Cardiovascular Service Line Newsletter

Heart & Cardiovascular News from the Georgia Health Sciences Heart and Cardiovascular Service Line

Welcome Dear Colleague, Welcome to the second edition of the Georgia Health Sciences University’s Heart and Cardiovascular Service line (HCVS) newsletter. We hope you will find it stirring and useful.

Our approaches to complex clinical issues offer a distinctive facet of the Georgia Health Sciences Cardiovascular Service line. The Georgia Health Sciences cardiovascular teams are diagnosing complex hypertension cases by working with interventional and non-interventional physicians as well as pharmacists, dietitians and home health personnel. Together we are creating an exceptional clinical environment where patients are overcoming their illnesses at higher rates than national averages. In this edition, Dr. Jason White, Associate Professor of Nephrology, writes about recent improvements in treating hypertension.

We are very proud of our highly effective cardiology training program led by Dr. Vincent Robinson, Professor of Cardiology and director of the program. This summer, four fellows graduated from our program. In July, we gained four trainees and wish them all the best during their time with the program. We hope the finest for our graduating trainees and anticipate they will remember their time with us with a sense of fulfillment and pride. In addition to the starting fellows, we welcome incoming faculty who have joined our team.

Many alumni practice in the Augusta Area, and we would like to invite them into the teaching process and to share their invaluable experience with us and our residents and fellows.

The cardiovascular service line is establishing an alumni group to cultivate and optimize such experiences. Our first meeting will coincide with the American Heart Association conference in Los Angeles on Nov. 5. Alumni from the cardiology and cardiothoracic training programs, past faculty and their spouses are welcome to join us. We also invite you to take a moment to provide us with your contact information, including an email address. For details of alumni and CME activities, or to volunteer your expertise and share your contact information, please contact Laura Johnson at laujohnson@georgiahealth.edu.

As always, we hope that you enjoy this edition.

Thank you.

M. Vinayak Kamath, M.D. Director, Heart and Cardiovascular Services and Chief, Cardiothoracic Surgery

Fall 2012

In This Issue • Welcome •

Cardiovascular Disease Fellowship Training

•

Resolving Resistant Hypertension

•

CME Lecture Calendar

•

Cardiovascular Conference Oct. 20-21, 2012

•

Bloodless Medicine Seminar Oct. 20, 2012

M. Vinayak Kamath, M.D.

Director, Heart and Cardiovascular Services and Chief, Cardiothoracic Surgery Georgia Health Science University 1120 15th Street, BA-4300 Augusta, GA 30912 706-721-3226 kamath@georgiahealth.edu

Cardiovascular Disease Fellowship Training CT Surgery Web Address: georgiahealth.edu/cardiothoracic

Vincent Robinson, M.B.B.S. Director of Cardiology Fellowship

Cardiology Web Address: georgiahealth.edu/cardio Cardiology Fellowship Web Address: georgiahealth.edu/cardio/fellowship

The Crown Jewel of an Academic Heart and Cardiovascular Disease Program

New Fellows

The GHSU Cardiovascular Disease Fellowship training program began in 1960 as a founding platform for the new subspecialty of cardiovascular disease.

The program’s 160-plus graduates serve throughout the Southeast and beyond in clinical practice and academia.

The program’s 160 plus graduates serve throughout the Southeast and beyond...

Approximately 75 percent of our graduates have gone on to further subsub-specialty training at some of the most prestigious institutions nationally.

Simi Kumar, M.D.

Jacob Misenheimer, M.D.

Residency: Internal Medicine at University of Connecticut

Residency: Internal Medicine at Vanderbilt University

Began GHSU Cardiology Fellowship 2012

Began GHSU Cardiology Fellowship 2012

Michele Murphy, Murphy, Michele M.D. M.D.

Lauren Holliday, M.D.

Residency: Internal Medicine at GHSU

Residency: Internal Medicine at University of South Carolina

Began GHSU Cardiology Fellowship 2012

Began GHSU Cardiology Fellowship 2012

New Physicians William Maddox, M.D.

Paul B. Pommipanit, M.D.

Paul B. Poommipanit, M.D., earned his medical degree at Tulane University School of Medicine in New Orleans, LA. He completed his internal medicine residency, cardiology fellowship and interventional cardiology fellowship programs at the University of California, Los Angeles Medical Center. He joins Georgia Health Sciences as the assistant professor of medicine and will practice coronary and vascular interventional cardiology.

William Maddox, M.D. Medical degree, MCG, AOA. He completed his internal medicine residency, chief medicine residency, and cardiology fellowship at MCG, Cardiac Electrophysiology fellowship training at the University of Alabama, Birmingham. Dr. Maddox will practice all aspects of clinical EP with a special interest in advanced ablation techniques for atrial fibrillation and ventricular tachycardia.

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Pascha Schafer, M.D.

Pascha Schafer, M.D. Medical degree, MCG, AOA. She earned her medical degree, completed her internal medicine residency and chief medicine residency training at MCG. Dr. Schafer completed her cardiology fellowship training at Wake Forest University Baptist Medical Center in June. She will practice general and non-interventional invasive cardiology. She will also serve as Associate Director of the Cardiology Fellowship Program.

Resolving Resistant Hypertension

Nationally, an increasing number of patients are diagnosed with treatmentresistant hypertension.

What is Resistant Hypertension?

Patients with treatment-resistant hypertension, or uncontrolled office blood pressure, are those who require three or more medications at optimal doses and a diuretic. Some patients are misdiagnosed with the condition and may have pseudoresistance.

Studies suggest that only 30 percent of patients fully comply with their blood pressure medications. Patient compliance is probably the most frustrating cause of pseudoresistance for physicians. True resistant hypertension requires properly measured blood pressure, appropriate and adequate treatments and patient compliance.

Interventions that improve compliance are ongoing patient education, increasing the frequency of blood pressure-related visits, encouraging self-monitoring of blood pressure and prescribing a costefficient daily fixed dose that causes the

Studies suggest that only 30 percent of patients fully comply with their blood pressure medications.

Additionally, physicians carry some blame when practicing poor prescribing habits and therapeutic inertia—continuing the same therapy when blood pressure is elevated. A recent multi-practice study demonstrated that changes were not made on 87 percent of patient encounters when blood pressure was elevated. It was estimated that increasing medications on 30 percent of those visits would increase blood pressure control from 45 percent to 66 percent.

Are Non-Pharmacologic Measures Effective in Resistant

The benefits of sodium reduction in patients with hypertension remain indisputable.

Hypertension?

Sodium reduction is closely correlated in fighting resistant hypertension. Lifestyle modifications such as weight reduction and dietary sodium restriction are particularly helpful. For every 10 kilograms of weight loss, systolic blood pressure decreases by 5 to 20 mmHg. Controversial news reports about dietary salt have caught national attention.

In a randomized controlled trial, a lowsodium diet compared with the usual American diet resulted in a 20/10 mmHg reduction in blood pressure. Individuals with resistant hypertension are relatively salt-sensitive and continue to respond favorably to a low-sodium diet.

Secondary Causes of Hypertension are Common in Resistant Hypertension All patients with resistant hypertension should be screened for secondary causes, which can include chronic kidney disease, renovascular disease, obstructive –3–

John J. White, M.D., F. A.S.N. Associate Professor Nephrology sleep apnea and hyperaldosteronism. With fewer than 100 yearly diagnoses of the rare pheochromocytomas, these diagnoses remain the focus of investigation.

Primary aldosteronism, once considered rare but now found in nearly 20 percent of patients with resistant hypertension, should also be excluded as a secondary cause. This condition can be reliably excluded by determining the patient’s aldosterone renin ratio; values lower than 20 to 30 percent rule out this condition with more than 90 percent accuracy.

Physicians should observe a cut-off for renin activity of 0.5 ng/ml/hr and at least 12 to 15 ng/dL for aldosterone before considering a diagnosis. A low renin level suggests excess sodium intake, and higher levels suggest renovascular disease. Renin levels are useful even in the absence of primary aldosteronism.

GHSU hypertension specialists recently evaluated a 26-year old African American female for resistant hypertension. Despite physical exam findings suggesting hypervolemia (edema), she had an aldosterone level of 32 ng/dL and a plasma renin activity of 16 ng/ml/hr.

These findings clearly showed a high aldosterone level driving her elevated blood pressure. The elevated renin level suggested renovascular disease.

A subsequent arteriogram demonstrated the beads-on-a-string appearance typical of fibromuscular dysplasia (Fig).

j

Cardiovascular disease remains the number one killer of Americans, directly causing 34 percent of deaths while playing a prominent role in 56 percent of all deaths.

Despite an armamentarium of therapeutic options, hypertension—the number one modifiable risk factor for cardiovascular disease—remains uncontrolled in half of all Americans with the condition.

least side effects when taken with other medications.

fibromuscular dysplasia

Resolving Resistant Hypertension (continued from page 3) Approach to Therapy

AHA Algorighms for Resistant Hypertension

Diuretics are significantly underprescribed for patients with uncontrolled hypertension. The long-acting thiazide diuretics prove most effective with chlorthalidone, which is preferred over hydrochlorothiazide. Chlorthalidone is roughly twice as potent, has a longer halflife and is associated with better 24-hour blood pressure control as compared to hydrochlorothiazide.

Confirm Treatment Resistance d Exclude Pseudoresistance d Identify & Reverse Lifestyle Factors d Discontinue Interfering Substances d Screen for Secondary HTN d Pharmacological Treatment d Refer to Specialist

Clues Suggesting More Diuretics Needed

· Dietary review suggesting high sodium intake · Larger, obese patients · Presence of Edema · Low (suppressed) plasma renin activity · Absence of increased BUN, creatinine, and uric acid while on diuretics · Chronic kidney disease Additionally, the proper combination of drugs is paramount. A common mistake is the accumulation of multiple drugs that block the renin-angiotensin-aldosterone system without administering a diuretic or vasodilator. A physician’s initial drug choice should be based on the likelihood of a stimulated RAAS system (this applies to young patients and Caucasian patients) that will respond best to ACE-inhibitors/ angiotensin-receptor blockers. Another scenario is salt-sensitivity, particularly likely among older patients and AfricanAmericans, who respond best to calcium channel blockers and diuretics. Generally, it is recommended maximizing an ACE or ARB plus a non-dihyropyridine calcium channel blocker, and an optimal dose of chlorthalidone before declaring treatment resistance.

Hypertension 2008;51:1403

My Patient Has Resistant Hypertension. What Now? Don’t fall prey to therapeutic nihilism.

Remember that cardiovascular mortality doubles for each 20/10 mmHg increase in blood pressure over 115/75. Every mmHg drop counts. For every 10-14 mmHg drop in SBP, cardiovascular-related deaths decrease by 17 percent, cardiovascular events decrease by 33 percent and stroke occurrence decreases by 40 percent.

After optimizing a three-drug regimen, a reasonable approach is to add a low dose of spironolactone. In a randomized controlled trial, almost 50 percent of patients with resistant hypertension achieved

their blood pressure target after adding 25 mg of spironolactone to their treatment regimen. Finally, the American Heart Association recommends referring patients to a hypertension specialist if treated blood pressure has been above goal for greater than six months.

We are pleased to evaluate and help manage your patients in our multifaceted hypertension clinic at GHSU.

Cardiovascular Physicians Manage Complex Cases The Heart and Cardiovascular Health Services physicians are specialists in managing complex Adult Congenital Heart Disease cases including cases such as Double Aortic Arch (shown here).

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Please contact us for more information (706)721-2328

CME Lectures Oct. 5 Speaker: Shumile Zaidi, M.D. 2nd year GHSU Cardiology Fellow Topic: Management of Unprotected Left Main Oct. 12 Speaker: Zahid Amin, M.D. from Rush University in Chicago Topic: Percutaneous and Hybrid Interventions in Congenital and Structural Heart Disease Oct. 19 Speaker: Narendra Singh, M.D. F.R.C.P.C. F.A.C.C. F.A.H.A. Atlanta Heart Specialists Topic: Ethnic Difference in Presentation and Outcomes of Cardiovascular Disease in North America

Your Heart. Our Hands.

Oct. 26

georgiahealth.org/cardio

Speaker: Michael Luc, M.D. 2nd year GHSU Cardiology Fellow

Dec. 7

Topic: Can diet and exercise prevent CV disease?

Speaker: Ashkan Attaran, M.D. 2nd year GHSU Cardiology Fellow

Nov. 2 Speaker: Michele Murphy, M.D. 1st year GHSU Cardiology Fellow

Topic: TBA Dec. 14

Topic: New Advances in Non-invasive Cardiac Imaging

Speaker: Simi Kumar, M.D. 1st year GHSU Cardiology Fellow

Nov. 9

Topic: Cardio-oncology

Speaker: Jacob Misenheimer, M.D. 1st year GHSU Cardiology Fellow

Jan. 11 Speaker: Fethi Benraouane, M.D. 3rd year GHSU Cardiology Fellow

Topic: Strategies for Managing Statin Intolerance Nov. 16

Topic: PFO and cryptogenic stroke, should we close them?

Speaker: Virgil Brown, M.D. Topic: Should the cardiologist consider HDLcholesterol a treatable risk factor?

Jan. 18 Speaker: Amin Yehya, M.D. 3rd year GHSU Cardiology Fellow

Nov. 30 Speaker: James Gossage, M.D. GHSU Pulmonary

Topic: Natriuretic Peptides in Congestive Heart Failure

Topic: Pulmonary Hypertension

Cardiovascular Conferences

Please contact us for more information (706)721-2328

Update in Cardiovascular Disease Management for Primary Care Providers Oct. 20-21, 2012 Augusta Marriot Convention Center $145 Physician Fee $95 NP, PA, RN, CRNA Fee 10 hours CME Credit

GHS Medical Center Holds Bloodless Medicine Seminar Oct. 20, 2012 GHSU Alumni Center 9 a.m. to 12:30 p.m.

The public is invited and light refreshments will be served.

georgiahealth.edu/cardio/ce

georgiahealth.org/bloodlessmedicine –5–

Non-Profit Org. U.S. POSTAGE

PAID Heart and Cardiovascular Health Services 1120 15th Street, BBR-6518 Augusta, GA 30912

Physician List Director of Heart and Cardiovascular Services M. Vinayak Kamath, M.D. Chief, Cardiovascular Medicine Sheldon Litwin, M.D. Chief, Pediatric Cardiology Kenneth Murdison, M.D. Cardiovascular Electrophysiology Adam Berman, M.D. William Maddox, M.D. Robert Sorrentino, M.D. Cardiovascular Imaging (Echo, MRI, CT and Nuclear Imaging) Preston Conger, M.D. Sheldon Litwin, M.D. Vincent Robinson, M.B.B.S. Pascha Schafer, M.D. Gyanendra Sharma, M.D. Cardiothoracic Surgery M. Vinayak Kamath, M.D. Vijay Patel, M.D.

Augusta, Georgia Permit No. 210

General Cardiology (Inpatient and Outpatient) Preston Conger, M.D. Chris Pallas, M.D. Vincent Robinson, M.B.B.S. Pascha Schafer, M.D. Gyanendra Sharma, M.D. John Thornton, M.D.

No-hassle referrals

Interventional Cardiology (Coronary and Vascular) Vishal Arora, M.D. Deepak Kapoor, M.D., M.B.B.S. Mahendra Mandawat, M.D. Paul Poommipanit, M.D.

Cardiac Surgery

Pediatric Cardiology William Lutin, M.D. Kenneth Murdison, M.D. Henry Wiles, M.D.

Convenient Locations

Pediatric Heart Surgery Mohsen Karimi, M.D.

Trinity Hospital (Summerville Bldg.)

706-481-7070

Rehabilitation and Prevention Preston Conger, M.D.

Washington Wills Memorial

706-678-9334

Vascular Surgery Gautam Agarwal, M.D., R.P.V.I.

Greensboro Lake Oconee

706-453-9803

Your time is valuable. To make an appointment for your patient, please call: Cardiology

706-721-BEAT (2328) 706-721-3226

Pediatric Cardiology

706-721-8522

Pediatric Cardiac Surgery 706-721-5621

Augusta GHSU

706-721-BEAT (2328)