The end of the 2011 American Heart Association meeting. It is good to think where we are. I think this has been a most interesting meeting. Heart medicine is moving into several new areas of treatment. My personal view is that Cardiac Surgery and Angioplasty are now mature techniques. Further improvements are likely to be marginal. We know that the ideal way to treat most heart attacks is to
open the blocked artery with a balloon as quickly as possible. For some cases changing the way we use blood thinners at the time of the procedure can increase the chances of success.

What is really exciting to me as a practicing cardiologist is that we are seeing the application of science to treat conditions for which we now have few options. We know that developments in the medical treatment of heart disease slow but do not stop its progress.

At this meeting it was clearly shown that statin drugs Atorvastatin and Resuvastatin used to lower cholesterol levels in the blood actually cause improvement in the
narrowings in the heart arteries which lead to angina and heart attacks. We now have evidence of benefit for the use of some additional drugs at an earlier stage of heart failure.

We heard of the development of Transcather Aortic Valve implantation - sometimes called TAVI. In this technique a new aortic valve is inserted into a patient through an artery - usually one at the top of the leg. This was first tried with very encouraging results in patients who were felt to be inoperable using conventional open heart surgery. More recently studies were done in patients who were considered operable but at high risk. The study showed better outcomes in this group. Over the coming years. I think research will tell us if this can be extended further into lower risk patients.

Less invasive surgery using a clip to repair leaky mitral valves was also discussed. It seems to me that there is still much work to be done to perfect this technique although there have been some positive results.

We had a lot of discussion of the use of a new generation of blood thinners taken by mouth and not needing regular blood tests to monitor their effect.
These are now licenced for use in the USA and Europe - and one, dabigatran, is currently being assessed by NICE in the UK. I suspect we are
going to see them very widely used in the next few years.


I think the most interesting work was the description of the first study of human stem cells to repair damaged heart muscle. This was an idea which seemed most improbable even 30 years ago. Now we are at the beginning of the actual use in man. I am sure we are going to hear a lot more about this in the next few years.

The other area that holds out much promise is the recognition that we do not yet understand all the factors which make us prone to heart disease.

Diabetes, raised cholesterol and raised blood pressure have all been known for some time. We know that there is no single gene that causes
heart disease but are beginning to understand that a number of genes are involved. Work is going on to measure the levels of some relatively simple
molecules in the blood which may act as additional "markers" of our risk of developing various diseases - so we may be able to treat earlier to
prevent or at least delay their onset.

This morning along with several hundred others, I had the privilege of attending a masterclass in cardiology. Over the space of three hours we were treated to the presentation of ground breaking research in heart medicine. In this blog I will highlight some of these and give you some of my initial thoughts.

 

Dabigatran - A new blood thinner - An alternative to Warfarin

There are several new drugs that are being developed to provide an easier, safer alternative to current treatment. Warfarin is used to reduce the risk of stroke in patients with a common heart rhythm disturbance - atrial fibrillation. In atrial fibrillation clots of blood can form inside the heart. Bits of clot can fly off and move via the arteries into the brain. There these block off the blood supply to the brain causing a stroke. At present we use a blood thinner - Warfarin to stop the clots developing. Dabigatran is a new blood thinner. Unlike Warfarin, Dabigatran does not require frequent blood tests to control the dose. It has, however, been shown to be at least as effective as Warfarin. At the same time it seems to cause less abnormal bleeding - particularly into the brain. Dabigatran has been licenced for use in the UK and USA.

A new way of replacing worn out Heart Valves without Open Heart Surgery

As people age the Aortic Valve which controls the supply of blood from the heart to the body may narrow and become inefficient. For many years the standard treatment has been surgical replacement of the warn out valve. In the last few years we have been developing a technique replacement of the valve via a tube inserted through an artery at the top of the leg. This new technique offers hope to patients who are often very elderly and too frail for open heart surgery. It has been found that for these patients this is a life saving procedure.

Advances in the treatment of Heart Failure

As people live longer the numbers of patients with heart failure are increasing. As well as being at increased risk of dying they often have frequent and some times long stays in hospital. Over the last fifteen years the drug treatment of heart failure has much improved. This study has shown improved outlook for these patients with damaged hearts even if they do not have severe symptoms. Patients survive longer and have fewer admissions to hospital when treated with this drug - Eplerenone even when they are already on a number of drugs which have been used up to now.

Over time I hope to cover these and other areas of heart care in my blogs. You can follow me on Twitter, @RobertGreenbaum to hear about these.

Warfarin is the commonest drug now used as a blood thinner. But being on warfarin is a hassle.  You have to have regular blood tests and the doses of drug you need to change may often change. Many other common drugs interfere with warfarin.

In spite of this, warfain is an important drug. It's main use is to reduce the risk of stroke for patients with a common heart rhythm disturbance - atrial fibrillation. In order to use warfarin complicated arrangements are needed - often running separate clinics either in general practice or at the hospital. Patients want a simpler and effective alternative.

Several drug companies have been working to develop such a drug for several years. Now one of these drugs is in the advanced stages of the European and British approval process.  This drug is called dabigatran. The trade name is Pradaxa.

In Great Britain dabigatran was approved for short turm use in patients undergoing hip or knee replacement in 2008. Dabigatran was the subject of a large study of over 18,000 patients publised in 2009.  The study was published in a leading medical journal - The New England Journal of Medicine.  In this study the new drug was compared against conventional treatment with warfarin.. Two doses of dabigatran 110 and 150 mg twice daily were compared with wafarin. The trial looked at the number of strokes and bad bleeds that happened in each of the groups. The average follow up was two years.

Both doses of dabigatran were effective. It was found that those patients on high dose dabigatran had less strokes than the patients treated with warfarin. Severe bleeding was uncommon - overall rates were similar in all the patients.

What does this mean for me?

Once the drug has a license initial availability will depend on the willingness of GPs to pay for the new drug. It is clearly not possible to switch patients taking warfarin to dabigatran immediately. Whilst the change over occurs the existing warfarin service will need to continue to be funded.

Dabigatrin is not for all patients.  Some groups will need to stay on warfarin at least for the present eg  Patients with artificial heart valves or who have suffered a clot passing to their lungs - a pulmonary embolus.

Welcome to my "Paris Blog"

Each spring there is a meeting where some 12,000 cardiologists and others come together to discuss the latest findings in interventional cardiology. The meeting started over 10 years ago to discuss advances in coronary angioplasty. This is the procedure where cardiologists stretch narrowings in the heart arteries using an inflatable balloon. Over the years angioplasty has rapidly developed and we have come to understand the things we need to do to get the best results.

A major development has been the use of stents. These are metal coils that are put into the heart arteries to keep them open after they have been opened with balloons.
One of the major achievemnts of angioplasty has been for some patients to avoid the need for coronary bypass surgery which involves general anaesthesia and
opening the chest.

When angioplasty was first introduced in the late 1970s it was only done in patients considered relatively straightforward. These were usually patients with a single narrowing in the artery supplying the front wall of the heart. As we became more experienced we treated patients with ever more complicated problems.

We now treat patients

• With several narrowings in the heart arteries.
• With narrowings where the procedure is more complicated eg at places where the arteries branch
• With arteries which are completely blocked - we may be able to reopen these
• Patients having a heart attack - an important group where angioplasty has been shown to save lives.

Over the years the quality of the materials we use, particularly the stents and the blood thinning drugs given to heart patients has greatly improved. We also are better at selecting the best type of stent for each individual narrowing. As a result angioplasty has become much safer and routine.

At the most recent meeting in Paris there was much discussion about how to treat patients with some of the most severe coronary disease. These patients have a narrowing of the main left coronary artery. This is a short artery but it gives rise to to
large branches - one supplies the front to the heart and the other the side. Traditionally patients with left main coronary disease have been referred for early Coronary Artery Bypass Surgery but with modern techniques some seem to do just as well with angioplasty. It was clear from the discussions that careful review of each individual patient is required by Cardiologists and Heart Surgeons before a
decision is made.