics and functional status
in patients with a DCM and LBBB morphology on EKG.
(click on image for larger view)
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Heart Center CME
Course Offerings
June 14-18
Emory Symposium on Coronary Atherosclerosis Prevention and Education
Sea Island, GA
The Cloister
September 2003
Intraoperative Echocardiography in the 21st Century
The Cardiac Surgical Patient in the 21st Century
Atlanta, GA
Grand Hyatt
Continuing Medical Education
1365 Clifton Road, NE
Building A, Suite A2204
Atlanta, GA 30322
888-727-5695
email: CME@emory.edu
web: www.emory.edu/CME
404-727-5695 (main line)
404-727-5667 (fax)
CONTRIBUTORS:
Medical Editor - Peter C. Block, MD
Editor - Kimberly Enard
Writer - Sherry Baker
Art Director - Mark Swilley
Graphic Design - Design Basics
We welcome your comments and suggestions. Please direct
correspondence to:
Cardiac Connection, 101 W. Ponce de Leon Ave, 3rd Floor, Decatur,
GA 30030,
or email us at cardiac_connection@emoryhealthcare.org
Archive of Cardiac Connection
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