Improving Heart Health - Part II
(Technology – the dominant player in future)
Technology in all forms – digital, catheter based and imaging – will play a big role in the management of heart disease in future. The joint multimodality imaging symposia was designed to give the audience some directions as to the optimal usage of the current imaging modalities – echocardiography, computed tomography (CT), fluoroscopy, nuclear imaging, cardiovascular (CV) magnetic resonance imaging (MRI), etc., in a given clinical scenario. In addition, innovative technologies such as smart phones with new apps, cloud computing and other digital strategies will put knowledge sharing and information gathering at our fingertips. “The use of mobile and digital tools in cardiology will only increase in future, so we need to mentor the next generation of physician leaders to function well in the digital era,” said Dr. John Gordon Harold, incoming president of American College of Cardiology.
Readmission in 30 days
Medicare is cracking down on readmissions after the initial hospitalization since this is expensive and often associated with poor long-term outcome. Currently, one in five Medicare patients is readmitted within 30 days after discharge. A special session explored the barriers and solutions to reduce readmission rate. Frequent readmissions for patients with heart failure, acute heart attacks and pneumonia are under close scrutiny. Innovative solutions such as routine monitoring and follow-up after discharge with the help of a ‘Grand-Aide’ (specially trained certified nurse aide) who will act as the physician extender to monitor and manage the patient while recovering at home are being considered.
Industry expert theater presentations were a new feature this time. The attendee was treated to a breakfast or lunch while listening to a core curriculum presentation on a clinically relevant current topic during these sessions. The small theater in the exhibit hall was always full whenever I attended a program.
ACC 13 Expo, as expected, featured the latest in CV products and services under one roof and included the newest drugs and devices for the heart, imaging technology and health Information Technology services. One product that received considerable attention was the new anticoagulant ‘Rivaroxiban’ (Xarelto). This drug is used for the treatment of clots in the legs or lungs, to reduce the risk of stroke and blood clots in people with atrial fibrillation and, for prevention of post operative deep vein thrombosis in the legs especially after orthopedic surgery. The main advantage of Xarelto is that the patient doesn’t need the monthly INR test for routine monitoring as in Warfarin.
Results of several late-breaking clinical trials were presented. The STREAM trial found that instituting the clot dissolving strategy during the first hour of a heart attack, called ‘thrombolysis,’ in patients who cannot for one reason or other undergo primary coronary intervention (PCI), is quite beneficial. PARTNER 2 trial found encouraging results with the new SAPIEN XT artificial valve system for Transcatheter Aortic Valve Replacement (TAVR). Indeed, one of the hottest topics of discussion was the emergence of ‘TAVR’ as the main approach for patients suffering from this disease. Isn’t it incredible that we can insert a prosthetic aortic valve into the heart without opening the chest! Already in use for five years in Europe, TAVR is becoming more popular in USA.
PREVAIL trial showed that, the small pouch in the left atrium, often the commonest site for clot formation leading to stroke in patients with Atrial Fibrillation can, be closed percutaneously with a special ‘Watchman device.’ This would obviate the necessity for long term anticoagulant therapy. Preliminary results are encouraging
“One of the prime focuses for ACC this year and in the coming years,” said Dr. William Zoghbi, is patient-centered care improving the quality of health care. The college is developing a patient – focused culture trying to educate and engage patients. A new CardioSmart.org website, mobile apps and text messaging services are being developed to encourage patients to adopt a healthy behavior – such as eating right, quitting smoking and doing more exercise, etc. Communicating with patients in an appropriate fashion will be important in the days to come, especially with all the health care changes happening in the country.
Advances in heart diseases are happening at a dizzying rate and that is good news for all cardiac patients.
This concludes the mini series on ACC 13 Annual Scientific Sessions.
GUEST COLUMN
Radial Keratotomy: Slice AND Shape to VISION!
Many of you have inquired of me regarding Radial Keratotomy. So, I shall devote this month’s column to what I recently taught at the National Conference for Eye Surgeons held in California as a pending refractive “epidemic.”
By naming it so, I have alerted eye surgeons to the fact that thousands of patients who have had Radial Keratotomy (RK) in the 1980s are now seeing their vision deteriorate either from a progressive farsightedness over time or associated aging situations such as cataracts.
Patients with previous RK are presenting with a challenging situation in eye surgery not only because of surgical complexity but also due to patient expectations as people who had these surgeries are typically “early adapters.” Fortunately, with technology today, these patients can once again see without glasses.
Radial keratotomy (RK) is a type of eye surgery used to correct Myopia (nearsightedness). It works by changing the shape of the cornea (flattens the shape) – the transparent part of the eye that covers the iris and the pupil (Refer to Khaasbaat article: Lasik).
History of RK dates back to 1936 when Japanese ophthalmologist Tsutomu Sato applied sharp slits in the cornea. In 1974, Svyatoslav Fyodorov in Russia removed glass from the eye of a boy who had been in an accident and shattered his glasses. When Dr. Fyodorov performed an operation resulting in numerous radial incisions like the spokes of a wheel on the cornea, the boy’s vision had improved and he did not need glasses anymore. A diamond knife was invented to replicate this technique successfully and many American eye surgeons journeyed to Moscow to learn this surgery and later modified it to a safer and more accurate procedure introducing it in the USA in 1978.
RK successfully treated people with low to moderate myopia and could also be paired with specific incisions to correct astigmatism.
With the advent of Lasik in 1995, RK was slowly relegated to history simply because Lasik is generally safer, predictable and accurate since it involved the micron-precision Excimer Laser rather than handheld blades as in RK.
A 10-year study shows that RK patients who were nearsighted (with steep corneas) before RK surgery, over time undergo continued flattening of their corneas so they become farsighted. Since this happens when most of them have become farsighted with age for reading (refer to Khaasbaat article: Presbyopia), it is a double whammy. These patients can be corrected with advanced Lasik techniques today.
In some patients, despite a well-done RK surgery, normal aging and cataracts affect vision and today, even these patients can be helped with laser cataract techniques and new-generation lens implants.
Additionally, new technology that firms up the cornea (Collagen Cross Linking) and prevents it from further flattening can be used in conjunction with Lasik or cataract surgery.
Thus, patients who have had RK surgery and enjoyed their vision freedom need not despair. Ask your eye doctor for your options and get back to the glasses-free lifestyle you once enjoyed. Once again!
Arun C. Gulani, M.D., M.S., is director and chief surgeon of Gulani Vision Institute in Jacksonville. He can be reached at [email protected] or visit www.gulanivision.com