Cardiology has come a long way over the past two decades, and today’s standards of care are proof-positive. Discover how stenting, ultrasound, minimally invasive surgery, and good old-fashioned prevention strategies are changing the game.
At some point in your life, there’s a good chance you or a loved one will wind up in the hospital with a heart condition.
In fact, almost 50% of hospital admissions are for heart failure or atrial fibrillation, says Dr. Charles Laham, an interventional cardiologist affiliated with Beloit Health System.
But the good news is that advancements in cardiac care have significantly reduced some of the most frightening statistics, adds Dr. Leo Egbujiobi, a cardiologist with Beloit Health System who has more than 30 years of experience in the field.
“From the time I got trained to now, a lot of advancements have helped patients,” Egbujiobi says. “Acute myocardial infarctions [heart attacks] have been cut down by almost 80%. By getting patients into the cath lab immediately, the result is tremendous – the death rate is cut down. The determinant is the time you get to the hospital.”
Katie Alvarado, director of Imaging Services and Cardiac Services at FHN in Freeport, has seen firsthand how advancements can better serve patients.
FHN recently reinvested in its entire cardiac service line. The cardiac catheterization lab – better known as a cath lab – was replaced and the space was remodeled.
One new purchase was an echo ultrasound unit, a tool that uses high-frequency sound waves to create images of the heart, Alvarado says. The hospital also purchased a SPECT.CT (single-photon emission computed tomography) unit for nuclear stress tests.
“The SPECT.CT is a nuclear medicine camera used during a nuclear medicine stress test that helps visualize the arteries that supply your heart muscle with blood,” Alvarado says.
But disease management goes far beyond equipment, she adds. For years, doctors have been making advancements in medical management – including early detection.
“The earlier you identify that there is a cardiac concern, the better,” says Alvarado. “I don’t think this was the case 10, 15, 20 years ago. Today, patients are discussing concerns with primary providers first, and there is more of an emphasis on preventative health. There may be diagnoses that you can identify efficiently with non-invasive tests – EKGs, stress tests and echocardiograms, to name a few. The whole spectrum of diagnostic cardiac testing has become less invasive with less recovery time, and early detection is key.”
Stenting, Ultrasound and Cath Labs
Many advancements in cardiac care aren’t necessarily new innovations. Oftentimes, it’s simply an evolution with improved procedures. That means patients are receiving better care than ever.
For example, coronary stents – which are metal, mesh-like tubing that help widen a clogged artery in the heart – have been used since the 1980s. But today’s stents can’t compare to the ones that were standard a few decades ago.
“I think stenting has become safer,” says Laham. “Patients have a better track record of not clotting as often, not taking blood thinners as long. And I think the results over time have been better as compared to 10 to 15 years ago, when we had to have people stay on blood thinners indefinitely. Now, with safer stents, patients can get off blood thinners if they have to. Some people want to stay on them long-term, and there is some data to support that. The literature has become more helpful in terms of figuring out which people are safer to get off blood thinners quicker.”
Alvarado agrees, noting that the variety of stents is much different today.
“Say Aunt Ruth had a stent put in place,” Alvarado says. “Stent delivery and composition are prone to fewer complications later. These are absolutely improvements to cardiac care.”
Similarly, there are new techniques for breaking up calcium or plaque buildup in arteries.
Rotational atherectomy – or rotablation – is a procedure that has been around for many years to open a blocked artery by “drilling” through thick calcium deposits.
But new ultrasound methods – sometimes a combination of an ultrasound and laser – can also help surgeons break up rock-hard calcium deposits.
“Before, we might have tried to balloon it, and it either cracks or shatters, or a surgeon tries to bypass it and it just falls apart,” Laham says.
Even the way cath labs perform certain procedures has advanced. A coronary angiogram, for example, is a procedure where a catheter is threaded through the radial artery in the wrist all the way to the heart to check if the arteries are clear of blockage. It used to be that these procedures started in the groin, not the wrist.
“Before, you’d have to lay flat for several hours with pressure on the site,” Alvarado says. “Now, it’s a pressure device that looks like a blood pressure cuff on the wrist. It really speeds up recovery time post-procedure. If you think about it, as a patient before, you were a little limited in mobility after a catheter procedure with groin access. With the access occurring in the patient’s wrist, the patient has the ability to ambulate sooner.”
The Evolution of TAVR
Transcatheter aortic valve replacement, or TAVR, has been an evolution in practice, says Dr. Alejandro Aquino, an interventional cardiologist at OSF HealthCare in Rockford. He should know – he’s followed the minimally invasive procedure since its inception.
During Aquino’s fellowship in 2010, surgeons were only using TAVR as an alternative to open-heart surgery to treat high-risk patients with aortic stenosis – a narrowed aortic valve that doesn’t open properly, thus blocking the flow of blood to the body and making the heart work harder.
In the decade since, the field has evolved, Aquino says. Based on study results, and with FDA approval, surgeons were eventually able to serve moderate-risk patients with this procedure, which uses a catheter to insert a manmade valve without removing the faulty one.
And just a few years ago, new data and FDA approval allowed surgeons to offer TAVR to low-risk patients, he says.
Technological evolution has paralleled procedural evolution, with engineers making advancements to the valves themselves, Aquino says. Doctors are using a third-generation – or newer – version of the valves first used in TAVR procedures.
While procedures have changed, so has patient care.
“Most importantly, the way we treat patients, the way we do things, has evolved,” Aquino says. “When I first started TAVR, patients stayed with us for up to a week. Now, the routine is next-day discharge. Some centers are pushing same-day discharge. I think there is still some merit in watching a patient overnight, and I think it helps with establishing a follow-up. These patients continue to be a little bit older, and having the support structure helps. But I’ve certainly sent some patients home the same day.”
For example, Aquino recently performed a TAVR procedure on a patient with mild dementia who was becoming confused in the early evening.
“That particular patient lived right across the street from the hospital, so I sent her home and saw her the very next morning,” he says. “That went very well for that patient. But I’ve still kind of kept the normal average stay about a day.”
Other evolutions in TAVR procedures include the application of anesthesia. Most TAVR cases at OSF HealthCare Saint Anthony Medical Center are moving away from general anesthesia and instead placing patients under conscious sedation, Aquino says.
Undiagnosed Chest Pain
Aquino is excited about other advancements in cardiac health, particularly the ability to treat patients who have angina – chest pain caused by a lack of oxygen-rich blood – but do not have coronary heart disease.
“They’ll take an annual stress test but have no significant blockage,” Aquino says. “Those patients are caught in limbo. It’s not your heart, it’s this; it’s not your lungs, it’s your heart. They’re going to the ER with chest pain but don’t receive a definitive diagnosis. We now have the ability to see if they have microvascular dysfunction.”
In 2020, the FDA approved the use of the Coroventis CoroFlow Cardiovascular System, which piggybacks on the technology of Abbott’s PressureWire X Guidewire, a commonly used assessment tool that measures blood pressure, blood temperature and other traits inside the heart.
CoroFlow allows surgeons to measure microvasculature – the system of tiny blood vessels that make up the body’s tissues – and help diagnose microvascular dysfunction, in which the blood vessels don’t work properly and cause chronic chest pain.
Microvascular dysfunction has been difficult to diagnose in the past because it’s a non-obstructive form of coronary disease, and earlier forms of technology, like the PressureWire, only measured blood flow across blockages.
This is particularly good news for women, who make up a majority of microvascular dysfunction cases, Aquino says.
“To me, it’s fantastic, because how many times do I do an angiogram or give patients the encouraging – or, in some cases, it’s discouraging – news, that they don’t have a blockage,” Laham says. “All they want to do is feel better. And this allows a good portion of patients who are having symptoms, but don’t have significant blockage, to have an answer. If they don’t have microvascular dysfunction, we can change therapies and maybe get them some relief.”
The Future of Cardiology
Although patients often want to know about the latest innovations and treatments available to them, sometimes it’s old knowledge and wisdom that can make the biggest difference in maintaining a person’s health.
If patients focus on smoking cessation, controlling their blood pressure and diet, and exercising on a regular basis, their overall health will be considerably better, doctors say.
“About 15 years ago, when they first banned smoking in California, there was a 15% drop in heart attack rates overnight from banning smoking in restaurants,” Laham says. “The more we do to try to reduce that statistic, the better. Education is needed.”
In fact, Laham and Egbujiobi agree that’s the future of cardiology: prevention and individualized care.
Doctors have done a tremendous job to better understand biology and pathology, Egbujiobi says.
“How much of a role does lifestyle, cholesterol, plaque and inflammation play into heart attack and stroke and everything else?” he asks. “We’ve mastered this over the years, across the board in the cardiology community, and we’re providing lifesaving procedures, but we’re also giving the knowledge to live longer by making adjustments in their lifestyles and medication. We can now say you are good for this type of drug and this amount of drug, and even though you have chest pain, you don’t have a blockage, so you can take this drug. It has revolutionized the care we give to people.”
That’s such an important issue, Laham says, because it has helped answer questions about why some seemingly healthy patients still wind up with cardiac issues.
“We know the people who are smoking – who have high cholesterol and high sugars – are the ones who are going to have more of a chance of heart disease,” Laham says. “But people with rheumatoid conditions, like rheumatoid arthritis, or some kind of autoimmune disease – like a thyroid issue where there’s inflammation that is causing plaque – may develop heart disease without any other risk factors.
“Sometimes it’s a seemingly healthy little old lady who has no calcium in her bones, but in all her joints – all in the wrong places – who has cardiac problems,” he adds.
Preventing cardiac issues often comes down to the basics: getting patients to eat healthier and live healthier lifestyles, Laham says.
But it’s not always as simple as you might think, he adds.
Apples, oranges, avocados, tomatoes, potatoes, peppers – those are all “healthy” foods that many people eat with a clear conscience, he says. But what people might not realize is that they’re also inflammatory foods that can be detrimental to those with coronary issues.
“They can do everything by the book, but they still have blockage,” Laham says. “I spend a lot of time – and Leo does, too – about counseling, about how they can improve their diet and exercise and lower salt intake and use more superfoods.
“I basically call it the ‘deer diet,’” he says of a superfood diet. “Deer have legs that are only an inch or two in diameter, yet they can jump so high, even with their small diet. We have calves that are much larger and we can only jump inches off the ground. The dumb ones [deer] eat corn and walk around in a fog and get hit by cars. It’s funny, but it’s absolutely true. You don’t have to eat more than a handful of the right stuff – like chia seeds – and you can run around all day like a rocket.”
Eating healthier keeps your heart healthier, too.
Egbujiobi remembers attending his clinical trials and being trained to remove blockage from arteries.
“Sixty percent of the content of the junk in the artery is cholesterol,” he says. “So, lowering cholesterol makes sense. It’s so important.”
While technology-based advancements in cardiac care are extremely important, unless patients buy into everyday self-care habits, doctors can only stop disease, not prevent it.
“Taking care of your health as far as exercise and eating healthy is a great start in being cardiac-conscious,” Alvarado says. “But for those who might not be at that spot, keeping a close relationship with your health care team is essential.”
Egbujiobi agrees and says a “team approach,” led by doctors who have the best intentions for a patient, is the way medicine needs to progress.
“In the business of making people live longer, a lot of things we do in emergency is to help people to live longer for that moment,” Egbujiobi says. “But some things you can buy into will make a difference and will improve the longevity and increase our long-term survival and help people get back to work and be productive in society. And I think that’s important.
“I think tomorrow’s cardiology is going to be a hybrid,” he adds. “Technology is great, but that application of technology and the individualization is more important.”