Peripheral Vascular Trends in Cardiology
What are the emerging trends in healthcare? Dr. Anuj Shah of Apex Heart and Vascular shares his predictions on the future of cardiology.
At the end of every year, I curate a list of the top 5 advances in vascular medicine to keep up with the rapid pace of medical science.
1. Efficacy of Rivaroxaban in Reducing Thrombotic Vascular Events in Patients Undergoing Lower Extremity Revascularization
In the VOYAGER PAD study, a double-blind trial, patients with peripheral artery disease (PAD) who underwent lower extremity revascularization were randomly assigned to receive Rivaroxaban plus aspirin or placebo. The trial concluded that rivaroxaban at a dose of 2.5 mg twice daily plus aspirin was associated with a significantly lower incidence of the composite outcome of acute limb ischemia, major amputation for vascular causes, myocardial infarction, ischemic stroke, or death from cardiovascular causes than aspirin alone. Treatment with Rivaroxaban in patients who underwent recent procedures to improve blood flow to their legs can reduce the chances of forming blood clots in the heart, brain, and legs.
2. Critical Limb Ischemia advancements with Endovascular therapy and pedal loop
Despite all the advances in medical science, early detection, and screening, critical limb ischemia (CLI) still remains the Achilles heel of peripheral arterial disease (PAD) because when people develop limb ischemia, they still have a very poor prognosis for their affected limbs and also a poor prognosis for their overall life expectancy. 25% die within 1 year and 25% lose limbs, only 50% live with 2 limbs at 1 year and out of which 30% die at 3 years. The best way to address this is by providing aggressive endovascular therapy first. Endovascular therapy has incredible new techniques including pedal access, using the pedal loop (TAMI), excellent new wires, and atherectomy devices. Now, we can open even occluded tibial and digital blood vessels and improve blood flow.
3. Intravascular Lithotripsy
Peripheral artery disease (PAD) is a circulation disorder that occurs when plaque builds up in the arteries that supply blood to the arms and legs. Treatment options include angioplasty, atherectomy, stenting, and intravascular lithotripsy (IVL), a relatively new option. IVL uses pulsatile sonic pressure waves that pass through soft tissue and selectively interact with high-density calcium, producing shear forces that fracture calcified plaque in the blood vessel, leading to the opening of a formerly narrowed blood vessel. Shockwave is creating waves in the world of vascular disease. Intravascular lithotripsy is a safe and effective method to significantly improve blood flow in heavily calcified vessels.
4. Smart Devices & Technology that Detect Disease & Diabetes early
2020 was the year of virtual visits between doctors and patients via smartphones, smart devices, and telehealth. Similarly, for people with peripheral vascular disease (PVD), especially those with diabetes, we can detect diabetic foot ulcers much earlier because of smart socks and other wearable devices for the feet that can do thermal mapping of the foot, which tells us when and where the risk is of developing future ulcers through the identification of areas of friction and hypoperfusion. This helps us detect and fix the disease early.
Not sure where to start? Here are 15 diabetes apps to manage your health.
5. COVID-19: A Vascular Disease
Initially, COVID-19 was thought of as solely a respiratory disease; however, recent research has shown that COVID-19 is associated with all three components of Virchow’s Triad, including intravascular vessel wall damage, stasis of blood flow, and the presence of a hypercoagulable state. This would account for the high rates of reported blood clots among many patients with severe COVID-19 infection, leading to an increased risk of heart attack, stroke, and pulmonary embolism. We are also seeing patients with vasculitis and arterial thrombus due to the induction of vascular inflammation. These patients who typically have high d-dimer levels are treated with anticoagulants to prevent the threat of blood clots.
Top 5 Landmark Advances in Cardiology
Latest innovations in trends in medicine
To keep up with the rapid pace of advances in cardiology, I have researched and curated a list of the top 5 advances in cardiology which are new and applicable to our day-to-day clinical encounters with patients.
1. Link between COVID-19 and Cardiovascular Disease
More than two thirds of patients who died from COVID-19 had underlying cardiovascular disease, indicating that cardiovascular disease is one of the biggest co- morbidities. Prior medical conditions such as diabetes, hypertension and having a heart attack in the past counts as a co-morbidity that increases one’s risk of mortality from COVID-19. Out of those who died from COVID-19, ten to twenty percent of these patients died from heart attack and arrhythmias. We have also seen high numbers of patients who suffered arrhythmias, myocarditis, pericarditis and pericardial effusion when infected with COVID-19. There were also reports of patients having thromboembolic events causing deep vein thrombosis and pulmonary emboli leading to right sided heart failure symptoms.
2. First Specific Treatment for Hypertrophic Cardiomyopathy
Hypertrophic cardiomyopathy (HCM) is a disease of the heart muscle where it thickens making it harder for the heart to pump blood. HCM affects approximately 1 in 500 people. The Explorer-HCM trial was the trial to test a new drug called Mavacamten, which is a first-in-class cardiac myosin inhibitor that directly targets the underlying cause of HCM and restores the heart’s normal function. Prior to this new medication, HCM was treated with beta-blockers which only treated the symptoms and not the underlying cause of the disease. The results of this new trial can change the paradigm of HCM and may reduce morbidity.
3. Transcatheter Aortic-Valve Replacement (TAVR) in Low-Risk Patients
TAVR is a minimally invasive alternative to open-heart surgical valve replacement (SAVR) for patients with severe aortic stenosis (AS). Severe AS occurs when the aortic valve becomes diseased (stenotic) and if left untreated can lead to death from heart failure in roughly two years. TAVR has historically been reserved for patients at increased risk for complications or death from surgery. The FDA recently approved the use of TAVR for low-risk patients and randomized trials have concluded that TAVR in low-risk patients was non-inferior to SAVR with respect to death from any cause or disabling stroke at twenty-four months (New England Journal of Medicine).
4. Diabetes Treatment
Sodium-glucose co-transporter-2 (SGLT2) inhibitors are a relatively new group of medication that is used to treat people with type 2 diabetes. They not only work by helping the kidneys to lower blood sugar levels, but they also provide incredible benefits for people with congestive heart failure and other cardiovascular diseases. Studies have shown that treatment with SGLT2 inhibitors are associated with a reduction in the incidence of major adverse cardiovascular events.
5. Percutaneous Mechanical Circulation Support Devices
Impella is used in patients with severe coronary artery disease who require angioplasty or stent placement, but are at high risk for adverse cardiac events, such as advanced heart failure, and cardiogenic shock. Impella systems include Impella 2.5, Impella CP, Impella CP with SmartAssist, Impella 5.0, and Impella 5.5 with SmartAssist, which are temporary ventricular support devices that prevent hemodynamic instability during angioplasty or stent placement, or for ongoing cardiogenic shock following acute myocardial infarction or open-heart surgery. Extracorporeal membrane oxygenation (ECMO) which is usually used for patients with life-threatening heart conditions is now being used for COVID-19 patients with severe respiratory distress. This machine can successfully stabilize patients so that they can recover from the viral illness.
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ABOUT THE AUTHOR
Anuj Shah, MD, FACC, FSCAI
Director Of Apex Heart & Vascular Care. Board Certified in Interventional Cardiology, General Cardiology, Internal Medicine (ABIM). Board Certified Echocardiography (ASE), Nuclear Cardiology (CBNC), Coronary, CT Angiography and vascular ultrasound (RPVI) Assistant Professor of Medicine, Mount Sinai Medical Center, New York, NY, Attending consultant – Hackensack, University Medical Center, St Mary’s Medical Center, Christ Hospital