Healthful Advice . Dr. Kenneth Adams

Having grown up in the "Star Trek" era, I remember the doctor on the Starship Enterprise making most of his diagnoses by moving a cursor over the patient's body. "Bones," as the doctor was affectionately called, would then turn to Captain James Kirk and give him a full report. This was the ultimate non-invasive test. Although we are many years from making diagnoses that way, we may have moved a few steps closer with the advent of cardiac CT scans.

For centuries, doctors have tried to assess internal organs by examining from the outside. In the case of the heart, one early method was to simply put your ear to the patient's chest and listen to the heart rhythm. This became more sophisticated with the use of a pipe and then a stethoscope.

Coronary artery disease, or blockages in the arteries feeding the heart muscle, is the leading cause of death in the United States. One of the challenges has been to obtain detailed and accurate information about the coronary arteries without doing an invasive procedure. Our "gold standard" for detailed and accurate information about coronary arteries has been cardiac catheterization. This is an invasive procedure that involves inserting a small tube or catheter into an artery at the top of the leg, threading this tube up to the heart, pointing the catheter into the coronary arteries, injecting contrast and taking an X -ray moving picture of the arteries.

Is there a way to obtain good pictures of the coronary arteries without doing an invasive procedure? The newer generation of CT scans offers a lot of promise, allowing us to perform angiograms using CT technology. CTA stands for computed tomographic angiography. CTA has been used for imaging many arteries including the aorta, kidney arteries and carotid arteries.

One of the difficulties in obtaining accurate Cardiac CTA relates to the heart being a structure with a lot of movement. In order to take accurate pictures of a moving object the pictures must be taken in a very short time frame. CT scans with a high number of detectors or "slices" can take pictures in a very short period of time. Right now, a 64-detector CT scan is being used for cardiac CTA. After timing measurements are made to determine when the contrast will reach the heart, contrast or dye is administered through an IV. The scanner is positioned over the heart. Pictures of the heart can be taken in five to ten seconds.

This is a very exciting technology, but it has its limitations and does not apply to every patient. Let me give you one example of a patient who would be a good candidate for cardiac CTA. I recently saw a 45 year-old patient in my office who was sent to me for evaluation of chest pain. The chest pain had some features that suggested the possibility of coronary artery disease, but I had my doubts. The patient did have some risk factors for heart disease, including high cholesterol and family members with coronary artery disease. This patient's stress test was inconclusive. I really wanted to know whether this patient had any blockages in her coronary arteries but I did not think an invasive procedure was warranted. I knew cardiac CTA might give me the information I was looking for.

Cardiac CTA has generated a lot of enthusiasm in the medical community. Articles about cardiac CTA have been in Newsweek and Time magazines, and there was even a segment on “Oprah.” Many cardiologists and radiologists have taken special training to learn how to read cardiac CT scans. Medical providers have to make sure they select the right type of patients for cardiac CTA.

Cardiac CTA is available in our community so that we may (to paraphrase from "Star Trek") boldly go forward, seeking new information for our patient.
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Dr. Kenneth Adams is the senior Cardiologist at Pentucket Medical Associates and is certified in Cardiac CTA. Dr. Adams can be reached at 978-521-3288 for additional information about this procedure.

By Kenneth Adams, MD, FACC

Heart disease remains a major threat to the health of many Americans - in fact, it is the #1 killer of adults in the United States. Over the years, much emphasis has been placed on research and diagnosis aimed at the prevention of cardiac disease. Key advances have also been made in technology and in diagnostic techniques that have helped to improve the care today’s physicians are able to provide to their cardiac patients. Some of the most exciting developments include:

• Advances in the treatment of cholesterol. It is widely known that lowering “bad” cholesterol and raising “good” cholesterol make a significant difference in the prevention of heart disease. Education on this front been widespread and effective, as has the development of successful drug therapies. Today’s statins and other cholesterol lowering agents provide positive results for millions.
• More accurate predictors and prevention methods. Research points to inflammation as a significant part of arteriosclerosis and heart attack. As a result, blood tests have been developed identifying markers as predictors of heart attack and stroke. One of the most important is C reactive protein or CRP. This test allows us to make better predictions and determine how aggressive to be with prevention
• New stents that keep arteries open. A stent is a thin tube or sleeve that is inserted into a “clogged” artery that has been opened by balloon angioplasty. With balloon angioplasty alone, 35-40% of arteries might restenosis or clog within 6 months. There has been a great improvement in this with stents/aspirin and plavix, reducing the restenois rate to 10-15%. With the recent discovery of sirolimus - a chemical coating added to the stent- nearly 100% remain open. This greatly reduces the need for repeat angioplasty and bypass surgery.
• Irregular heartbeats can now be corrected permanently. With the development of new techniques including the use of radio waves aimed at the heart, physicians are often able to permanently correct disturbances in the beating of the heart. In the past, drug therapies produced unpredictable results and had serious side effects.
• Mass access to defibrillators. Many public areas and nearly all first responders now have effective defibrillators. Compact, easy to use models are also available for in-home use. These devices shock the heart and restore normal rhythm patterns, and are true life-savers for heart attack victims. A defibrillator wire can also be inserted into the heart of a vulnerable patient shocking the heart into a normal rhythm if needed. Implanted devices save valuable time in critical situations.
• Improvements in the treatment of acute heart attacks. Emergency department personnel are much more aggressive and sophisticated in the treatment of cardiac arrest. We understand, for example, that time is muscle - the quicker patients are treated, the less heart muscle is damaged. Treatment methods have also improved. Today’s ER staff is equipped with effective clot busting thrombolytic agents that help open culprit arteries. With reduced “door to needle time,” and the option of primary angioplasty, more patients are surviving acute heart attacks.
• Surgery is now safer, quicker and less traumatic. Years ago, heart surgery was almost always “open” involving extensive trauma and long recoveries. Today, valve repair and replacement as well as bypass surgery can be performed using small incisions in the chest wall. Patients recovery faster and have far fewer complications.
• Advances in the treatment of congestive heart failure. Congestive heart failure (CHF) is the #1 diagnosis for hospital admissions. Research has provided us with a better understanding of the causes of CHF as well as some very good treatment regimens and surveillance programs. Today, we are better at identifying the early warning signs of CHF and have better treatment choices.
• Women and Heart Disease. In the 1960’s, heart disease was viewed as a men’s disease. It is now abundantly clear that heart disease is the number one cause of mortality for both men and women. Women tend to develop heart disease later in life than men but when it develops, it can be more severe. Today, we are taking just as aggressive an approach in diagnosing and managing heart disease in women as in men. Many heart research studies are including more women.

While diagnosis and treatment options continue to improve, it should be no surprise that prevention continues to be the first line of defense in cardiac care. Eating well, exercising and managing stress are all key components for good heart health.

By Kenneth Adams, MD, FACC

There have been many advances over the years that help us treat patients who experience heart attack. In this article, I want to describe what happens when a heart attack occurs so you will understand how these new treatments work. Then, I want to tell you a personal story to help explain how important these advances in treatment are to all of us.

What Happens When a Heart Attack Occurs?
When someone has a heart attack it means that the heart muscle is injured. A plaque in one of the coronary arteries that feeds the heart muscle has cracked, split or ruptured exposing a gel or matrix. The body then thinks that it must repair the artery and the only way it knows how to do that is to form a blood clot. The blood clot or thrombus totally blocks the artery so no blood flow gets to that part of the heart. That’s why we used to refer to a heart attack as a coronary thrombosis. The longer that blood clot is present, the greater the amount of injury to the heart.

What Method is the Best Treatment for Heart Attacks?
In 1979, I was assigned to the Intensive Care Unit during the first month of my medical internship. One of my distinct memories is taking care of a patient who came in with a major heart attack (MI for Myocardial Infarction). His heart attack involved the front of the heart where there is a major amount of heart muscle. Most likely, the artery feeding the front of his heart was blocked with blood clot—the coronary thrombosis. I didn’t have much to offer for treatment that was really going to help him. I gave him pain killers and some nitroglycerin paste. I stayed at his bedside as he became more comfortable but I knew the outcome was not going to be good—either sustaining major heart damage or not making it at all.

Today, we have clot busters called thrombolytics to dissolve the blood clot in the artery. These clotbusters have come a long way. Originally, they had to be injected directly into the artery but later they could be given intravenously so they could be given much more quickly. Then, angioplasty and stents became available, and the debate began as to which method—clotbusters or angioplasty and stents—would be the best treatment for heart attacks. Of course, most hospitals have thrombolytics or clotbusters available but not every hospital has a catheterization lab for angioplasty or stents. Early on, angioplasty and clotbusters were running neck and neck in terms of success. Giving clotbusters could be done so quickly versus the time and manpower it would take to get a patient to the cardiac cath lab for treatment.

Current Research Sheds New Light
A recent Danish study compared angioplasty to thrombolytic (clotbuster) treatment for heart attacks even if patients had to be transferred to get this done. Angioplasty was a superior treatment whether it was done on site or if the patient had to be transferred as long as the transfer took two hours or less. Cardiology organizations and community hospitals are now, more than ever, grappling with the question of whether they should have the capability to perform angioplasty on site for heart attack treatment. Keep in mind that clotbuster treatment is still very good in many circumstances.

What Should You Do If You Think You Are Having A Heart Attack?
First and foremost go to the nearest emergency room as quickly as possible. As soon as you are there, a diagnosis can be made and treatment options discussed. Remember, the sooner treatment can be started, the better the outcome. There are so many treatment options available to you now compared with just a short time ago. Please let us do the best that we possibly can for you.