Drugs and Devices for Women with Heart Disease Sharonne N. Hayes MD, FACC Director, Women s Heart Clinic Mayo Clinic Rochester, MN CP986192-1 CP1045209-2 Goals of Medical Treatments for Heart Disease Make you feel better Make you live longer Medical Management of Angina / Chest Pain Treatment Aims Preferably both!! Drug & Surgical Therapies Can Improve Clinical Outcome by As Much As 50%-80%. Relieve Symptoms Prevent Heart Attacks Medical Management of Angina Relieve Symptoms Medications Percutaneous Interventions Angioplasty Stents, etc Bypass Surgery EECP Prevent Heart Attacks Antiplatelets Statins ACE inhibitors Beta blockers Risk factor modification Bypass Surgery Myocardial Oxygen Supply and Demand Increase Blood Flow = Limit O2 Use 1
Myocardial O 2 Supply:Demand Balance Drugs that treat Angina typically either demand supply Increase supply Reduce demand Drugs that treat Angina typically either Drugs that treat Angina typically either Dilating (opening up) the arteries Reducing heart rate Reducing the force of contraction Decreasing afterload Increase supply Reduce demand Antianginal Treatment Oxygen demand Beta Blockers Ca ++ Channel blockers Nitrates ACE inhibitors Supply Ca ++ Channel blockers Nitrates PTCA/Stenting Bypass Surgery Nitroglycerin: isosorbide, Nitrostat etc Beta Blockers: metoprolol, atenolol, carvedilol Common Drug Treatments for Heart Disease Dilates the coronary arteries and veins allowing blood to flow to the heart muscle Reduces the workload of the heart. Slows the heartbeat. Decreases blood pressure. 2
Common Drug Treatments for Heart Disease Ranolazine: a new anti-anginal Calcium channel blockers: diltiazem, amlodipine ACE Inhibitors and angiotensin receptor blockers (ARB s) Relax arteries, improve blood supply and reduce workload. Decrease: blood pressure, heart rate (some), Afterload reducers - lowers blood pressure: Reduces heart work LV Diastolic Tension Ischemia Ca 2+ i Overload Ju YK, et al. J Physiol. 1996. Murphy E, et al. Circ Res. 1991. Jansen MA, et al. Circulation. 2004. Ranolazine (Ranexa) Na + i Surgical Treatments for Heart Disease Artery Coronary Artery Bypass Surgery (CABG) Stent and/or Balloon Angioplasty Enhanced External Counter Pulsation-EECP The Scrubb The interventional cardiologist The patient lies here 3
Anti-Platelet Drugs Aspirin, Plavix - Lowers heart attack risk by thinning blood and reducing risk of clots CP1044045-8 I m catering to the age-35-andup market. Statins: Reduce production of cholesterol Improve endothelial function Reduces heart attack and death CP1044081-2 What is Congestive Heart Failure? A bad name for a treatable condition Not always congestive Associated with poor pumping function of the heart Is NOT a heart attack Does NOT mean your heart has stopped What is Heart Failure? Weak heart muscle Enlarged heart Stiff heart Leads to fluid back upshortness of breath (fluid in the lungs) edema (swelling) ascites (fluid accumulation abdomen) 4
Goals of Therapy Standard Heart Failure Drugs *Relieve Symptoms Prolong Life *Improve Quality of Life Slow progression Reverse process ACE Inhibitors (or ARB s) Beta Blockers Spironolactone Digoxin Diuretics A walking pharmacy IMPROVE SURVIVAL Reduce Hospitalization Heart Failure Do s Don t stop meds just due to low Blood Pressure Avoid Salt Substitutes (potassium) Avoid Alcohol Fluid Restriction Daily Weights If Wt up 3-5 lb, contact care provider or adjust diuretics September 22, 2010 on NEJM.org 2002 1995 2011? CP879869- CP1074317-2 29 5
Study Devices Aortic mitral fibrosa Anterior lateral Anterior commissure leaflet A1 Posterior medial commissure P1 A2 A3 P2 P3 Normal Posterior leaflet Flail posterior leaflet Edwards-SAPIEN THV Retroflex 1 23mm and 26mm valve sizes 22F and 24F sheath sizes Resection of flail segment Repaired mitral valve CP1023486-1 Implantable Devices Pacemakers Biventricular Pacemakers (BiV) Resynchronization Therapy Implantable Cardioverter Defibrillators CP879869-34 A Brief History of Pacemakers The Pulse Generator: Contains a battery that provides the energy for sending electrical impulses to the heart Houses the circuitry that controls pacemaker operations Circuitry Battery 6
Leads Are Insulated Wires That: Deliver electrical impulses from the pulse generator to the heart Sense cardiac depolarization Lead Pacemaker Myths Cardiac Electrical System No more drugs! A pacemaker will fix heart palpitations, skipped beats, VT, SVT TRUTH- Pacemakers prevent slow heart rates (bradycardia) and treat heart block drugs treat fast heart rates CP879869-40 You May Need a Pacemaker if: Your heart rate is too slow You have certain types of heart block Drugs that you need to take slow the heart too much After AV node ablation Heart Failure- Resynchronization (Biventricular, Bi-V) Rate Responsive Pacing Adjusting Heart Rate to Activity Daily Activities Rate Responsive Pacing Normal Heart Rate Fixed-Rate Pacing 7
Cardiac Resynchronization (BiV, Biventricular pacing) Cardiac Resynchronization Over a third of moderate to severe heart failure patients have ventricular dysynchrony Associated with Limited exercise tolerance Impaired quality of life and functional capacity Poor left ventricular systolic function Aaronson KD, et al. Circulation 1997; 95:2660-2667. Zardini M, et al. Eur Heart J 2000; 2(Suppl J): J16-J22 CP879869-44 Sudden Cardiac Death vs. Heart Attack Cardiac arrest, sudden cardiac death (SCD) - a severe heart rhythm disturbance (ELECTRICAL) Heart attack - partial or complete vessel blockage, heart muscle dies (PLUMBING) Cardiac arrest is NOT a heart attack, but a prior heart attack can put someone at risk for SCD. Implantable Cardioverter Defibrillators CP879869-46 Monitored Cardiac Arrest Rhythm Strip ~ SCD Episode ICD Therapies 6:02 AM 6:05 AM 6:07 AM Source: After Josephson, ME Defibrillation termination of an arrhythmia by delivery of an electrical shock (non-synchronized) Cardioversion termination of an arrhythmia by delivery of a synchronized electrical shock 6:11 AM 8
19-year-old female (now 21) Onset 19-year-old female (now 21) Therapy CP985319-52 CP985319-53 SCD VTRescue -- Defibrillation-- ~ Defibrillation Pacing CP879869-52 What Does It Mean? AICD - Automatic Implantable Cardioverter Defibrillator PCD - Pacemaker/Cardioverter Defibrillator ICD - Implantable Cardioverter Defibrillator BiV Biventricular (leads in left and right ventricles-resynchronization) Think About an ICD if: A prior cardiac arrest Ventricular tachycardia (VT) Ventricular fibrillation (VF) Ejection fraction less than 30 to 35 % High risk for sudden cardiac death (SCD) because of an inherited heart abnormality (Long QT) Atrial Fibrillation 9
Pacemaker Myths You ll have to give away your microwave and cell phone TRUTH- Only strong or very close magnetic fields affect pacemakers- but no more MRI s (for now) MRI safe pacemakers coming soon Electronic Equipment and PPM / ICDs Anti-theft devices Cell phones Magnet therapy Medical tests Household appliances Electromagnetic Interference Implications for PPMs / ICDs Other Potential Sources of EMI May cause oversensing that inhibits (temporarily stops) pacing May be interpreted as VT/VF and deliver an inappropriate shock to the patient Arc Welding Large electrical generators Chain saws Running car motor Power tools Ventricular Assist Devices LVAD, RVAD Bridge to transplant Destination therapy 10
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