The Beat: A Bryan Heart Blog
The Beat is a monthly blog from Bryan Heart cardiologists to keep you informed on trending topics, advancements and news in heart care.
Spontaneous Coronary Artery Dissection – A Wolf in Sheep’s Clothing
Written by Joseph Kummer, MD
Contemporary management of Acute Coronary Syndromes (ACS) involves comprehensive therapies derived from an abundance of scientific evidence. These are generally designed to treat acute rupture of an intracoronary atheromatous plaque. However, there are several “wolves in sheep’s clothing” that mimic a plaque rupture event in clinic presentation but involve a very different pathologic event.
One such entity is Spontaneous Coronary Artery Dissection (SCAD). A recent review article in The New England Journal of Medicine regarding this topic was very informative and I will highlight the issues discussed.1 It is very important to recall that not all myocardial infarctions are due to atherosclerosis, even in the setting of a typical clinical presentation for a plaque-rupture event. SCAD is a great example of this.
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Colchicine: A Novel Treatment Of Coronary Artery Disease
Written by Joseph Kummer, MD
The role of inflammation in development of atherosclerotic coronary artery disease (CAD) has long been a source of debate. Pro-inflammatory markers are often elevated in patients with CAD, and inflammation appears to be pro-atherogenic. Despite this, numerous studies of anti-inflammatory medications have failed to demonstrate a reduction in cardiac events. In fact, several agents actually demonstrate a tendency toward increased adverse cardiac outcomes. Renewed interest in this area was sparked by the CANTOS Trial in 2017 which suggested beneficial cardiac outcomes from the monoclonal antibody canakinumab. Although the results of this trial are compelling, this medication was not approved in the United States for cardiovascular protection.
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Bempedoic Acid: When Clinical Trials Come Full Circle
Written by Joseph Kummer, MD
Throughout the years, Bryan Heart has actively been involved in hundreds of clinical research trials. Research trials vary vastly from surgical procedures, cutting edge technology, devices, innovative medications and data registries.
Medication Study of Bempedoic Acid: CLEAR Serenity
One particular study – CLEAR Serenity – that Bryan Heart began in 2017, involved a study medication: bempedoic acid. The information obtained during that study has helped this medication come full circle to be available to patients today.
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Coronavirus and Arrhythmia
Written by W. Michael Kutayli, MD
Since emerging in Wuhan, China late last year, Coronavirus Disease 2019 caused by severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV 2), has taken the world by storm and Nebraska has been no exception. There have been over 113,029 cases in our state, resulting in the deaths of 905 of our fellow Nebraskans as a direct result of the Coronavirus pandemic.
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Status of ACEI/ARBs in COVID-19 Patients
Written by Todd Tessendorf, MD
During this year’s European Society of Cardiology’s Congress 2020 digital seminar, one of the more timely trials presented was The BRACE CORONA Trial. In the beginning stages of the pandemic, research was pointing toward membrane-bound angiotensin-converting enzyme 2 (ACE2) as a functional receptor for COVID-19. Data collected indicated increased mortality rates from COVID-19 in patients with coronary heart disease, diabetes and hypertension – which lead to some speculation that patients taking ACE inhibitors or angiotensin-receptor blockers were at an increased risk.
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A restrictive or liberal approach: which is the best for patients with Acute Myocardial Infarction and Anemia?
Written by Todd Tessendorf, MD
The European Society of Cardiology’s Congress 2020 recently concluded. During this year’s digital seminar, the REALITY trial shed light on the management of anemia in the setting of acute coronary syndrome.
The goal of this trial was to assess the safety and efficacy of a restrictive versus liberal red blood cell (RBC) transfusion strategy among patients with acute myocardial infarction (AMI) and anemia.
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Nuclear Cardiac Study Now Available for Diagnosis of Suspected Cardiac Amyloidosis
Written by Keith Miller, MD
A new cardiac nuclear imaging study is now available at Bryan Heart for the evaluation of suspected cardiac amyloidosis. Technetium-labeled pyrophosphate (99mTc-pyrophosphate; 99mTc-PYP) localizes to myocardium infiltrated with amyloid fibrils composed of transthyretin, the basis of the most common form of cardiac amyloidosis. Combined with cardiac MRI, which Bryan Heart has offered for nearly 10 years, the 99mTc-PYP study affords the capability to definitively diagnose most cases of cardiac amyloidosis safely and non-invasively, without myocardial biopsy.
Once thought of as rare and without viable treatment options, cardiac amyloidosis (or amyloid cardiomyopathy) is now thought to be much more common than previously recognized.
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Return to Sports and Exercise during COVID-19 Pandemic
Written by John Steuter, MD
Over the past few months we have witnessed almost every sport be impacted by COVID-19 – March Madness and basketball seasons ceased abruptly; then hockey, track, golf and baseball/softball seasons were vastly modified. But not just team sports took a hit, personal exercise also took on a new look/feel for many individuals. With local gyms closed, people have been forced to get creative with at-home workouts.
While exercise as a whole is great, how are those individuals who have been exposed or diagnosed with COVID-19 to proceed? What implications should we as practitioners be aware of?
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Comprehensive Therapy Lowers Risk for Cardiovascular Death or Heart Failure Hospitalization by Over 60%
Written by John Steuter, MD
Heart failure has long since plagued the human race. Over the years countless pharmacological therapies have been developed to help treat and increase the quality of life for patients suffering from heart failure. As more pharmacological therapies become available, the need to evaluate the effectiveness from one treatment versus another is necessary for the advancement of heart failure care.
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Novel Therapies for Cardiovascular Risk Reduction in Patients with Type 2 Diabetes
Written by Keith Miller, MD
Until recently, the secondary prevention of atherosclerotic cardiovascular events in patients with type 2 diabetes (T2DM) focused on lifestyle recommendations, antiplatelet therapy, lipid management primarily with statins and blood pressure control.
While aggressive management of non-glucose risk factors yielded major improvements in the natural history of cardiovascular disease (CVD), diabetics still face a major excess risk of heart attack, stroke, congestive heart failure and cardiovascular death compared with those without diabetes. Thus, CVD remains the leading cause of morbidity and mortality in patients with type 2 diabetes.
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Caring For Patients During a Pandemic
Written by John Steuter, MD
Every day we learn more and more about how SARS-CoV-2 virus impacts the health of infected individuals. The following diagram is an effort to explain the current understanding of how the virus changes cell signaling pathways and leads to clinical compromise. It also looks to identify methods of treatment. The mechanism for SARS-CoV-2 infection is the requisite binding of the virus to the membrane-bound form of angiotensin-converting enzyme 2 (ACE2) and internalization of the complex by the host cell.
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COVID-19 and the Implications it has on Cardiology Patients
Written by John Steuter, MD
As each day goes by, we learn more about COVID-19 and the impact it has not only those infected by the virus but also the general public. All of the top health care organizations – World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), etc. – are encouraging people to practice social distancing and especially those who are considered high-risk to stay at home to reduce their chances of potential exposure to COVID-19.
When it comes to cardiology patients the implications and risks from COVID-19 are real. Learn we have encountered so far.
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ISCHEMIA Trial: Findings & Conclusions
Written by Chris Balwanz, MD
Many of you may have heard about the ISCHEMIA trial results that were presented at AHA in November. This large, multi-center, randomized control trial has important implications on how we care for patients with STABLE ischemic heart disease (SIHD).
In addition, there was an associated study ISCHEMIA QoL that examined quality of life in these patients.
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Appropriate Use Criteria (AUC) and What it Means For You and Your Patients
Written by John Steuter, MD
By now you have probably heard the term "Appropriate Use Criteria" or "AUC" and with the January 1, 2020 Education and Operations Testing Period start date right around the corner, you may be asking yourself, what does this mean for me and/or my practice?
Chances are you most likely will need to modify a few things on your end.
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Heart Disease in the Diabetic Patient: It’s Not Just About the Blood Sugars
Written by Keith Miller, MD
November is Diabetes Awareness Month and as you know diabetes is a major contributor to many other conditions including cardiovascular disease. But did you know that as many as 50-60% of all diabetics will die a cardiovascular (CV) death?
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Adult Congenital Heart Disease
Written by John Steuter, MD
Congenital heart defects are the most prevalent type of birth defect. In children born with a heart defect, 1 in 4 are considered a critical case that require surgery or procedures within their first year of life. With advancements in technology and treatment, children nowadays facing the same diagnosis of CHD are looking at 85-90% survival rate of living to adulthood. This increased survival rate is leading to a growing prevalence of Adult Congenital Heart Disease (ACHD).
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Minimally Invasive Treatment for Myasthenia Gravis Patients
Written by John Steuter, MD
Various studies and trials conducted are providing the data needed to show that thymectomies are beneficial for clinical outcomes. Learn about the advances of thymectomies, surgical options and how Bryan Heart is performing minimally invasive robotic-assisted thymectomies for better precision and outcomes.
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The Latest in Management of Aortic Stenosis
Written by John Steuter, MD
The American College of Cardiology (ACC) held their 2019 Scientific Session this spring. One of the most talked-about sessions included findings from the PARTNER 3 and Evolut TAVR trials in low risk patients.
What were the results of the two trials? Find out.
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Is my swelling and shortness of breath normal during and after pregnancy?
Written by John Steuter, MD
Peripartum cardiomyopathy is a weakness of the heart muscle that begins during the final month of pregnancy through about five months after delivery, without any other known cause. Most commonly, it occurs right after delivery. While it’s relatively rare peripartum cardiomyopathy can be life-threatening. Rates of prevalence vary widely from one in 3,000 births to one in 10,000 births.
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Advances in Pulmonary Embolism Treatment
Written by John Steuter, MD
Pulmonary embolism (PE) is a common condition that nearly all medical professions encounter through their career. In cases of submassive or massive pulmonary embolism, this may lead to a strain on the heart’s ability to pump blood through the lungs which can then lead to heart failure and/or cardiovascular collapse. PEs can be immediately fatal and are responsible for more deaths in the United States each year than breast cancer and AIDS combined.
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When should I start Entresto?
Written by John Steuter, MD
When a patient is hospitalized for heart failure (HF), it is a sentinel moment for many reasons, one of which is that their risk for subsequent events is significantly higher. Also, following hospitalization, patients are much more willing to accept changes in their medical regimen, including aggressive titration of medication or addition of new therapies.
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What is my target number? 2018 ACC/AHA Multisociety Guidelines on the Management of Blood Cholesterol
Written by John Steuter, MD
The 2018 American College of Cardiology (ACC) and American Heart Association (AHA) multisociety guidelines aim at reducing risk of atherosclerotic cardiovascular disease (ASCVD) through lipid management. Compared to the 2013 these guidelines emphasize a more intensive approach based on recent controlled studies and expert consensus.
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MitraClip: Treatment of Secondary Mitral Regurgitation
Written by John Steuter, MD
The MitraClip device is already approved in the U.S. for use in primary mitral regurgitation (MR), a condition in which the mitral valve leaflets do not function properly due to a degenerative defect. Whether the device is useful for secondary MR, in which the valve structure is normal, but the ventricle is enlarged, has still been in question. The prognosis for heart failure patients who develop severe secondary mitral regurgitation is poor with limited treatment options.
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I have heart failure, should I keep walking?
Written by John Steuter, MD
Heart failure affects people of all ages, yet it is more prevalent among seniors over the age of 60. The American Heart Association (AHA) recommends people at risk should avoid smoking, exercise more, eat heart-healthy foods. But more specifically what can walking do to help heart failure?
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Is Valsartan Safe?
Written by John Steuter, MD
Last month the U.S. Food and Drug Administration (FDA) issued a recall on pharmaceuticals containing the active ingredient valsartan. Valsartan is used to treat high blood pressure and heart failure. An impurity that can cause cancer has been found in batches of the ingredient valsartan manufactured in China. The recall is due to changes in the way the active substance was manufactured. However, not all products containing valsartan are being recalled.
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How important is good sleep to my patient’s heart health?
Written by John Steuter, MD
For some time, we have known that insufficient sleep increases blood pressure, and, therefore, the risk of heart-related diseases. A recent study from Columbia University assessed whether or not less serious sleep issues could cause measurable cardiovascular effects. An estimated one third of people in the United States do not get enough sleep. And, women seem to be affected more often than men.
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Stent versus CABG to treat multivessel coronary artery disease
Written by John Steuter, MD
Cardiac revascularization in patients with significant coronary artery disease (CAD) is an important therapeutic intervention to improve symptoms and prognosis. Along with revascularization, patients should receive guideline direct medical therapy. The best current revascularization results achieved with percutaneous coronary intervention (PCI) are with new-generation drug-eluting stents (DES) and for coronary artery bypass grafting (CABG) with maximal use of arterial grafts. The best option is still a large question as many different patient characteristics exist.
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Does fish oil reduce my risk of heart disease?
Written by John Steuter, MD
Historically, ecologic studies found low rates of coronary heart disease (CHD) deaths among Greenland Eskimos consuming large amounts of seafood. Subsequent animal studies, observational studies and clinical trials examined the health effects of seafood consumption. These studies identified the long-chain n-3 polyunsaturated fatty acids (n-3 PUFA) in fish oil, eicosapentaenoic acid (EPA) and docosahexaenoic (DHA) acid as the likely active contributors to lowering heart disease.
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Treating Heart Failure and Atrial Fibrillation
Written by John Steuter, MD
Is the end of Digoxin nearing? Digitalis has been used for over 200 years to treat patients with heart failure and atrial fibrillation (afib). Digoxin is used for rate control of afib and in the treatment of heart failure, yet has recently come into question with concern for increased mortality.
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Understanding Advanced Heart Failure
Written by John Steuter, MD
A large spectrum of disease severity exists when it comes to patients with heart failure. Medical therapy, revascularization with stents or bypass, and defibrillator placement are some common tools utilized to treat a patient for heart failure.
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What is causing my chest pain?
Written by John Steuter, MD
Evaluating patients for coronary artery disease (CAD) is a common clinical scenario that providers face on a daily basis. A variety of tests exist that can be utilized to sort through the multitude of such patients from stress tests to heart catheterization. Tests can be categorized into either being functional assessments for significant CAD such as treadmill stress tests, nuclear stress tests or into anatomic, as in heart catheterization or cardiac CT. Each modality has strengths and limitations.
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What is my blood pressure goal?
Written by John Steuter, MD
Hypertension, the world’s most common and modifiable cardiovascular risk factor, has been the focus of multiple clinical practice guidelines. In hopes to address the ongoing controversies and to account for new evidence from recent trials that focused on hypertension, the American College of Cardiology and the American Heart Association (ACC/AHA) have now produced the 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults.
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The WATCHMAN Device: An Alternate Treatment to Blood Thinners
Written by Robert Percell, MD
Atrial fibrillation (AFib) is a chaotic rhythm of the upper chambers of the heart called the atria and is the most common heart rhythm disorder. More than 2.7 million people in the United States have AFib. The average person with AFib is five times more likely to suffer a devastating stroke than someone with a regular heartbeat. More than 90% of stroke-causing clots originating from the heart are formed in a small structure called the left atrial appendage. A stroke results when a blood clot escapes from the left atrial appendage and travels to the brain cutting off the blood supply.
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Why Did My Patient “Pass Out”?
Written by John Steuter, MD
Syncope is a clinical syndrome in which transient loss of consciousness (TLOC) is caused by a period of inadequate cerebral flow. Typically the period of time with inadequate cerebral flow is relatively brief and, by definition, self-limited. It is often the result of cerebral hypo-perfusion due to transient hypotension.
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New Diabetes Therapy Lowers Risk of Death from Cardiovascular Causes and Could Reduce Weight and Blood Pressure
Written by John Steuter, MD
Type 2 diabetes mellitus (T2DM) patients often suffer from obesity and hypertension, increasing their cardiovascular risk. To improve outcomes for patients with T2DM, empagliflozin (Jardiance) a sodium-glucose cotransporter 2 inhibitor (SGLT2-I), was approved in 2015 as monotherapy or as an add-on therapy.
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Is it Safe to Participate in Sports? Cardiovascular Screenings for Athletes
Written by John Steuter, MD
Cardiovascular screening in athletes is universally supported, but the best model for accurate detection of athletes and children with potentially lethal heart disorders remains challenging and often controversial. Most athletes who suffer sudden cardiac arrest do not have warning signs or symptoms before their cardiac arrest. Some symptoms can be under-reported by athletes or go unrecognized by medical providers.
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For Afib Patients, to Bridge or not to Bridge? That is the Question.
Written by John Steuter, MD
To clarify questions and standardize patient care, in 2017, the American College of Cardiology (ACC) came forth with new guidelines and recommendations for which atrial fibrillation patients should be “bridged” during the perioperative period and which should not. The guidelines and recommendations apply to non-valvular atrial fibrillation (afib) patients undergoing surgery.
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PCSK9 Inhibitors: An Effective Option for Cholesterol Treatment
Written by Ryan Whitney, MD
Heart disease is a leading health problem in America. It affects over 92 million people and accounts for one of every four deaths each year. Aggressively treating cholesterol is a key component of managing cardiovascular disease and reducing the risk of future complications. A class of medications called the statins have been, and still are, the cornerstone of cholesterol lowering therapy. However, the PCSK9 inhibitors are a new class of medications approved to complement statin use in certain high risk individuals.
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Cardiac MRI: Powerfully Clear Imaging to Identify Heart Issues
Written by John Steuter, MD
In the last 10 years cardiac magnetic resonance imaging (MRI) has emerged as a tool to better visualize the heart and define abnormal disease states. This minimally invasive procedure does not involve radiation and delivers unparalleled image quality. Cardiac MRI offers new levels of specificity in the diagnosis and management of heart care.
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What is the Ideal Amount of Exercise?
Written by John Steuter, MD
With a new year upon us, resolutions to improve our physical fitness are plenty. Patients often ask how much should I exercise? Is it possible to exercise too much?
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Preventative Measures to Reduce Heart Disease
Written by John Steuter, MD
Heart disease is the leading cause of death in the United States and has carried the number one spot for many years. Yet, heart disease deaths are steadily decreasing in many states and cancer is gradually becoming the leading cause of death.
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New Coronary Stents Fully Absorb in Patients
Written by John Steuter, MD
Every day patients receive stents to keep their arteries open to supply blood to the heart. Interventional cardiologists at Bryan Heart now have a new approach to make this procedure easier and safer for patients.
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Revolutionary Pacemaker Lessens Patient Complications
Written by W. Michael Kutayli, MD
Micra is the newest and smallest pacemaker, approved for use in the United States by the FDA in April 2016. Bryan Heart is the first in Nebraska to offer this true revolution in pacing technology.
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Coronary Calcium Screening: A Simple Test to Prevent Heart Attack
Written by John Steuter, MD
A coronary calcium screening is a test that looks for areas of calcium in the walls of the coronary arteries, which could ultimately cause a heart attack. Calcifications in the coronary arteries are an early sign of atherosclerosis.
MitraClip: A Minimally Invasive Procedure to Reduce Mitral Regurgitation
Written by John Steuter, MD
Mitral regurgitation develops when the heart's mitral valve leaflets fail to close tightly causing blood leak back through into the left atrium. As a result, the heart must then work harder to push the extra blood through the heart.
Preventing Readmissions for Heart Failure Patients
Written by John Steuter, MD
Heart failure is a major problem in the United States. Over five million people suffer from heart failure with over 650,000 new cases and over one million heart failure admissions a year.
