Healthy Heart (Vol-5, Issue-54) May, 2014 - Dr. Ajay Naik-31 0 8 6 3 11 23 11 16 24 25 26 22 Figure...

Volume-5 | Issue-54 | May 5, 2014

Price : 5/-`

Healthy HeartHonorary Editor :

Dr. Ajay Naik

From the desk of Hon. Editor:

CIED is a collective term for

implantable cardiac devices such as

Pacemakers, Defibrillators, CRT,

Implantable Loop and Cardiac

Monitors. With widespread and

exponential growth of CIED

implants, the number of patients in

the community is rising rapidly.

These patients need to be

periodically and assiduously

monitored to optimize the device

performance for maximal patient

benefit. For the last 5 decades, the

monitoring has been performed in

person at the Arrhythmia / HF

clinic, thus flooding the clinic

capacity and compromising

optimal care. Remote monitoring

is an extremely efficient and

effective way of monitoring devices

and patients. This promises to be

the standard of the future.

- Dr. Ajay Naik

The Future has arrived: Home Monitoring of Devices, Arrhythmias and Heart Failure patients

Cardiovascular Implantable Electronic

Device (CIED) Monitoring

Remote monitoring allows patients to

transmit CIED data from the comfort of

their homes. Even though this technology

is fairly recent, it has received widespread

acceptance for several reasons.

Device Related

u Assessing / Optimizing device

performance and safety

u Identify/ correct any system

abnormalities

u Plan elective replacement of device

Patient Related

u Patient education, reassurance

u Records, databases

Disease Related

u Monitor arrhythmias

u Monitor Heart Failure parameters

Communication Related

u Reports to physicians and health care

providers

www.indianheart.com1Care Institute of Medical SciencesCIMS

R

Dr. Ajay Naik (M) +91-98250 82666

Dr. Satya Gupta (M) +91-99250 45780

Dr. Vineet Sankhla (M) +91-99250 15056

Dr. Gunvant Patel (M) +91-98240 61266

Dr. Keyur Parikh (M) +91-98250 26999

Dr. Dhiren Shah (M) +91-98255 75933

Dr. Dhaval Naik (M) +91-90991 11133

Dr. Saurabh Jaiswal (M) +91-95867 25827

Dr. Niren Bhavsar (M) +91-98795 71917Dr. Hiren Dholakia (M) +91-95863 75818Dr. Chintan Sheth (M) +91-91732 04454

Dr. Kashyap Sheth (M) +91-99246 12288 Dr. Milan Chag (M) +91-98240 22107

Dr. Amit Chitaliya (M) +91-90999 87400

Dr. Ajay Naik (M)

Dr. Vineet Sankhla (M) +91-99250 15056

+91-98250 82666

Dr. Shaunak Shah (M) +91-98250 44502

Dr. Milan Chag (M) +91-98240 22107

Dr. Urmil Shah (M) +91-98250 66939

Dr. Hemang Baxi (M) +91-98250 30111

Dr. Anish Chandarana (M) +91-98250 96922

Cardiologists Cardiothoracic & Vascular Surgeons Cardiac Anaesthetists

Neonatologist and Pediatric Intensivist

Pediatric & Structural Heart SurgeonsPediatric CardiologistsCardiac Electrophysiologist

v

value of implantation.

v The implication of CIED implantation

is that it has a sustained purpose.

v In order for that purpose to be

mani fest , the C IED must be

monitored, maintained and followed

up regularly.

Remote or Trans-telephonic monitoring of

stored data via wireless GSM or cable

systems has shown to be an accurate

method for control of the implanted

cardiac device and with some restrictions

also of the device patient. This

telecardiology can be applied for the

necessary data reduction without loss of

periodic crucial information on numerous

device parameters and some patient

c h a r a c t e r i s t i c s . T h i s t e c h n i c a l

breakthrough can have so many

consequences that the cardiology

p r o f e s s i o n h a s t o p r e p a r e i t s

implementation for daily practice.

The focus of CIED use has been on the

www.indianheart.com2

Healthy Heart

Care Institute of Medical SciencesCIMS

R


Device and Patient Management

scenario

u

receiving CIEDs have chronic

diseases that, like their devices, are

likely to stay with them till they die.

u Monitoring of CIEDs is important in

managing both the devices and the

diseases.

u CIEDs are sophisticated devices that

require spec ia l i zed experts ,

physicians and other providers, for

optimal follow up.

u CIED patients and their follow-up

providers are frequently significantly

geographically separated.

u Reduced time spent in health care

activity is a good thing for patients,

other things being equal.

u Although expensive, health care is

also an important issue.

Electrophysiology (Arrhythmia and HF)

clinic visit for follow up has some

complexities like:

u Escalating patient volumes

u Increasing Device complexity

u U n s c h e d u l e d a n d m i s s e d

appointments

u Patients and families' desire of

convenience and continuity of care

u Maintenance of Electronic Health

Records (EHR)

u S ta f f s h o r ta ge ( N u rs e s a n d

Technicians)

These directly or indirectly affect the

patient care. So Remote device follow up

is the best remedy for the improvement

in the patient care.

In CIED patient care: Patients

Figure 1 : This monitoring affects the device and patient management

0

10

20

30

40

50

60

70

80

90

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

5

29

33

52

44

51

54

60

85

55

61

73

89

Figure 2: Pacemaker implant growth at THCC from 2001 - 2013

0

5

10

15

20

25

30

35

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

0 0 1 2

8

6

10

12

12

14

8

25

31

Figure 3: ICD implant growth 2001 - 2013 at The Heart Care Clinic (THCC)-

0

5

10

15

20

25

30

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

10

8

6

3

11

23

11

16

2425

26

22

Figure 6: CRT implants 2001 -2013 at THCC

www.indianheart.com 3Care Institute of Medical SciencesCIMS

R

Healthy HeartVolume-5 | Issue-54 | May 5, 2014

Device follow-up recommendations

Number of visits / number of months

Pacemakers:

u 2/12 Within 1st year of implant

u 1/12 Subsequent Years

u 2/12 Near battery replacement

Implantable defibrillator (ICD)

u 4 - 3 / 1 2 T h r o u g h o u t d e v i c e

lifetime

u Cardiac Resynchronization Therapy

(CRT) : Pat ient and Therapy

dependent 4-12 visits per year

Factors Influencing Follow Up

u Patient preference

u Underlying medical condition

u Device related issues

u Geographic isolation

u Cost effectiveness of FU

u Follow-up clinic resources

Paradigms of Device monitoring

u In Person monitoring

q Complete device evaluation

q Interrogation evaluation

q Peri-procedural evaluation

u Remote monitoring

q Trans Telephonic Monitoring

without Interrogation

q Pa t i e n t I n i t i a t e d Re m o t e

Transmission

q D e v i c e I n i t i a t e d R e m o t e

Transmission

Figure 4: ICD follow up clinic: A representative example of rising volumes

Figure 5 : LAO view of a CRTP and a CRTD device


Healthy Heart


R


A d v a n t a g e s o f “ D i s t a n c e ” o r

“Wireless”telemetry

u

can be done passively by patient.

u Eliminates need for remembering to

transmit and allows patient to

“forget” about chronic illness.

Transmission of routine information

u

problems (alerts) can occur without

the requirement for patients to be

symptomatic or be aware of a

problem.

Transmission of device and patient Advantages of Wireless Network

u

changing needs and schedules of

both patients and of clinicians.

u Easier for clinician to set up a

scheduling routine that fits into

c u r r e n t p r a c t i c e m e t h o d s .

Scheduling becomes automated,

saving time for the clinic.

u Automatic prescheduled checks can

i m p r o v e p a t i e n t c a r e a n d

convenience whi le reduc ing

compliance issues

u Alerts triggered by device or

physiologic events, provide early

event notification to help better

manage patient outcomes.

Remote monitoring of CIEDs may help in

many aspects like :

u Improve QOL

u Improve Re-hospitalisation/FU rate

u Improve Morbidity and Mortality

u Reduction of costs

u Early detection of patient, lead or

device related issues

u Immediate and Continuous control

on therapy changes

u Improvement of event free survival

The Electrophysiology community are

the initial owners of this technology, but

it will spread to many other disciplines.

The standards that we create will be

replicated. It is our job and a great

opportunity.

Better able to accommodate

Figure 8: Home Monitoring

Figure 9: Device Follow up Paradigms: Remote

Home Drive Clinic Wait Physician Drive Home

Figure 7: The standard follow up In Person monitoring


R

Healthy HeartVolume-5 | Issue-54 | May 5, 2014

Dr. Anish Chandarana & Dr. Satya Gupta has been awarded

Fellowship of American College of Cardiology (FACC) in the rd

63 Annual American College of Cardiology convocation st

held in Washington DC last Monday (31 March 2014).

Fellowship of American College of Cardiology (FACC) is a

symbol of excellence, achievement and commitment in the

field of cardiology.

This fellowship is usually awarded to a cardiologist after

several years of experience and those who have

significantly contributed to recent clinical, educational,

investigational, organizational or professional aspect of

the cardiology.

Dr Satya Gupta was also felicitated, honored and awarded

a special certificate of outstanding cardiologist.At CIMS... We Care


R

Dr. Anish Chandarana Dr. Satya Gupta

Congratulation Dr. Anish Chandarana & Dr Satya Gupta

ECG Learning Course

CIMS Hospital : Opp. Shukan Mall, Off Science City Road, Sola, Ahmedabad - 380060 Phones : +91-79-3010 1059/60/61Email: Website: [email protected] www.cims.me

Registration Fees ` 500/-Venue : CIMS Hospital, Ahmedabad

For registration contact

Schedule of Basic ECG Learning Course 2014

Please tick the batch of your choice.

June 15-06-2014

August 24-08-2014

October 19-10-2014

December 21-12-2014

Sunday (8.00 am to 2.00 pm)

Organized by


R

At CIMS... we care

n Mr. Ketan Acharya :+91-98251 08257

n Mr. Mahendra Desai :+91-90990 66527

n Mr. Nirav Patel :+91-90990 66528

Who should attend

u General Practitioners /

Family Physicians

(All speciality)

u Interns

u Post Graduates

u Para Medical &

Technical Staff

DD or A/c. payee cheque to be made in the name of

“CIMS Hospital Pvt. Ltd." Kindly mail the Registration Form

along with the Cheque/DD to the hospital address


Healthy Heart


R

In the setting of left ventricular failure with markedly reduced

ejection fraction , selection of patients with ischemic heart

disease who will benefit from coronary revascularization often

is problematic. It has been correctly noted that coronary

artery bypass grafting (CABG) carries increased risk in this

patient group. In the Coronary Artery Surgery Study registry,

for instance, surgical mortality was as much as threefold

greater and 5 y survival was one third less for patients with

reduced left ventricular ejection fraction (LVEF) than for

patients with normal LVEF . However, in a more recent series,

operative mortality was only 3.8% and actuarial survival was

94%, 82%, and 68% at 1, 2, and 5 y, respectively, after surgery

in 79 consecutive patients with a mean LVEF of 18% ± 5% .

Nevertheless, physicians are understandably reluctant to

recommend surgery for these patients if the prospects for

benefit are limited.

The search for myocardial viability typically commences at this

juncture. If substantial viable myocardium is present, the

benefits logically outweigh the risks of CABG and are widely

believed to do so. However, more precise framing of the

question of benefit, and consideration of mortality versus

symptomatic status, are important. Indeed, several authors

have suggested that recruitable contractile reserve is an

important determinant of improvement after CABG in

ischemic heart disease patients who undergo surgery

primarily for heart failure . Patients without such reserve are

less likely to benefit symptomatically from CABG, whereas

those with reserve are. Further, studies have shown that

ischemic heart disease patients with a low LVEF who undergo

surgery primarily for angina are more likely to obtain

symptomatic benefit than are those who undergo surgery

primarily for heart failure . Mortality data, however, generally

focus on all comers with ischemic heart disease and low LVEF

and typically show benefit relative to historic control subjects

who are medically treated . Mickleborough et al. reported no

difference in long-term survival between patients who

underwent surgery primarily for angina and patients who

underwent surgery primarily for heart failure. A prospective,

randomized clinical trial with endpoints of mortality and

symptoms in this patient group, however, has not been

performed and clearly is required to address these issues

more definitively.

A substantial body of data indicates that survival is improved

by CABG in patients with ischemic heart disease and left

ventricular dysfunction, especially triple-vessel disease, the

evidence regarding improvement in functional capacity has

been more variable. As the authors appropriately note, a

recent study by Samady et al. showed that symptoms of heart

failure and angina were improved after CABG in patients with

a low LVEF preoperatively (0.24 ± 0.05), independently of any

improvement in global left ventricular systolic function. Also,

no difference in survival was seen for 32 mo between the

group without improvement in LVEF (from 0.24 ± 0.05 to 0.23 ±

0.06) and the group with improvement (from 0.24 ± 0.05 to

0.39 ± 0.10).

The correlation between exercise capacity and LVEF in patients

with either idiopathic or ischemic dilated cardiomyopathy is

known to be poor . A recent PET study also failed to show a

correlation between the amount of viable but asynergic

myocardium and a change in either post-CABG exercise

capacity or symptomatic status, even though the number of

viable, dysfunctional segments was predictive of

improvement in LVEF. Shivalkar et al.studied patients at

baseline and 3 mo after CABG and showed improved LVEF in a

subset of patients with regional hypokinesis and a PET

mismatch pattern. The authors speculated, however, that

improvement in this subset might have been seen even sooner

had they looked earlier. They reported another subgroup with

a matched, moderate reduction in flow and FDG and evidence

of myocyte injury on biopsy. This subgroup, as a whole, failed

to show improvement in LVEF at 3 mo, although 7 of 15

individuals actually did improve. The authors speculated that

LVEF might eventually improve in the others if myocytes,

which showed excess glycogen on histologic examination,

could regenerate the contractile apparatus, which appeared

deficient or absent.

Where are we left, then, in terms of answering the questions

posed by the title of this commentary? Prior data , along with

the data of Bax et al. and of a recent similar investigation ,

generally confirm the hypothesis that the greater the amount

of dysfunctional but viable myocardium before CABG, the

greater is the likelihood of improvement in LVEF after CABG.

The minimum number of segments required to make the

Does CABG Improve Left Ventricular Ejection Fraction in Patients with Ischemic Cardiomyopathy, and Does It Matter?



R

Healthy Heart

surgery worthwhile is unclear, although the authors of this

study suggest that the amount is substantial, perhaps as

much as one third of the left ventricle. Others have suggested

an even higher threshold of 50% . Also to be remembered is

that the augmentation of LVEF after CABG generally is

modest.

In light of these considerations, one might ask what the

usefulness of assessing pre-CABG viability may be and what

tests are most appropriate. One answer will not fit all. A

younger patient with known multivessel coronary disease, a

history of myocardial infarction, and typical angina on

maximal medical therapy either may not require viability

assessment (angina generally indicates viable myocardium)

or may be best served with a high-sensitivity test combining

assessment of both myocardial perfusion and metabolism.

When PET or FDG is not available, rest–redistribution

thallium is an excellent alternative. However, if the patient is

older and the primary indication for CABG is relief of heart

failure symptoms, then an examination that has higher

specificity for recovery of contractile function (e.g.,

d o b u ta m i n e ra d i o n u c l i d e ve nt r i c u l o g ra p hy o r

echocardiography) may be preferred, although the

limitations must be considered. A positive result (i.e.,

demonstration of substantial contractile reserve) would be a

good indication to proceed, but a negative result should not

necessarily exclude the patient from CABG, especially if

regional ischemia was evident during the test and was

sufficient to account for failed augmentation of global LVEF

with low-dose dobutamine. Other clinical scenarios in

patients with chronic ischemic cardiomyopathy can be readily

imagined and suggest the general principle that the

diagnostic approach should be tailored to the CABG

indication. Finally, until the results of a randomized clinical

trails become available, the connection between predicting a

return of global or regional contractile function and patient

outcome, be it mortality or symptomatic status, will remain

murky.

JICJoint International Conference

2015January 23-25, 2015

Cheque or DD's to be made A/C payee and in the name of ‘CIMS Hospital Pvt. Ltd.’ Kindly mail the registration form along with the cheque/DD to our office. All Cash Payments are to be made at ‘CIMS Hospital, Ahmedabad' only.

Registration Information

CIMSRE

Care Institute

Medical Society

for Research

and Education

GMERS

Medical College,

Sola, Ahmedabad

Organized by

Conference Secretariat : CIMS Hospital, Nr. Shukan Mall, Off Science City Road, Sola, Ahmedabad-380060. Phone : +91-79-3010 1059 / 1060 Fax: +91-79-2771 2770 Email : [email protected], www.jicindia.org

To download registration form visit www.jicindia.org

Courtesy : CIMS Cardiac Surgery Team

Module

Full Conference (January 23-25, 2015)(including Special Tracks)

Special Tracks (January 24-25, 2015)

** Deposit for Hotel Accommodation (Separate cheque)

For students doing MD (Medicine) with proof

Spouse Hotel Registration (Non- refundable)

Foreign Delegates

In case of cancellation

** Hotel Accommodation is optional. If you have applied for accommodation, please send a separate deposit cheque of 5000 to cover the cost of your stay for two nights. Spouse hotel registration will be charged extra. Students also need to pay for Hotel

Accommodation at the same rate.₹

Before31-10-2014

` 3500

` 5000

` 4000

` 5000

$ 500

25 %

` 6500

Before30-06-2014

` 3000

` 5000

` 3500

` 5000

$ 400

15 %

` 5000

Before31-12-2014

` 4000

` 5000

` 4500

` 5000

$ 600

50 %

` 7500

Spot Registration(After 31-12-2014)

` 4500

` 5000

` 5000

` 5000

$ 700

100 %

` 10000

Dr. Dhiren Shah+91-98255 75933

Dr. Dhaval Naik +91-90991 11133

Dr. Saurabh Jaiswal+91-95867 25827


Printed, Published and Edited by Dr. Keyur Parikh on behalf of the CIMS HospitalPrinted at Hari Om Printery, 15/1, Nagori Estate, Opp. E.S.I. Dispensary, Dudheshwar Road, Ahmedabad-380004.

Published from CIMS Hospital, Nr. Shukan Mall, Off Science City Road, Sola, Ahmedabad-380060.

Healthy Heart Registered under thPublished on 5 of every month

th thPermitted to post at PSO, Ahmedabad-380002 on the 12 to 17 of every month under

stPostal Registration No. issued by SSP Ahmedabad valid upto 31 December, 2014thLicence to Post Without Prepayment No. valid upto 30 June, 2014

RNI No. GUJENG/2008/28043

GAMC-1725/2012-2014CPMG/GJ/97/2012

If undelivered Please Return to :

CIMS Hospital, Nr. Shukan Mall,

Off Science City Road, Sola, Ahmedabad-380060.

Ph. :

Fax:

Mobile : +91-98250 66664, 98250 66668

+91-79-2771 2771-75 (5 lines)

+91-79-2771 2770

Subscribe “Healthy Heart” : Get your “Healthy Heart”, the information of the latest medical updates only ` 60/- for one year. To subscribe pay ` 60/- in cash or cheque/DD at CIMS Hospital Pvt. Ltd. Nr. Shukan Mall, Off Science City Road, Sola,

Ahmedabad-380060. Phone : +91-79-3010 1059 / 3010 1060. Cheque/DD should be in the name of : “CIMS Hospital Pvt. Ltd.”Please provide your complete postal address with pincode, phone, mobile and email id along with your subscription

www.indianheart.comCare Institute of Medical SciencesCIMS

R

Healthy Heart

8


CIMS Hospital Pvt. Ltd. | CIN : U85110GJ2001PTC039962 | | [email protected] www.cims.me

CIMS A new hopeKILL CANCER...

First time in Asia, Versa-HD for radiation therapy to treat wide range of tumors and for treatment of highly complex cancers

CIMS Cancer Center brings world’s latest Cancer technology to help you fight cancer


R

At CIMS... we care

CIMS Hospital : Nr. Shukan Mall, Off Science City Road, Sola, Ahmedabad-380060. Ph. : +91-79-2771 2771-75 (5 lines) Fax: +91-79-2771 2770 [email protected] www.cims.me

Latest technology

Highly skilled oncologists

Efficient and personalized

cancer solutions

Early detection and diagnosis

CIMS CANCER EXPRESS

For Radiotherapy/Chemotherapy/Surgery

Consultation, Second Opinion

Same day appointment service to serve you better

Daily OPD (Monday to Saturday) 9 am to 8 pm

+91-99792 75555+91-79-3010 1257

Call forAppointment

u Head & Neck Cancer

u Breast

u Gastric & Colorectal Cancer

u Prostate & Bladder Cancer

u Gynec Cancer

u Thoracic Cancer

Cancer Speciality Clinics

u Pediatric Cancer

u Muskuloskeletal (Bone Cancer)

u Neuro-Oncology (Brain Cancer)

NABL

Healthy Heart (Vol-5, Issue-54) May, 2014 - Dr. Ajay Naik-31 0 8 6 3 11 23 11 16 24 25 26 22 Figure...

Documents

Transcript of Healthy Heart (Vol-5, Issue-54) May, 2014 - Dr. Ajay Naik-31 0 8 6 3 11 23 11 16 24 25 26 22 Figure...