Category Archives: Heart Valves and Murmurs

My Top Four Practice-Changing Presentations From the ACC 2019 Meeting: From Alcohol To Aspirin

The ACC meetings in New Orleans have wrapped up and I must stop letting the good times roll.

In the areas I paid attention to I found these four presentations the most important:

1. After the historic back to back presentations of the Partner 3 and Evolut trials it is clear that catheter-based aortic valve replacement (TAVR) should be the preferred approach to most patients with severe symptomatic aortic stenosis.

Both TAVR valves (the baloon-expanded Edwards and the self-expanding Medtronic) proved superior to surgical AVR in terms of one year clinical outcomes.

2. The Alcohol-AF Trial. It is well known that binge alcohol consumption (holiday heart) can trigger atrial fibrillation (AF) and that observational studies show a higher incident of AF with higher amounts of alcohol consumption.

This trial was the first ever randomized controlled trial of alcohol abstinence in moderate drinkers with paroxysmal AF (minimum 2 episodes in the last 6 months) or persistent AF requiring cardioversion.

Participants consumed >/= 10 standard drinks per week and were randomized to abstinence or usual consumption.

They underwent comprehensive rhythm monitoring with implantable loop recorders or existing pacemakers and twice daily AliveCor monitoring for 6 months.

Abstinence prolonged AF-free survival by 37% (118 vs 86 days) and lowered the AF burden from 8.2% to 5.6%

AF related hospitalizations occurred in 9% of abstinence patients versus 20% of controls

Those in the abstinence arm also experienced improved symptom severity, weight loss and BP control.

This trial gives me precise numbers to present to my AF patients to show them how important eliminating alcohol consumption is if they want to have less AF episodes.

It further emphasizes the point that lifestyle changes (including weight loss, exercise and stress-reduction) can dramatically reduce the incidence of atrial fibrillation.

3. AUGUSTUS. This trial looked at two hugely important questions in patients who have both AF and recent acute coronary syndrome or PCI/stent. The trial was simultaneously published in the New England Journal of Medicine. The questions were:

Apixaban (Eliquis, one of the four newer oral anticoagulants (NOAC)) versus warfarin for patients with AF: which is safer for prevention of stroke related to AF?

Triple therapy with  low dose aspirin and clopidogrel plus warfarin/NOAC versus clopidogrel plus warfarin/NOAC: which is safer in preventing stent thrombosis without causing excess bleeding in patients with AF and recent stent?

Briefly, they found:

The NOAC apixaban patients compared to warfarin had a 31% reduction in bleeding and hospitalization. No difference in ischemic events.

Adding aspirin  increased bleeding by 89%. There was no difference in  ischemic events. (Major or clinically relevant nonmajor bleeding was noted in 10.5% of the patients receiving apixaban, as compared with 14.7% of those receiving a vitamin K antagonist (hazard ratio, 0.69; 95% confidence interval [CI], 0.58 to 0.81; P<0.001 for both noninferiority and superiority), and in 16.1% of the patients receiving aspirin, as compared with 9.0% of those receiving placebo (hazard ratio, 1.89; 95% CI, 1.59 to 2.24; P<0.001).)

This means that the dreaded “triple therapy”  after PCI in patients with AF with its huge bleeding risks no longer is needed.

It also further emphasizes that NOACs should be preferred over warfarin in most patients with AF.

The combination of choice now should be a NOAC like apixaban plus clopidogrel.

4. REDUCE-IT provided further evidence that icosapent ethyl (Vascepa) significantly reduces major cardiovascular events in patients with establshed CV disease on maximally tolerated statin therapy.

The results of the pirmary end point from the REDUCE-IT were presented at the AHA meeting last year and they were very persuasive. At the ACC, Deepak Bhatt presented data on reduction of total ischemic events from the study and they were equally impressive. Adding the pharmaceutical grade esterified form of EPA at 2 grams BID reduced first, second, third and fourth ischemic events in this high risk population.

The benefit was noted on all terciles of baseline triglyceride levels. Thus, the lowest tercile of 81 to 190 mg/dl benefitted as well as the highest tercile (250 to 1401).

Although I dread the costs, it’s time to start discussing adding Vascepa on to statin therapy in high risk ASCVD patients who have trigs>100 .

As I wrote previously I didn’t learn anything from the much ballyhooed and highly anticipated Apple Heart Study . It’s entirely possible more participants were harmed than helped by this study.

Philomathically Yours,

-ACP

In Historic Moment, Transcatheter Aortic Valve Replacement Proven Superior to Surgical AVR

Three years ago after hearing two amazing presentations at the ACC meeting the skeptical cardiologist opined:

These studies suggest to me for the first time that TAVR may ultimately replace SAVR for all patients with severe aortic stenosis, low to high in their risk for surgery.

Clearly, we need ongoing follow up of these patients and more long term data, but as these devices improve and the operators gain more experience it is likely that results will only get better.

This represents a huge paradigm shift in our approach to valvular heart disease.

This morning I watched two more amazing study presentations at the ACC meeting in New Orleans which unequivocally establish the minimally invasive TAVR procedure (which my cardiology colleagues perform here at St. Luke’s) as the treatment of choice for patients who have symptoms related to severe narrowing of their aortic valve (aortic stenosis).

I just published a piece on the presentations for the physician social media site, SERMO which follows:

Since 2015 it’s been clear to me that catheter-based procedures (TAVR) were a better option than open-heart surgical aortic valve replacement for most of my patients with severe symptomatic aortic stenosis who were at high (>8% STS )  and intermediate (>4% STS) risk for surgery.  

Based on continued durability of TAVR results and outstanding results in my own institution, I’ve been advising my low risk patients with severe aortic stenosis that it was only a matter of time before TAVR would become the best option for them.

At the American College of Cardiology Meetings in New Orleans this morning two back to back presentations have confirmed that TAVR should be considered the treatment of choice rather than surgical aortic valve replacement ( SAVR) for most low risk patients with severe symptomatic AS.

This is such a dramatic paradigm shift in the treatment of AS that the Eugene Braunwald (now 90 years old) the first discussant of the presentations after reviewing the history of the treatment of AS, described it as an “historic moment” , one that we will tell our grandchildren that we were present at.

Furthermore, in a display I’ve never seen at an ACC session, the audience spontaneously stood and gave the presenters a standing ovation. 

Both studies were published yesterday in the NEJM (something the presenters indicated was an error) and disappointingly I read the results described in a New York Times article prior to watching the live presentation.

The first presentation was from Martin Leon on the Partner 3 trial which utilizes the Edwards Sapien 3, third generation baloon-expandable valve. The study randomized 1,000 patients to either TAVR  or standard SAVR with a bioprosthetic valve. The primary endpoint was the composite of death from any cause, stroke or re-hospitalization at one year after the procedure. At one year, the primary endpoint occurred in 8.5 percent of the TAVR group compared with 15.1 percent of the surgery group, meeting the requirements for both noninferiority (p<0.001) and superiority of TAVR vs. surgery (p<0.001).

The Kaplan-Meir analysis of the primary endpoint components with TAVR vs. surgery found mortality rates of 1.0 percent vs. 2.5 percent, stroke rates of 1.2 percent vs. 3.1 percent, and rehospitalization rates of 7.3 percent vs. 11.0 percent, respectively. The length of hospital stay was reduced from seven to three days with TAVR.

A cardiac surgeon, Michael Reardon (who I described as cocky and folksy in my 2015 post on TAVR), presented the results of the  EVOLUT  trial which randomized 1,468 patients to TAVR with a self-expanding bioprosthesis compared with surgical replacement. The primary endpoint was the composite of death from any cause or disabling stroke at 24 months. At 24 months, death or disabling stroke occurred in 5.3 percent of the TAVR group compared with 6.7 percent of the surgery group,

At 30 days, TAVR was statistically superior to surgery for the secondary combined endpoint of all-cause mortality or disabling stroke (0.8 vs. 2.6 percent). Patients receiving TAVR had significantly better quality of life and hemodynamics at 30 days.

I concur that these studies represent tremendous data that will drive a paradigm shift in the treatment of AS and anticipate that we will rapidly receive approval to use these two TAVR devices in all patients who meet the entry criteria (note that bicuspid AV was an exclusion but a subsequent presentation at ACC19 suggests that outcomes are similar in bicuspid valve patients to tricuspid valve patients).

Transfemorally Yours,

-ACP

My Dad’s Heart Murmur and The Botched Echocardiogram

My dad was recently told he had a heart murmur by his internist. An echocardiogram (ultrasound of the heart) was ordered.

A heart murmur is basically any unusual sound that the doctor hears when he/she places a stethoscope on the anterior chest  in the vicinity of the heart.  Blood flows across various valves as it makes its way through the cardiac chambers. If the valves are functioning normally we usually can’t hear anything because the blood velocity is low and the flow is not disordered.

The majority of murmurs that are detected are due to either:

(1) narrowing (stenosis) of a valve that results in an acceleration of blood velocity.

(2) failure of a valve to close properly (insufficiency or regurgitation) and prevent back flow.

Cardiologists have developed an absolutely awesome tool for  both visualizing the valves anatomical structure and movement, and precisely measuring the flow of blood through the heart.

The full name of this awesome tool is Doppler-echocardiography. The echocardiogram constructs a moving two-dimensional (more recently three-dimensional) “movie” from analyzing the time and intensity of sound waves reflected off the various valves, walls and structures within the heart.

The Doppler principle is utilized to precisely measure the location and velocity of blood flowing through the heart from high frequency sound waves reflected off red blood cells.

I call this test an echo or TTE (Transthoracic Echocardiogram)

The Importance of Being Expert in Echo Performance and Interpretation

I considered asking him to have the echocardiogram done at my hospital here in St. Louis. I’m the medical director of the laboratory and spend a lot of time making sure that we get high quality echocardiograms and that they are interpreted correctly.

When an echocardiogram is done elsewhere, I have no guarantees that it has been performed and/or interpreted properly.

One would hope that a TTE done in a doctor’s office in Tulsa, Oklahoma and one done in a hospital outpatient facility in St. Louis on the same patient would yield identical results on key findings, but this is often not the case.

On a regular basis, I see serious and highly significant errors made in the findings of TTEs performed elsewhere on patients that come to me for a second opinion or due to moving from another city.

Causes of Errors in Echos

The heart alone, among the body’s organs, is constantly moving. This means that standard ultrasound and x-ray techniques, which work great for static body parts, are useless. The techniques in a modern TTE that have evolved to fully evaluate all of the heart’s highly dynamic functions are complicated and require state-of-the art ultrasound equipment, as well as a sonographer who has been fully and expertly trained in using such equipment.

Such sonographers typically go through a two year program that is specific for cardiac ultrasound. To verify their knowledge and skills, they have a certification from either RDMS or CCT.

Will a competent, registered sonographer perform my dad’s exam? He and I have no way of knowing short of calling up the lab and asking very specific questions.

There is no government or insurance company mandate that a TTE be performed by a qualified, competent sonographer!

This, alone, is quite shocking, but it gets worse.

Who will read my dad’s TTE? Will it be read by a cardiologist trained like me who has gone through an additional year of cardiology training specifically in echocardiography, and who has reached what is termed Level III training?

Does that reading doctor have, like I do, verification of the acquisition and maintenance of the incredibly complicated knowledge base for echocardiography by taking and passing the National board of Echocardiography examinations?

Is he/she keeping up to date on new techniques and scientific findings in the field by attending regular CME sessions?

Does he/she regularly try to correlate the findings from the TTEs he/she reads with findings from other imaging techniques and surgical pathology?

Chances are the answers to all of the above questions will be no.

There is currently no country-wide government or insurance company mandate requiring the reader of a TTE to be competent to get reimbursed!

Thus, we have no guarantees that the TTE on my dad will be competently performed and interpreted.

This sad situation is the cause of the serious and significant errors in TTE results that I regularly encounter.

Dr. Kiran Sagar presented findings confirming this at the 2010 scientific meeting of the American Society of Echocardiography. According to news reports, she was fired shortly afterwards.

The study reported at the ASE meeting involved a review of 235 echocardiograms done at St. Luke’s hospital in Milwaukee, WI (not related at all to my St. Lukes hospital in Chesterfield, MO) from August 2007 to October 2008:

“Of the 35 physicians who performed clinical readings of the echocardiograms reviewed in the study, only three were Level 3 specialists within cardiology.
Sagar’s analysis revealed that 68 of the 235 imaging studies, or 29 percent, were misread.
In at least five of those cases, patients actually went into the operating room with a faulty diagnosis, although the problem was discovered before surgery was done.
In addition, 18 patients were subjected to more invasive echocardiography in which a probe was inserted down the throat and 19 underwent invasive coronary angiography. The misreadings also resulted in increased healthcare costs for the patients”

How Can You Be Sure Your Echo Is Competently Recorded And Interpreted.

I have no good answer to this question.

The only organization that provides any method for evaluation of individual echo labs is the Intersocietal Accreditation Commission. According to the IAC website “The purpose of the IAC Echocardiography accreditation program is “to ensure high quality patient care and to promote health care by providing a mechanism to encourage and recognize the provision of quality echocardiographic diagnostic evaluations by a process of accreditation.””

Echo labs that are accredited by IAC go through a process every three years that insures that they are following the IAC guidelines on acquisition and reporting. This means that the report from an IAC accredited echo lab will comment on all the structures of the heart that should be commented on and will report out basic, rudimentary measurements.

The IAC requires that the medical director of the echo lab have advanced training in echocardiography, but does not require the sonographers who perform the exams to be accredited.

There is no IAC requirement for significant evidence of competence or adequate training for the physicians who read echocardiograms. I quote from their documentation which states that a physician qualifies as a reader:

“if echocardiography training was completed prior to 1998 – three years of echocardiography practice experience and interpretation of at least 1200 echocardiogram/Doppler examinations…”

This type of physician reader does not have to document any significant training or competence, just that he/she has been reading echos for a while and has reached a certain volume.

My Dad’s Echo

We decided to let my dad get his echo done at the facility his primary care physician utilized. It was done at one of the largest hospitals in Tulsa, Oklahoma and I had him obtain both the report and the actual echo recordings for me to review.

The results were quite disappointing as several key elements of the exam were misinterpreted.

As I feared, my dad’s echo was botched.

What Americans Should Demand For Quality and Consistency in Echos

The payers in healthcare should mandate the following if an echo is to be reimbursed:

  • It is performed in an IAC accredited echo laboratory
  • It is performed by a registered sonographer
  • It is interpreted by a cardiologist with advanced training and competence in echocardiography (how advanced and how that is measured or certified can be debated)

Until this kind of quality assurance is tied to reimbursement, it won’t happen voluntarily.

You, as the consumer, have to make sure you are getting the best quality echocardiogram you can.
Ask questions about the lab, the sonographer and the reader who will be doing your exam.
A faulty interpretation of your echocardiogram could result in unnecessary and dangerous testing and surgery.
Failure to identify significant cardiac pathology could delay appropriate treatment.
HAPPY FATHER’S DAY!
To my dad, and all you other dads.
May your hearts keep pumping efficiently and may all your tests be interpreted correctly.
-ACP