A Heart-to-heart With Dr. Spies
Interviewed by Melissa Moniz
Wednesday - January 27, 2010
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Dr. Christian Spies
Can you discuss the prevention of heart attacks and how that’s improved?
You can prevent heart attacks via two major pathways. One is lifestyle modifications, which include a healthy diet low in cholesterol and saturated fat, limited red meat, nothing deep-fried, weight loss if someone is overweight and regular exercise. The general recommendation is 30-60 minutes of aerobic exercises five times a week, and, of course, quitting smoking is of paramount importance. This is where I have seen the most improvement over the last 10 years, as people smoke less. Some studies have shown that banning public smoking has had an impact on overall mortality of the population. So we are certain that the reduction of primary and secondhand smoke cut down on the chances of suffering a heart attack.
The second pathway to prevent heart attacks, complementary to lifestyle modifications, basically is medications. These include drugs that make the blood somewhat thinner such as aspirin, and medications that lower cholesterol such as statins. In particular, those two groups of medications - aspirin and statins - have been shown to prevent heart attacks very effectively.
Once you have a heart attack, does that put you at higher risk to have another one?
Yes, the odds are much higher than if you never had one in the first place.
Can you talk about the treatment of heart attacks and prevention of reoccurance?
The treatment of heart attacks, of course, depends on the patient. There is a whole “spectrum of heart attacks.” There are heart attacks that go almost unnoticed. In fact, it is believed that 30 percent of heart attacks don’t cause any chest pain, which would be the typical complaint of the patient who suffers a heart attack. The other end of the spectrum is sudden cardiac death. Individual presentation determines how rapidly the patient needs to be treated. The mechanism by which a heart attack causes damage to the heart is a blockage or complete occlusion of a heart artery. So there are certain heart attacks, so-called ST-elevation myocardial infarctions, where we aim to open the heart artery by means of angioplasty, catheter-based techniques, where we put small balloons and metal meshes called stents into the heart artery within 90 minutes from the time the patient comes to the emergency room. With other heart attacks, so called nonST-elevation myocardial infarction, we usually have some time to treat patients with potent blood thinners before we do such procedures.
Aside from those treatments for the acute phase, the key thing is prevention of repeat heart attacks. We do that by using the same therapies that we recommend to prevent heart attacks, but to a more intense degree.
Can you discuss new technology and techniques available that offer patients treatment without undergoing major surgery?
What we have talked about so far is the treatment of coronary artery disease, which involves the heart arteries supplying the heart muscle with blood. There are many other problems that can happen. For example, heart valves becoming leaky or narrowed, or heart defects that people are born with, such as holes in the heart. Some of these holes can go unnoticed through all childhood and into adulthood. It is in this arena that interventional cardiology has expanded dramatically, and is referred to as interventional therapies for structural heart disease. The technology itself is not new, it actually goes back over 30 years, but it has not been introduced into routine clinical practice until recently.
If someone had a hole in their heart, such as an atrial or ventricular septal defect, one would have to undergo open-heart surgery. Nowadays we can put little plugs into those holes inside the heart, which are delivered through catheters inserted from the groin. This commonly can even be done without general anesthesia, just with use of local anesthetics.
Other areas where this technology can be applied are patients with patent foramen ovale (PFO) and stroke. A PFO is a small hole in the heart, which may increase the risk of suffering a stroke. The theory is that because of such a PFO, blood clots may travel from one side of the heart to another and then make it to the brain, causing a stroke. PFOs are very common and, for the most part, patients with a stroke and PFO may be treated with medications alone. However, in certain patients, closing those holes with a plug or small umbrella device delivered with catheters through the veins may be more effective in preventing repeat strokes.
This is just a small portion of what new technology and techniques are available. The future is even more exciting. In the very near future, we will probably be able to repair certain leaky valves with catheter techniques without any form of surgery. Also, hopefully within the next year or two in the U.S., we’ll even be able to replace narrowed heart valves with catheters without open-heart surgery. This is something that we are very much looking forward to.
I think another exciting development is that cardiology and cardiothoracic surgery are moving closer together. Traditionally, both specialists are dealing with the same heart problems, but there was little overlap between the work of a cardiologist and a cardiac surgeon. We recently started doing procedures where we actually combine surgical techniques and catheter-based techniques at The Queen’s Medical Center, called hybrid-procedures, basically fusing the expertise of two physicians into one single procedure.
How are these holes detected?
There are all different kinds of holes. Some of them create very obvious problems and some very subtle problems. The subtle problems are easy to miss until adulthood. If they are very big holes, they are usually detected early in childhood by simply listening to the baby’s heart. The pediatrician will usually notice a murmur, and that usually triggers further examination with an echocardiogram. However, there are other holes, in particular holes in the upper chamber of the heart, so-called atrial septal defects, which don’t necessarily create murmurs in childhood or adulthood. If unnoticed and over several decades of existence of these holes, the heart starts to fail, and this is when patients start to see symptoms of heart failure, such as difficulties breathing or leg swelling.
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