From Beaumont Physicians and Allied Health Professionals Spring Issue 2011

Like many other areas in healthcare, the practice and business of cardiovascular medicine has been

the focus of substantial change in the past few years, impacting patients, physicians and health care systems. During these challenging times, we should not lose sight of the amazing advances that have occurred in this field, with many of these quantum leaps taking place here at Beaumont. For example, the rate of survival after an acute heart attack has dramatically improved, largely due to the pioneering efforts of Beaumont cardiologists Cindy Grines and William O’Neill. Research performed by our Cardiac Imaging team has radically improved the care of patients with chest pain presenting to the Emergency Room. Seminal observations related to coronary atherosclerosis have paved the way to identify coronary artery plaques that may cause heart attack. Leading edge research by Dr. Barry Franklin and his associates has shown us the tremendous importance of lifestyle modification and cardiac rehabilitation. These are just a few examples of the outstanding work that Beaumont cardiologists and allied health professionals have done to transform patient care, not only here, but also throughout the world. It was Beaumont’s international reputation for excellence in cardiovascular medicine that drew me here from New Zealand 12 years ago.

So, what’s on the horizon in 2011? One of the most exciting new projects this year, will be the launch of our Transcatheter Aortic Valve Implantation program. Our cardiologists will be working side-by-side with our cardiac surgeons, Drs. Marc Sakwa and Frank Shannon, to replace diseased aortic valves using a minimally invasive technique. This procedure is truly one of the modern miracles of medicine, and I encourage you to learn more about it in Dr. Hanzel’s article in this issue of “State of the Heart.” One of the key features of this program is a collaborative team-based approach to diagnosis, treatment and follow-up, which I strongly believe is the optimal way to manage patients with complex valve and other heart conditions. Through a generous gift, we are fortunate to have the state-of-the-art Ernst Cardiovascular Center to facilitate the

evaluation and care of these patients. Additionally, we will be developing an Advanced Heart Failure Program, with a team dedicated to the care of patients with congestive heart failure and cardiomyopathy, which is now one of the leading causes for hospital admission throughout the nation. This program will

include new and innovative techniques to improve patient comfort and allow patients to return home as soon as possible. In the Ernst Center, we also plan to open a Marathon Clinic to focus on early detection and treatment of potentially life-threatening heart conditions in marathon runners and other athletes.

Our research team is continuing its work on many cutting edge studies, including stem cell therapy for patients with heart attack, new devices for treatment of atrial fibrillation, genetic determinants (continued on page 12)

Beaumont cardiovascular medicine 2011 1

Cardiovascular benefits of yoga 2

Optimistic heart patients live longer 3

Exercising to stay W.E.L.L. 4

A new tool to identify lipid-rich plaques 5 in the arteries of the heart

Common Q & A 6

Peripheral artery disease – A well 6 kept secret

Heart beat newsline 7

Enhanced external counterpulsation 8 therapy

Heart catheterization via the wrist 8

Sitting too long, too often may 9 be hazardous to your health

Exercise and diabetes 10

Aortic stenosis and new, minimally 11 invasive treatments

I N S I D E T H I S I S S U E

Beaumont cardiovascular medicine 2011: The view from 30,000 feet…

F R O M T H E C H I E F

Simon R. Dixon, M.D., MBChB Chair, Department of Cardiovascular Medicine Beaumont Hospital, Royal Oak

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Justin Trivax, M.D.Cardiology Fellow Department of Cardiovascular Medicine Beaumont Hospital, Royal Oak

Current recommendations regarding the prevention of heart disease advise individuals to integrate “structured exercise,” specifically moderate intensity aerobic activity, into one’s routine five days a week, complemented by strength training two days a week. Although there is no mention of regular yoga practice in these recommendations, there is increasing evidence that yoga is not only beneficial for prevention, retardation, and reversal of heart disease, but is also important for spiritual healing and well-being.

Your blood pressure is elevated. You blame it on chronic stress and the bag of chips you finished in the waiting room. Your doctor

wants to treat you with medication. What should you do? Practice yoga. Although many physicians have

become accustomed to prescribing multiple antihypertensive medications, in a

randomized controlled trial of middle-aged adults, daily yoga practice was as effective as

medical therapy in controlling high blood pressure (Indian Journal of Physiology and Pharmacology, April 2000). Yoga effectively reduces blood pressure by reducing excitatory hormones such as adrenaline, noradrenaline and aldosterone. It also improves the functioning of specialized receptors that control blood pressure.

Your doctor notes that your cholesterol level has increased, you are borderline diabetic, and you’ve gained 30 pounds in the past two years? Now what? Practice yoga. Modern-day yoga has become more rigorous, recruiting large muscle groups and substantially increasing caloric expenditure. Yoga lowers cholesterol levels, decreases body weight and fat stores, and improves the body’s ability to transport sugar to working muscles. A 17 percent decrease in LDL-cholesterol was reported in patients with moderately elevated cholesterol who participated in daily yoga for three months (Acta Physiologica Scandinavica Suppl, 1997). In a study of over 100 patients with

diabetes, improvements of blood glucose and reductions in oral diabetes medication were noted in those who completed a 40-day yoga class (Diabetes Research Clinical Practice, Jan. 1993).

Maybe you were experiencing exertional chest pain and you had an abnormal stress test. A subsequent cardiac catheterization showed moderate blockage in your coronary arteries. You don’t want stents and you don’t want bypass surgery. Time for yoga? Recent studies suggest that it may complement conventional medical therapy. In addition to treatment with certain medications (cholesterol medications [statins], aspirin, and blood pressure drugs), patients with documented coronary disease who participated in a one-year yoga intervention several times per week used less nitroglycerin for angina, demonstrated improved cardiorespiratory fitness, required much less need for revascularization with stents or bypass, and actually exhibited more coronary plaque regression and less plaque progression when compared with a sedentary group (Journal Association of Physicians India, July 2000).

You had a heart attack 10 or 20 years ago? What’s done is done, but now only one-third of the pumping capacity of your heart remains and you often feel short of breath. What can you do? Practice yoga (in addition to remaining on standard medical therapy, of course). Nineteen patients with advanced heart failure were studied to determine the effect of yoga on their health.Ten were randomly given standard medical therapy. The other nine were given standard medical therapy complemented by a yoga intervention. After eight weeks, the yoga patients showed greater improvements in levels of inflammatory markers, exercise capacity and quality of life (Journal of Cardiac Failure, June 2008). It has been postulated that yoga improves heart failure symptoms by reducing sympathetic drive, similar to beta-blocker therapy, and through improved breathing techniques.

The popularity of yoga continues to rise. What was once considered to be a system of physical and mental disciplines may now become central in the treatment of patients seeking alternatives or complements to traditional medical therapy. As we continue to learn more about the advantages of yoga, perhaps we can all benefit from less drugs and more downward dog.

Cardiovascular benefits of yoga

E X E R C I S E A P P L I C AT I O N S

Third Annual

Saturday, June 25, 2011

Location: Marriott Centerpoint, Auburn Hills/Pontiac, Michigan

For additional information go to:www.beaumonthospitals.com/HDPrevention

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Today, increasing numbers of heart patients are entering their 70’s, 80’s, and 90’s, often outliving their counterparts without heart disease. Indeed, the average age of our “active” program participants at the Beaumont Health Center (cardiac rehab program) is now 73; our oldest patient is 95. In our experience, these tend to be patients who take care of themselves and perhaps equally important, develop the mind-set necessary to deal with the challenges of heart disease.

Today, there is considerable evidence in the psychosocial literature to suggest that we get what we expect and attract what we fear. Invariably, those heart patients who not only survive but thrive believe they can achieve longevity and a high quality of life. A classic example is my good friend and esteemed colleague, Joe Piscatella, who had triple vessel coronary artery bypass surgery at the age of 32. He’s now 66 years of age.

Recently, researchers at Duke University Medical Center tracked the health outcomes of 2,818 patients who had just undergone coronary angiography, a procedure used to confirm their underlying heart disease. At the time, all were given a brief questionnaire to assess how much or how little optimism they felt about their diagnosis and recovery (Archives of Internal Medicine, Feb. 2011).

Over the next 15 years, 1,637 of the study patients had died, and about half of the deaths were related to heart disease. The researchers found that favorable expectations were a strong predictor of overall survival. Patients who scored low on optimism tests were 30 percent more likely to die during the follow-up period, even after the researchers controlled for

potential confounding variables, including age, gender, heart disease severity, other medical conditions, and depression. These findings add to a compelling body of scientific evidence that supporting optimistic expectations may be associated with significant survival benefits.

The authors suggested two possible reasons why optimism may lead to better cardiovascular outcomes. First, the optimistic patient may be more likely to heed the doctor’s advice, take prescribed medications and adopt long-term lifestyle changes, compared with a pessimistic patient. Second, optimism may help buffer the health consequences associated with chronic stress and anxiety.

Several years ago, I counseled a new patient in our cardiac rehab program. Bill, a 48-year-old truck driver in good physical condition, had recently experienced a mild heart attack. His face was racked with anxiety and depression – he clearly thought his life was over and that he was on “borrowed time.”

I reviewed his medical records and found that his ejection fraction after

the heart attack, a key index of heart function and survival, was still within the normal range. His fitness from a post-heart attack exercise stress test was “high” for a healthy man his age. Thus, two key prognostic indicators were in his favor. “If you take care of yourself, you’ve probably got many, many years ahead of you,” I told him.

Heart patients often assume the worst. We’ve got to do a better job in promoting hope and optimism. By doing so, especially when it’s truly justified, we may be helping them – perhaps more than we’ll ever know.

Optimistic heart patients live longer

F R O M T H E E D I T O R Barry A. Franklin, Ph.D.Director, Preventive Cardiology and Rehabilitation, Beaumont Hospital, Royal Oak

Cardiac rehabilitation: Inspiring outcomesCurrently, there are approximately 300 active phase 3 cardiac rehab participants at the Beaumont Health Center, Royal Oak. The youngest patient is 31,

whereas the oldest is 95. The mean age of all active program participants is 73, and the average U.S. lifespan is presently 78 years. The take home message? In view of the highly effective treatments for heart disease that are available

today, including cardiac rehab, patients with cardiovascular disease can often achieve life spans

that meet or exceed the national average.

Preventive Cardiology Conference

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Pamela Marcovitz, M.D.Director, Ministrelli Women’s Heart Center Beaumont Hospital, Royal Oak

Have you ever wondered why your doctor keeps nagging you to engage in regular exercise? The reason is because of the myriad of health benefits that can be obtained. Exercising 30 or more minutes at least three to four times a week has been found to have multiple cardiovascular benefits including lowering blood pressure, decreasing cholesterol and helping to control diabetes. In addition, exercise has been shown to reduce body weight and fat stores, improve sleep, decrease depression and increase overall well-being. Several studies have reported that individuals who engage in regular exercise can prevent initial or recurrent cardiovascular events, leading to a longer lifespan. One study estimated an increased longevity of about two hours for each hour of regular exercise. Another study found that healthy individuals may extend their lives by up to 12 years, while those with cardiovascular disease may live up to four years longer when they engage in regular exercise. These are just some of the reasons why the Ministrelli Women’s Heart Center and the Beaumont Cardiac Rehabilitation Program have teamed together to start a new physical conditioning program for women to reduce the future risk of cardiovascular disease.

The W.E.L.L. (Women Exercising to Live Longer) program began about six months ago through a generous grant provided by a donor to Beaumont Hospital in order to offer ‘at risk’ women, especially those for whom joining an exercise club might pose a financial burden, as a way to lower future cardiovascular risk. Because the program targets those who would benefit most from primary prevention, it is designed for women with significant risk factors but without previous heart problems. Women with multiple cardiovascular risk factors, including high blood pressure, elevated blood cholesterol, diabetes, or obesity, are referred to the program by their physician. After an intake

interview and basic instruction on the equipment at Beaumont’s Cardiac Rehabilitation center, the enrollees may begin to exercise on a variety of aerobic and resistance training exercise machines, alongside the cardiac rehab patients. Prior to the start of the program, one-on-one counseling is provided by an exercise specialist to set goals and track individual progress. Women enrolled in the W.E.L.L. program may also attend group tai chi and yoga classes, as well as lectures on achieving a healthy lifestyle provided by Beaumont staff. All enrolled women are asked to make a commitment to exercise for a minimum of three hours weekly for a total of six months and to sign a contract stating so. The written six-month commitment underscores the goals of the program to foster healthy lifestyle habits after the program ends and throughout their lifetime.

In order to maintain between 50 and 75 women in the program at any one time, enrollment is ongoing. Of 29 women who have completed the W.E.L.L. program since June of 2010, ongoing assessments have found that many women were able to lower the number of diabetic and blood pressure medications they were taking and reduce their waistline measurement, another index of cardiovascular risk. Many of the women also reported better sleep habits; a few were even able to discontinue using sleep apnea machines because of weight loss. Almost all women have reported better mobility with some stating they feel more autonomy in completing activities of daily living that were previously difficult or impossible. Through interviews, it is clear that exercise has had an empowering effect on many of the women.

Follow up assessments will be used to determine if the lifestyle changes made during the six month program have continued. It is hoped that the W.E.L.L. women who develop healthy habits during six months of supervision and monitoring will maintain them well into the future and throughout their lifetime. Plans are for the program to continue for at least five years.

Exercising to stay W.E.L.L.

P R E V E N T I V E C A R D I O L O G Y

To inquire about enrollment in the W.E.L.L. program, call

248-655-5781.

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Heart attack: the riskiest time of day?Numerous studies have now shown that the riskiest time of day for heart attacks is between 6 a.m. and noon. Why? Researchers now believe that cyclic morning increases in hormone levels, blood pressure and artery stiffness heighten the possibility of clot formation.

(Source: Piscatella J, Franklin B. Prevent, Halt & Reverse Heart Disease, Workman Publishing, 2011)

Ryan D. Madder, M.D.Cardiology Fellow, Department of Cardiovascular Medicine Beaumont Hospital, Royal Oak

Over the course of their adult lifetime, many individuals develop the gradual build-up of plaque within the arteries of the heart. Although most of these plaques either remain clinically silent or progress slowly over time, some plaques will ultimately cause a heart attack. Most heart attacks occur when plaques within the coronary arteries suddenly rupture, leading to the formation of a clot within the artery. This process causes blood flow within the artery to abruptly transition from normal to severely reduced, thereby causing a heart attack. The sudden-nature of these plaque rupture events explains why many patients often feel fine leading up to the heart attack.

Importantly, not all plaques that accumulate within the coronary arteries are the same. Many plaques are composed of fibrous material (i.e., hard plaques) and are thought to be more stable, whereas other plaques, particularly those composed of lipid-rich cores (i.e., soft plaques), may be more prone to rupturing and causing heart

attacks. Additionally, lipid-core plaques are thought to lead to more rapid progression of coronary artery blockages and may even be more susceptible to complications during stent placement within the artery. Therefore, the development of a tool capable of detecting these lipid-core plaques may eventually allow cardiologists to identifying patients who may be at greater risk of future heart attacks.

Interventional cardiologists at Beaumont have recently been using a novel catheter system within the coronary arteries of select patients to identify lipid-rich

plaques. This is performed using a technique called near-infrared spectroscopy, or NIRS, and involves advancing a tiny catheter containing an infrared laser at its tip into the coronary artery. The entire artery is then scanned with the infrared laser, which can identify the presence and

location of a lipid-rich plaque. Multiple studies are now underway to determine how best to utilize NIRS in clinical practice. If novel tools such as NIRS can be proven to identify plaques, which are vulnerable to rupture, cardiologists may one day be able to use this technology to prevent heart attacks.

A new tool to identify lipid-rich plaques in the arteries of the heart

I N T E R V E N T I O N A L C A R D I O L O G Y

Recently, researchers combined data from 36 separate studies and calculated the relative risk posed by varied known heart attack triggers, including the proportion of all heart attacks estimated to have been caused by each trigger. Although cocaine use was identified as the most likely to provoke a cardiovascular event in an individual, air pollution, particularly in heavy traffic, had the greatest negative population effect as more people are exposed to it. The investigators concluded that improvement of air quality is a very relevant target to reduce the incidence of cardiovascular disease in the general population.

(Source: The Lancet, Feb. 2011)

Flossing teeth = healthier blood vesselsFor the first time, scientists have now demonstrated that an intensive treatment for periodontitis (gum disease), including flossing, directly improved the health of blood vessels. Although the authors acknowledged that further studies are needed, the findings suggest that dental hygiene may be important for the prevention of heart attacks and strokes.

(Source: New England Journal of Medicine, March 2007)

Air pollution and heart disease

Normal artery

Narrowing of artery

Narrowed artery

Artery wall

Artery cross-section

Plaque

Plaque

Normal blood flow

Abormal blood flow

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Robert N. Levin, M.D.Medical Director Coronary Care Unit Beaumont Hospital, Royal Oak

Q: My elderly mother (age 85) was diagnosed with congestive heart failure, but her ejection fraction is 60 percent, which I am told reflects normal pumping action of the heart. How could she have heart failure if her heart pump activity is normal?

A: There are several entities that can result in congestive heart failure without having underlying impairment of the heart

pumping activity. One such entity is known as diastolic congestive heart failure, also known as heart failure with normal ejection fraction, in which case the heart pumps well but its stiffness impedes proper filling of the heart. The analogy that I usually use with patients is that a balloon with thin latex rubber inflates and empties easily. If one envisions the same balloon with 1 inch thick tire rubber rather than latex, it would be very difficult to fill the balloon, though it would empty without any problem. Another possibility would be heart failure due to an abnormality of one of the heart valves (i.e., either a leaky or narrowed heart valve), or, less likely, a temporary decrease in the pumping effectiveness of the heart due to coronary artery blockage. There are several tests that your cardiologist can do to help sort out these possibilities.

Q: I had a recent heart attack and I am on Lipitor. My doctor said my LDL cholesterol is 80, but my HDL is only 27, which puts me at “increased risk.” Should I take a different medication?

A: Ideally, HDL, or “good” cholesterol, should be greater than 40 in order to decrease a person’s cardiac risk. The higher the

HDL, the better. Your “statin” drug has apparently lowered your LDL, or “bad” cholesterol, but had little or no impact on increasing your HDL. Raising HDL levels can be somewhat challenging. Your doctor may choose to start you on niacin, either in addition to the Lipitor or possibly in place of the Lipitor. Other options to consider would be drugs known as the “fibric acid” derivatives, such as fenofibrate (Tricor), gemfibrozil (Lopid), or an omega fatty acid product (such as Lovaza). New drugs, such as “CETP inhibitors” are being investigated that can potentially raise HDL levels, but these products are not yet approved by the Food and Drug Administration. Lifestyle modifications that may help include exercise and moderate alcohol consumption. However, with drug treatment options, especially in combination with a statin, blood tests need to be followed to detect possible liver enzyme abnormalities and/or evidence of skeletal muscle breakdown.Good Cholesterol Bad Cholesterol

Good cholesterol is called HDL Bad cholesterol is called LDL

Helps to keep the arteries from clogging up

Causes the build up in your arteries and cause blockages of your arteries

Protects against heart disease Causes heart disease

Good level = 60mg/dL or more Good level = under 100mg/dL

C O M M O N Q & A

D I A G N O S T I C T E S T I N G

Peripheral artery disease – A well kept secret

Phillip Bendick, Ph.D.Technical Director, Peripheral Vascular Diagnostic Center, Director of Surgical Research, Beaumont Hospital, Royal Oak

Peripheral arterial disease (PAD), while widely prevalent in our population, is largely unrecognized

and underdiagnosed. It is “guesstimated” that anywhere from five to 10 million adults in the United States have significant PAD, the wide range an indication of the lack of certainty in the diagnosis. (By comparison, approximately 12 million adults have coronary artery disease, a more specific estimate.) Although PAD shares the same set of risk factors as other cardiovascular diseases, surveys consistently show that the awareness of PAD is only one-third that of coronary heart disease or stroke; the general awareness of ALS (Lou Gehrig’s disease), multiple sclerosis and cystic fibrosis all exceed that of PAD. Yet it is one of the strongest known markers

of the systemic nature of atherosclerotic disease, and patients with PAD have a greater than six-fold increase in the risk of cardiac death than those without the condition. Moreover, patients with PAD have a higher one-year cardiovascular death rate than patients with coronary artery disease. How can the diagnosis of PAD be improved? Fewer than 5 percent of patients with PAD have obvious symptoms of leg pain at rest – they are the tip of the iceberg. For the vast majority of patients, the level of suspicion for the presence of PAD should be directly proportional to the patient’s age; there is a 12 to 15 percent prevalence in adults over age 55, but this increases to a 30 to 35 percent prevalence over the age of 70. Patients may be at increased risk based on their medical history, particularly a history of tobacco usage, elevated cholesterol levels, and the presence of diabetes. Commonly, the patient’s symptoms are progressive: no leg pain at rest, onset of leg pain with walking, increasing severity of pain with increasing duration of the exercise eventually limiting the patient’s ability to continue, relief of the pain with rest, and the

(continued on page 12)

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Joel Kahn, M.D.Medical Director, Preventive Cardiology and Rehabilitation Beaumont Hospital, Royal Oak

Shake, rattle and roll 

A recent perspective (Preventive Cardiology, Fall 2010) reviewed the fitness benefits from structured exercise programs but points out that for many people, exercise is time-consuming and competes with other responsibilities of daily living. Therefore, a distressingly small percentage of people actually participate in structured exercise programs on a regular basis. The authors note that frequent periods of inactivity, as can occur at work in long meetings, in front of the TV or computer, are associated with higher rates of mortality, diabetes, and the metabolic

syndrome. Even slight body movements called NEAT (non-exercise activity thermogenesis) such as fidgeting, standing while reading, or moving the legs in a meeting or at a computer, can facilitate a substantial energy expenditure. Simply standing and

other examples of NEAT may serve as an alternative way of burning calories.

Comment: The wellness community has embraced NEAT by encouraging walking meetings instead of sitting, standing frequently during extended meetings, and taking breaks to move more and sit less. Think about it during your day at home or at work, and give a little shake, rattle and roll for improved health and fitness.

NEAT, longevity predictors, and physician health habits

H E A R T B E AT N E W S L I N E

It’s NEAT

How do you get to be 90?

Live at least 89 years would be one answer. Recently, researchers in Sweden studied 111 men who were initially examined at age 50 and who lived to 90+ years of age (Journal of Internal Medicine, Nov. 2010). Men over 90 were more likely at age 50 to be non-smokers,

consume less coffee, have higher socio-economic status, and have lower serum cholesterol than their counterparts who did not reach old age. Measures of cardiorespiratory fitness and blood pressure also predicted survival.

Comment: These data were not surprising. Don’t smoke. Control your blood pressure and cholesterol. Stay physically active and fit through your lifespan. Limit your coffee (and, more likely, the sweets often eaten with coffee). Enjoy a comfortable lifestyle with strong social support. Reaching age 90 may require some good genes and good fortune, but with a healthy lifestyle, the odds can be increased in your favor.

Is the doctor a good patient?

Investigators at the University of Michigan examined whether residents and attending physicians followed healthy diet and exercise recommendations in their own lives. Furthermore, they looked at whether doctors practicing good health habits provide these recommendations to their patients (Preventive Cardiology, Fall 2010). Responses were obtained from 102 residents and 81 attending physicians. Both groups demonstrated low consumption of fruits and vegetables, averaging two servings each a day. Residents ate “fast-food” somewhat more than attending physicians. Exercise recommendations were met fully by 26 percent of attendings and only 8 percent of residents, perhaps due to their long hours. Attending physicians were more likely to recommend diet and exercise plans to patients during visits. Predictors of counseling patients on lifestyle behaviors were the physicians’ own habits of exercising more than 150 minutes a week and specialized training in patient counseling.

Comment: This interesting study supports an old teaching adage: “What you do speaks more loudly than what you say.” A doctor who doesn’t follow a preventive diet and exercise program is not as credible or as confident in recommending lifestyle changes as one who does. Doctors are simply patients in “white coats” who also need to follow preventive care, know their numbers, eat recommended amounts of fruits and vegetables, and sweat and stretch regularly.

I N T E R V E N T I O N A L C A R D I O L O G Y

Anne Davis, R.N. Preventive Cardiology and Rehabilitation, Beaumont Hospital, Royal Oak

If you have had coronary artery bypass surgery, angioplasty or stents and still find yourself plagued with exertional chest pain or shortness of breath, there is another treatment option that is safe, non-invasive and proven to significantly relieve symptoms of heart disease. The Beaumont Health Center has provided Enhanced External CounterPulsation, or EECP®, to patients with chronic heart disease for the last eight years. Patients are treated five days a week, for seven weeks with pressurized cuffs applied to the legs and hips. After this outpatient therapy, most patients report a decrease in their cardiac symptoms, as well as improved exercise tolerance and higher levels of energy. Some have even been able to reduce their anti-anginal medications. These results are consistent with data collected over several years, by the International EECP® Patient Registry, which reports a 70 to 80 percent effectiveness with benefits lasting three years or more. We’ve had the opportunity to witness many life-changing stories. At 65 years of age, Jane arrived at Beaumont with a four-year history of debilitating chest pain and shortness of breath. Her symptoms didn’t allow her to complete even the lightest housework. Her medical history included a heart attack at age 47, previous insertion of eight cardiac stents, a pacemaker and a failed coronary artery bypass surgery. Today, a year after completing EECP®, she’s participating in routine household chores, as well as making regular trips to the mall just to get her walking in. The stories may differ to some degree, but ultimately, we see the same results – improved quality of life.

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Enhanced external counterpulsation therapy: Hope for chronic chest pain

P R E V E N T I V E C A R D I O L O G Y

Traditionally, heart catheterization procedures have been performed from the femoral artery in the leg up to the groin; however, there is growing enthu-siasm for ‘transradial’ catheterization procedures, using the radial artery in the wrist. Although transradial procedures are commonplace in Europe, only 8 percent of cardiac catheterizations in the United Sates are performed using this approach. Technically the procedure can be more challenging for cardiologists to learn as the radial artery is smaller than the femoral artery in the leg, and in some patients the arteries in the arm can take loops that make it more difficult to advance catheters to the heart. With experience however, transradial procedures can be performed as easily as leg cases in the majority of patients. In recent years, the equipment used to perform transradial procedures has also improved greatly.

Heart catheterization via the wrist. “Sign me up.”Simon R. Dixon M.D., MBChB Chair, Department of Cardiovascular Medicine Beaumont Hospital, Royal Oak

If you would like more information on EECP®, please call Beaumont’s Preventive Cardiology Department at 248-655-5750.

Transradial catheterization has several major advantages including a much lower risk of bleeding complications, and greater patient comfort since patients may sit up immediately after the procedure. At Beaumont, more than 20 percent of heart catheterizations are now performed using this approach, including both diagnostic catheterizations and complex stent

procedures to treat occluded coronary arteries. Compared with the traditional leg procedure, recovery after transradial procedures is rapid and easy, with many patients returning home the same day. For more information on this innovative technique, please contact your Beaumont cardiologist. If you do not have a Beaumont cardiologist, please call 800-633-7377 for a referral.

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Amy Fowler, B.S.Manager, Preventive Cardiology and Rehabilitation Beaumont Hospital, Royal Oak

Those of us with sedentary jobs or hobbies have perhaps felt redeemed by our trips to the gym three to four times per week, our brisk evening walks with the family dog, and the fact that we usually take the stairs. Although the American public has known about the benefits of regular aerobic exercise for quite some time, we have been seemingly unaware of the harmful effects of prolonged sitting.Recently, researchers reported on the leisure time and physical activity habits of ~100,000 U.S. adults over a 14 year period (American Journal of Epidemiology, July 2010). Time spent sitting was independently associated with total mortality, regardless of the amount of time individuals spent in recreational activity. In fact, those who spent greater than six hours per day seated (versus those who spent only three hours seated) had 20 and 40 percent higher all-cause mortality rates for men and women, respectively. According to a recent issue of the European Heart Journal (Jan. 2011), data from the U.S. National Health and Nutrition Examination Survey demonstrated associations between prolonged sitting time and inflammatory biomarkers like C-reactive protein,

which is associated with the development of coronary artery disease. Investigators also found that frequent breaks in sitting time were associated with a reduced waist circumference, a surrogate marker for abdominal obesity.

These studies highlight the need for Americans to take frequent breaks from the amount of time we spend sitting – to lessen the negative health impact of our increasingly hypokinetic lifestyle. This will be of critical importance as we navigate through the modern age of conference calls, webinars, texting, and instant messaging.

Tips to reduce time spent sitting:

• standupfrequentlywhiletalkingonthephone• walktospeakwithcolleaguesratherthane-mailingthem•usetherestroomorwaterfountainsfarthestawayfrom

your office• takeregularbreaksfromcomputerusagetostand,stretch,

or walk a short distance

Sitting too long, too often may be hazardous to your health

E X E R C I S E A P P L I C AT I O N S

American Heart Association (AHA): Life’s Simple SevenCardiovascular health encompasses two basic components: ideal health behaviors and ideal health factors. The behaviors include not smoking, maintaining a healthy weight, and meeting or exceeding AHA recommendations for physical activity and eating a healthy diet. The health factors include blood pressure, fasting blood glucose and total cholesterol levels that are within AHA’s recommended range – preferably without needing medication to keep them there. To receive your personal cardiovascular health assessment based on Life’s Simple Seven and learn the steps you may need to take to improve heart health, visit: www.heart.org/MyLifeCheck.

Replace ‘coffee breaks’ with ‘walking breaks;’ walk at least 10 minutes during the lunch period

Manage Blood Pressure

Eat Better

Control Cholesterol

Get Active

Lose Weight

Reduce Blood Sugar

Stop Smoking

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Medication, blood glucose management, and exercise are the cornerstones of diabetic management. Yet, only 39 percent of diabetic adults exercise regularly. The American Diabetic Association recommends 150 minutes per week of moderate intensity exercise (similar to a brisk walk, or an intensity corresponding to 50 to 70 percent of the maximum heart rate achieved during exercise stress testing). Aerobic activity five days per week complemented by resistance training is widely promoted for optimum blood glucose management.

Before beginning a physical conditioning program, an initial evaluation is essential to ensure that there are no contraindications to exercise. Because exercise lowers blood glucose levels, it may be necessary to monitor your blood glucose more frequently and

alter your meal times. The risk of hypoglycemia (low blood glucose) and hyperglycemia (elevated blood glucose) are significant among diabetics who exercise. Because exercise transiently reduces blood sugar, it is recommended that you do not exercise with a blood glucose below 100 mg/dl. In some diabetics, hormone shifts can transiently elevate blood glucose levels. This is why checking your blood glucose before you exercise and again after exercise is critical, especially when you start an exercise program. Following exercise your blood sugar can continue

to drop for 24 hours. Accordingly, rechecking your blood glucose several hours after your exercise is strongly recommended.

Most diabetics know how they feel when their blood glucose level drops below 70 mg/dl: shaky, weak, tired, hungry, and irritable. Many patients complain of blurred vision. If you’re a diabetic and you experience these symptoms, it’s probably due to a transient drop in your blood glucose level and one of the following is recommended: three to four glucose tablets; 4 oz. of any fruit juice; 4 oz. of a regular soft drink; or, 8 oz. of milk. Recheck your blood glucose after 15 minutes. If it is still low or you do not feel any improvement, have another snack. Repeat these steps until your blood glucose is 90 mg/dl or higher and your symptoms are resolving. This is called the “Rule of 15.” Each snack example above provides 15 grams of carbohydrate. After ingesting the snack wait 15 minutes and recheck your blood glucose level. These measures are expected to raise your blood glucose about 15 points.

After the first week of tracking your blood glucose levels, you should be able to anticipate any blood sugar modulations and adjust your diet/snacks accordingly. You should no longer require frequent blood glucose checks unless you substantially increase your exercise frequency, intensity, duration, or combinations thereof. For example, if you decide to progress from brisk walking to slow jogging, it is wise to go back to more frequent blood glucose monitoring until you know how your blood glucose will respond.

Exercise and diabetes

E X E R C I S E A P P L I C AT I O N S

Kathy Faitel, R.N. Preventive Cardiology and Rehabilitation Beaumont Hospital, Royal Oak

Susan Halley, R.N.Preventive Cardiology and Rehabilitation Beaumont Hospital, Royal Oak

Home exercise guidelines include:

• Chooseactivitiesthatyouenjoyandthat fit into your lifestyle.

• Investingoodexerciseequipment,i.e.,comfortable walking shoes.

• Startslowlyandgraduallyincreasefrequency, duration, and intensity.

• Chooseanexercisetime of day to provide consistency.

• Exerciseforlongerduration and lower intensity to promote reductions in body weight and fat stores.

• Includeafiveto10minutewarm-upandcool-down at the beginning and end of the exercise period.

• Increasephysicalactivityduringlifestyleactivities (park farther away from stores when shopping, use the stairs rather than taking the elevator, walk to co-worker’s offices rather than e-mailing them).

•Ifexercisingalone,carryidentification, a carbohydrate

snack, and a cell phone.

The number of diabetic patients in the U.S. is skyrocketing. Accordingly, the more fully patients understand the nature of the delicate balance that exercise has in treating diabetes, the greater the benefits they are likely to achieve. Without

question, exercise is sound medicine.

Consequently, regular exercise is widely considered an integral ingredient in a diabetic’s recipe for a well-balanced, healthy life.

11

Aortic stenosis and new, minimally invasive treatmentsGeorge S. Hanzel, M.D.Director, Structural Heart Disease Beaumont Hospital, Royal Oak

Everyone has heard of coronary artery disease, congestive heart failure, and atrial fibrillation. But what is aortic stenosis? Aortic stenosis is a common cardiac condition that affects four to five percent of people over the age of 75. Approximately 80,000 aortic valve operations are performed each year in the United States. With the aging “baby boomers,” the number of patients with aortic stenosis is expected to dramatically increase over the next 15 years.

Understanding the problem

The aortic valve is a one-way valve that separates the left ventricle (the heart chamber that pumps oxygen-rich blood to the body) from the aorta (the main blood vessel of the body). When the left ventricle squeezes, the aortic valve opens and allows blood to flow from the heart to the body. Aortic stenosis is a narrowed aortic valve that prevents efficient and unimpeded blood flow from the heart to the rest of the body.

The narrowing of the valve burdens the heart and causes it to work harder. Eventually, if the narrowing is severe enough it can lead to congestive heart failure, (which is manifested by fatigue, fluid retention, and shortness of breath), angina (chest pains), or fainting. In some cases, severe aortic stenosis can lead to fatal cardiovascular events. There are several causes of aortic stenosis, but the two most common are bicuspid aortic valves (a congenital defect in which a person is born with two instead of three aortic valve leaflets) and “senile” degeneration of a normal trileaflet valve.

Treatment Options

Unfortunately, there are no medications that can treat or improve aortic stenosis. Milder degrees of aortic stenosis do not require treatment and can be monitored on a routine basis. Currently, the standard treatment for more severe degrees of aortic stenosis is open-heart surgery to replace the aortic valve. This is a proven and effective means of improving symptoms and life expectancy. Cardiac surgeons at Beaumont Hospital have helped pioneer new minimally invasive ways of performing traditional aortic valve replacement surgery. Unfortunately, approximately one-third of symptomatic patients over the age of 65 do not undergo this life saving surgery due to either age or the coexistence of major medical problems.

Several years ago, Beaumont Hospital was first in the United States (and the second in the world) to perform transcatheter aortic valve implantation. In this procedure, a tube (or catheter) is inserted into the artery in the groin and threaded to the heart. A stent with

a tissue valve sutured inside it is then advanced to the aortic valve and implanted, pushing aside

the old narrowed valve and allowing the new valve inside it to open and close normally.

These novel devices are still investigational. Cardiologists and cardiac surgeons at Beaumont

Hospital will soon be collaborating to further study “stent-valves” to treat aortic stenosis. Patients who are

considered higher-risk for traditional aortic valve surgery will be selected at random and have traditional surgery or the

new “stent-valve” implanted either through the groin or a small incision in the chest. Patients who are nonoperative will all be treated with the “stent-valve.” It is hoped that this investigational device will alleviate aortic stenosis while reducing risk, trauma and recovery time and that this study will help lead to Food and Drug Administration approval of this “stent-valve” to treat severe aortic stenosis in higher-risk and nonoperative patients.

I N T E R V E N T I O N A L C A R D I O L O G Y

Female fatalities

Cardiovascular disease is the #1 killer in women, taking 432,000

women annually – 10 times as many deaths from breast cancer

and twice as many deaths from all cancers combined. Learn more

about this disease and what you can do to prevent it at

heart.beaumonthospitals.com/ministrelli-womens-heart-center.

Hold the salt!An escalating body of scientific evidence now links sodium intake with elevated blood pressure and other adverse cardiovascular outcomes. Recently, the American Heart Association recommended that the general population consume no more than 1500 milligrams (mg) of sodium a day because of the harmful effects of sodium – hypertension and increased risk of stroke, heart attack and kidney disease.

(Source: Circulation, Jan. 2011)

STATE OF THE HEAR T L INE-UP

Editor-in-chief: Barry Franklin, Ph.D. Co-editor: Simon Dixon, M.D. Associate editor: Robert Levin, M.D. Managing editor: Brenda White

PANEL OF EXPER TS

Clinical cardiology: Aaron Berman, M.D.; Terry Bowers, M.D.; William Devlin, M.D.; Harold Friedman, M.D.; Andrew Hauser, M.D.; Robert Levin, M.D.; Steven Timmis, M.D.; Douglas Westveer, M.D.; David Forst, M.D.

Interventional Cardiology: Steven Almany, M.D.; Nishit Choksi, M.D.; Cindy Grines, M.D.; Phillip Kraft, M.D.; George Hanzel, M.D.

Nursing: Steve Albertus, R.N.; Kathy Faitel, R.N.

Pharmacology: Heidi Pillen, PharmD.

Exercise Physiology/Fitness: Kim Bonzheim, M.S.; Adam deJong, M.S.; Angela Fern, M.S.; Kirk Hendrickson, M.S.; Tom Spring, M.S.

Geriatrics: Michael Maddens, M.D.; John Voytas, M.D.

Psychosocial Issues: Jackie Odom, Ph.D.; Dan Stettner, Ph.D.; Julie Upp, M.S.; Gene Ebner, Ph.D.

Electrophysiology: David Haines, M.D.

Diagnostic Testing/Nuclear Medicine: Darlene Fink, M.D.; Ralph Gentry, R.T. (R) (MR) (CT); Gilbert Raff, M.D.

Cardiovascular Surgery: Marc Sakwa, M.D.; Frank Shannon, M.D.

Preventive Cardiology: Steve Korotkin, M.D.

Obesity, Diabetes, Metabolism: Wendy Miller, M.D.; Kerstyn Zalesin, M.D.

Enhanced External Counterpulsation Therapy: Anne Davis, R.N.

Women’s Issues: Pamela Marcovitz, M.D.; Melissa Stevens, M.D.

12

Beaumont cardiovascular medicine 2011 (continued from page 1)

of heart disease, preventive cardiology and cardiovascular disease in women. Cardiac imaging remains a hot area, with our researchers leading the nation in techniques and applications of coronary computed tomographic angiography, a non-invasive method to obtain information about the coronary arteries. In the near future, bio-absorbable stents will be tested, as well as a fascinating new ‘one-time’ technique to treat hypertension called ‘renal denervation’. Despite these exciting developments, our work as cardiologists is far from being done. Cardiovascular disease remains the number one killer of Americans every year. In a recent report from the American Heart Association, it was estimated that 41 percent of the U.S. population would have some form of cardiovascular disease by the year 2030, in large part attributable to American’s 78 million Baby Boomers and related medical conditions such as obesity, diabetes and high blood pressure. Costs associated with cardiovascular disease are projected to triple from $273 billion to $818 billion. As a society the only conceivable way for us to address this problem is through effective prevention strategies, such as diet, weight loss, smoking cessation and reducing physical inactivity. I encourage you to “know-your-numbers.” This issue of the newsletter will provide many helpful tips and behavioral strategies to reduce your risk of cardiovascular disease.At Beaumont, I am proud to have a superb team of people in the Department of Cardiovascular Medicine, who are committed to our goal of providing the highest level of care for you and your family. As we strive to further improve our program, please do not hesitate to contact me if you have any comments or suggestions regarding your experience here at Beaumont.

PAD (continued from page 6)

whole cycle reproducible and repeatable– classic claudication.

But classic claudication is present in only about one-quarter of patients with PAD. Another 25 percent of patients have some type of exercise-associated leg pain that falls outside the description of a classic presenta-tion, and nearly 50 percent of patients with significant PAD are asymptomatic, many because they simply don’t walk enough to produce symptoms. A definitive diagnosis is most easily established by measuring the Ankle-Brachial Index, or ABI. This is the ratio of the systolic pressure at the ankle (usually measured by a Doppler technique) to the arm systolic pressure. A ratio less than 0.90 is considered positive for PAD. More comprehensive noninvasive diagnostic studies can be done using a combination of plethysmography and duplex ultrasound, which allows precise localization and classification of the severity of atherosclerotic lesions. If intervention for debilitating symptoms is needed, examination of the lower extremity blood vessels can be done.

The goals of treatment are to relieve exertional symptoms and to improve walking capacity in those patients with

claudication, improve quality of life in patients with symptomatic PAD, and, most importantly, by aggressive manage-ment of risk factors and lifestyle, to prevent and retard the progression of systemic atherosclerosis and adverse cardiovascular outcomes. This initially requires the identification of the disease and then directing the patient to the care appropriate for it’s severity. For the vast majority of patients, medications and lifestyle changes – including an exercise program – are sufficient to prevent the need for invasive interventions. Post-intervention exercise programs have also been shown to improve quality of life. The most effective exercise programs are those that are conducted at least three times a week, at an intensity sufficient to evoke mild-to-moderate leg discomfort. For those patients who are able to exercise (successfully completing a cardiac stress test is necessary), both progressive walking exercise and upper body activities can be highly beneficial. A Beaumont Vascular Rehab Program is being designed to benefit all PAD patients, not only those who may have claudication but also those who are asymptomatic or have severe disease, requiring intervention. Stay tuned.