oct. 2015 vol. 1 - cardiovascular interventions0.2% incidence of hemoptysis, sensor malfunction,...
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8 | P a g eCVI Newsletter
Location of Cardiovascular
Interventions
We are just North of Downtown at
1900 N. Mills Ave, Orlando, FL, 32803
Getting off Interstate 4 at exit 85
head East on Princeton Ave. Make a
Right on Mills Ave and take your next
Right. You are at CVI!
November 2015 CVI Newsletter
Oct. 2015 Vol. 1
CardioMems!
The Newest Device in
Cardiac Health
Also in this Issue
Changes to statin
therapy
guidelines to
prevent
atherosclerosis
Usefulness of
statin therapy in
HIV infected
patients
Poly-Pill
EECP
And more!!
Dr. Pradip Jamnadas MD
MBBS FACC FSCAI FCCP FACP
Founder and Director of
Cardiovascular
Interventions
Editor CVI Newsletter
Dear Patient,
We have some exciting updates to announce concerning our office and new developments in the field of cardiology! First off, a special thank you to Dr. Jamnadas for taking his staff on a Caribbean Cruise to Cozumel in September. If you'd like a behind the scenes look at our office vacation, check out our Facebook page for pictures!
Special notice: Edarbi is now accepted on Aetna insurance formulary, please speak to your provider if you are on ARB therapy. Thank you to all CVI patients for your patience in the matter.
We are Central Florida's original cardiology practice that offers walk-in urgent cardiac care and is designed to reduce unnecessary hospitalizations. We are also one of the few clinics that electronically sends our office note regarding your visit to your primary care provider on the same day you are seen.
CardioMems HF Device
CardioMems is a new device approved for implantation in patients with congestive heart failure class III. It has been clinically proven to reduce heart failure hospital admissions by 37%. The sensor is implanted during a right heart catheterization procedure. The sensory is the size of just a small paperclip. A limited pulmonary angiogram is also done at the time.
During the cath it is permanently placed in the pulmonary artery without the need of maintenance, as there is no battery in the device. The sensor monitors the pressure in the pulmonary artery and the patient takes daily readings from home using the patient electronic system, which sends the information to the provider.
CardioMems HF System, hardly bigger than a dime!
Upon analyzing the information, the provider can make changes to the patient’s medication to preempt a hospitalization. It is only contraindicated for those patients who are unable to take dual antiplatelet therapy for 1 month following the sensor implant. After one month, dual antiplatelet therapy is no longer needed. In the studies, there was a 0.2% incidence of hemoptysis, sensor malfunction, TIA, atypical chest pain, sepsis, arrhythmias, arterial embolism, or pulmonary artery embolism. Although the implantation is indicated for congestive heart failure and reduction of hospitalizations, there was a 20% relative risk reduction in mortality. This means that this is a very efficacious way to monitor and manage patients with congestive heart failure.
2 | P a g e CVI Newsletter
Usefulness of Statin
Therapy in HIV
Infected Patients
HIV patients now have
a dramatic improvement
in survival rate with anti-
retroviral therapy. HIV
infected adults have 1.5-
2 times greater risk of
myocardial infarction and
atherosclerosis
compared to those who
are uninfected. The risk
increases for those
infected because of
chronic inflammation,
endothelial dysfunction,
and side effects of
medications. All of these
factors contribute to the
greater likelihood of
atherosclerosis.
Up to 80% of HIV
infected patients have
significant dyslipidemia
and only 6% are on
statin therapy. Statins
are used in the
treatment of
dyslipidemia and
prevention of
atherosclerosis. In
2015, the American
Journal of Cardiology
evaluated 18 clinical
trials addressing statin
use in HIV infected
subjects receiving anti-
retroviral therapy. This
study demonstrated
that statins are
efficacious in reducing
the lipid levels in these
patients, and the use of Pravachol,
Crestor, Lipitor, and fenofibrate are
all well tolerated. Zocor in particular
is not well tolerated, specifically
because of its effects on the
cytochrome P4 50 3A4. Further,
statins also appeared to be
efficacious in reducing the burden of
subclinical cardiovascular disease in
HIV infected patients by improving
endothelial function measured by
brachial flow mediated dilation,
carotid intima media thickness, Lp-
PLA2 levels, and soluble CD 14, but
there is no data on mortality
reduction. Because of the lack of
hard core outcomes data, the
American College of Cardiology
guidelines do not make a specific
recommendation for HIV infected
patient management with statins for
lipid management. However, in a
smaller study of 108 HIV infected
patients with known clinical
cardiovascular disease, only one
underwent CT coronary angiography.
74% of the infected subjects with
high risk morphology and had
subclinical coronary piquing would
not have received statin therapy
based on the current 2013 ACC and
AHA guidelines. Therefore, although
more studies are needed, based on
the above discussion, Dr. Jamnadas
has established his own approach to
guidelines on prevention of
atherosclerosis in HIV infected
patients.
HIV infected patients should be
counseled about cardiovascular risk
reduction and a multidisciplinary
approach should be implemented
The use of statin therapy is
encouraged for patients with an
LDL level greater than 100, and in
those who have subclinical
evidence of coronary vascular
disease, the aim should be to
reduce the LDL to around 70.
Statins are well tolerated, the
recommended statins will be used
predominantly, Pravachol and
Crestor.
Changes to Statin Therapy Guidelines for Risk Reduction of Atherosclerotic Cardiovascular Disease (ASCVD)
In November 2013, the AHA in
association with the ACC released
novel guidelines regarding the
management of hyperlipidemia.
These guidelines essentially
separate management into two
broad categories; primary, and
secondary prevention.
Primary prevention is separated
into patients with LDL-C >
190mg/dL, patients with diabetes
mellitus (type I or II) aged 40-75,
with the remainder of patients
stratified based on their estimated
10 year ASCVD risk.
In a strongly positive move, all patients with a history of ASCVD, defined as a history of MI, stable or unstable angina, any arterial
7 | P a g e CVI Newsletter
6 | P a g e CVI Newsletter
Current recommendations on optimal oral antiplatelet therapy in acute coronary syndromes The P2 Y 12 inhibition is very important in acute coronary syndromes and especially when primary percutaneous coronary intervention (PCI) is planned. If there is ST elevation myocardial infarction, my recommendation is loading dose of Brilinta 180 mg, followed by maintenance dose 90 mg twice a day. This is probably superior to clopidogrel. If clopidogrel is used, a loading dose of 600 mg is suggested followed by 150 mg a day maintenance for 10 days followed by 75 mg a day when PCI is done I will consider intravenous Cangrelor followed by Plavix when this drug becomes available at Florida Hospital.
Dr. Jamnadas’ Physician’s Corner
These are new guidelines that Dr. J has personally developed. While they are in depth, they are something to consider even if you are not a physician, if they describe symptoms you yourself possess.
_________________________ EKG effects of amitriptyline overdose: Amitriptyline blocks the sodium channels, resulting in a wide complex QRS tachycardia, predominant negative complexes and 1, aVL, and greater than 3 mm complex in aVR. The treatment is sodium bicarbonate which restores the sodium channel.
Lyme disease in young patients
Patients can present with isolated neurological defects, but in addition there are many manifestations in the hot. This may be a mild pericarditis which presents as chest discomfort, mild congestive heart failure with cardiomegaly, and can also present with conduction disease such as severe first-degree heart block, complete AV disassociation, and even complete heart block. A young patient who has had an isolated neurological deficit, a previous exposure to ticks, erythema migraines, and recurrent migraine free arthralgia, are prime candidates for a workup for Lyme disease with an ELISA test.
3 | P a g e CVI Newsletter
revascularization, stroke, TIA, or peripheral arterial disease of atherosclerotic origin, are recommended to be prescribed a high-intensity statin unless contraindicated or intolerant. Statins have been categorized into high-, moderate-, and low-intensity based on their predicted percentage reduction in LDL-C. On page 7 is a table outlining these categories and the statins which satisfy each treatment criterion.
GET YOUR FLU
SHOT-
Many studies
support that The
Influenza (flu) Vaccine Decreases Risk
of Cardiovascular events such as
Heart Attack and Stroke by 12.9%.
JAMA Article: October 2013; Harvard
Medical School, October 23, 2013
Thousands of patients die of influenza
infection and the complications it
causes each year. Less than 50% of
high risk patients over 65 are
vaccinated! Life threatening
complications of Flu
include pneumonia,
heart attack and
stroke. All Cardiac
patients should ask to
be vaccinated!
Vaccine lowers the
odds of having a
major event like a
heart attack or
stroke, including
death by nearly a
third over the year
following.
The annual influenza vaccine does
more than just prevent the flu. It also
prevents complications associated
with the flu such as pneumonia and
numerous other conditions that would
require hospitalization.
Meet the rest of the physicians here at CVI!
Dr. Brian Kelly, DO
Dr. Alan Rosenbaum, MD
Dr. Chandra Bomma, MD
4 | P a g e CVI Newsletter
Cath Lab Corner In this segment we will present actual cases performed in the CVI Cath Lab with photos and brief procedural descriptions. We will tell the story so that all our readers may comprehend the remarkable things we do here for our patients.
Scott Douglas, Director of Operations.
Case Study:
A 53 year old woman is
referred for palpitations,
subclavian steal
syndrome, and weakness
and tingling in her left
arm. She additionally
complains of severe post
prandial abdominal pains
that result in nausea and
vomiting. In recent months, she has
developed an avoidance of food
leading to a loss of 35lbs. Despite a
GI work-up and CT, no clear cause had
yet been identified. The patient was
emotionally distressed when
discussing the lack of results from so
many of the previous tests
Dr. Brian Kelly, DO,
recommended a cardiac
work-up, specifically an echo
and cardiac stress
test. Additionally an
invasive catheterization was
ordered to assess the left
subclavian artery and the
abdominal aorta to identify
any vascular cause of her
abdominal angina. Dr. Pradip
Jamnadas, MD, performed the
catheterization in CVI’s own lab two
days later, where she was
discovered to have a long total
occlusion of the left subclavian
artery and a significant high grade
lesion in the celiac artery. Dr.
Jamnadas placed a Medtronic bare
metal stent in the celiac artery
without complication and
successfully restored blood
flow. The patient was recovered
for 2.5 hours and discharged home
without complication.
Remarkably, we brought lunch in
for her and her spouse during
recovery and allowed her to eat
while under observation. She had
previously had symptoms within 10
minutes of eating. That mark came
and went and soon, 30 minutes had
turned into 90 and still no
symptoms. Now that is called a CVI
Happy Meal!
Catheterization and angioplasty are
not just limited to the heart. As seen
in this case study, stenosis
(blockages) can cause a whole host
of problems elsewhere in the body.
Just another reason to stay on top of
your cardiac health!
5 | P a g e CVI Newsletter
The patient
was
discharged
and seen
the next day
in our office
after having
dinner that
night and
breakfast in the morning
without symptoms.
She will continue with
scheduled cardiac testing
and intervention of the
left subclavian artery in
two weeks. This is
another example of the
extraordinary medicine
delivered at
Cardiovascular
Interventions by Dr.
Pradip Jamnadas, MD
and Dr. Brian Kelly, DO.
Here are two of our fantastic mid-
level providers!
Julie Wiedman
MMS, PA-C
Julie graduated from Nova
Southeastern University as a
Physician’s Assistant with a specialty
in Cardiology.
With a stent placed in the celiac
artery, blood flow has been
restored, thus alleviating all of her
previous gastric symptoms!
A stent like the one used in
this case!
Joniruth Digaum
MSN, NP-C, CCRN-CMC
Joniruth graduated from South
University Tampa with her Nurse
Practioner, specialty in Cardiology.
Pradip Jamnadas, MD | Brian Kelly, DO
Alan Rosenbaum, MD | Chandra Bomma, MD
4 | P a g e CVI Newsletter
Cath Lab Corner In this segment we will present actual cases performed in the CVI Cath Lab with photos and brief procedural descriptions. We will tell the story so that all our readers may comprehend the remarkable things we do here for our patients.
Scott Douglas, Director of Operations.
Case Study:
A 53 year old woman is
referred for palpitations,
subclavian steal
syndrome, and weakness
and tingling in her left
arm. She additionally
complains of severe post
prandial abdominal pains
that result in nausea and
vomiting. In recent months, she has
developed an avoidance of food
leading to a loss of 35lbs. Despite a
GI work-up and CT, no clear cause had
yet been identified. The patient was
emotionally distressed when
discussing the lack of results from so
many of the previous tests
Dr. Brian Kelly, DO,
recommended a cardiac
work-up, specifically an echo
and cardiac stress
test. Additionally an
invasive catheterization was
ordered to assess the left
subclavian artery and the
abdominal aorta to identify
any vascular cause of her
abdominal angina. Dr. Pradip
Jamnadas, MD, performed the
catheterization in CVI’s own lab two
days later, where she was
discovered to have a long total
occlusion of the left subclavian
artery and a significant high grade
lesion in the celiac artery. Dr.
Jamnadas placed a Medtronic bare
metal stent in the celiac artery
without complication and
successfully restored blood
flow. The patient was recovered
for 2.5 hours and discharged home
without complication.
Remarkably, we brought lunch in
for her and her spouse during
recovery and allowed her to eat
while under observation. She had
previously had symptoms within 10
minutes of eating. That mark came
and went and soon, 30 minutes had
turned into 90 and still no
symptoms. Now that is called a CVI
Happy Meal!
Catheterization and angioplasty are
not just limited to the heart. As seen
in this case study, stenosis
(blockages) can cause a whole host
of problems elsewhere in the body.
Just another reason to stay on top of
your cardiac health!
5 | P a g e CVI Newsletter
The patient
was
discharged
and seen
the next day
in our office
after having
dinner that
night and
breakfast in the morning
without symptoms.
She will continue with
scheduled cardiac testing
and intervention of the
left subclavian artery in
two weeks. This is
another example of the
extraordinary medicine
delivered at
Cardiovascular
Interventions by Dr.
Pradip Jamnadas, MD
and Dr. Brian Kelly, DO.
Here are two of our fantastic mid-
level providers!
Julie Wiedman
MMS, PA-C
Julie graduated from Nova
Southeastern University as a
Physician’s Assistant with a specialty
in Cardiology.
With a stent placed in the celiac
artery, blood flow has been
restored, thus alleviating all of her
previous gastric symptoms!
A stent like the one used in
this case!
Joniruth Digaum
MSN, NP-C, CCRN-CMC
Joniruth graduated from South
University Tampa with her Nurse
Practioner, specialty in Cardiology.
Pradip Jamnadas, MD | Brian Kelly, DO
Alan Rosenbaum, MD | Chandra Bomma, MD
6 | P a g e CVI Newsletter
Current recommendations on optimal oral antiplatelet therapy in acute coronary syndromes The P2 Y 12 inhibition is very important in acute coronary syndromes and especially when primary percutaneous coronary intervention (PCI) is planned. If there is ST elevation myocardial infarction, my recommendation is loading dose of Brilinta 180 mg, followed by maintenance dose 90 mg twice a day. This is probably superior to clopidogrel. If clopidogrel is used, a loading dose of 600 mg is suggested followed by 150 mg a day maintenance for 10 days followed by 75 mg a day when PCI is done I will consider intravenous Cangrelor followed by Plavix when this drug becomes available at Florida Hospital.
Dr. Jamnadas’ Physician’s Corner
These are new guidelines that Dr. J has personally developed. While they are in depth, they are something to consider even if you are not a physician, if they describe symptoms you yourself possess.
_________________________ EKG effects of amitriptyline overdose: Amitriptyline blocks the sodium channels, resulting in a wide complex QRS tachycardia, predominant negative complexes and 1, aVL, and greater than 3 mm complex in aVR. The treatment is sodium bicarbonate which restores the sodium channel.
Lyme disease in young patients
Patients can present with isolated neurological defects, but in addition there are many manifestations in the hot. This may be a mild pericarditis which presents as chest discomfort, mild congestive heart failure with cardiomegaly, and can also present with conduction disease such as severe first-degree heart block, complete AV disassociation, and even complete heart block. A young patient who has had an isolated neurological deficit, a previous exposure to ticks, erythema migraines, and recurrent migraine free arthralgia, are prime candidates for a workup for Lyme disease with an ELISA test.
3 | P a g e CVI Newsletter
revascularization, stroke, TIA, or peripheral arterial disease of atherosclerotic origin, are recommended to be prescribed a high-intensity statin unless contraindicated or intolerant. Statins have been categorized into high-, moderate-, and low-intensity based on their predicted percentage reduction in LDL-C. On page 7 is a table outlining these categories and the statins which satisfy each treatment criterion.
GET YOUR FLU
SHOT-
Many studies
support that The
Influenza (flu) Vaccine Decreases Risk
of Cardiovascular events such as
Heart Attack and Stroke by 12.9%.
JAMA Article: October 2013; Harvard
Medical School, October 23, 2013
Thousands of patients die of influenza
infection and the complications it
causes each year. Less than 50% of
high risk patients over 65 are
vaccinated! Life threatening
complications of Flu
include pneumonia,
heart attack and
stroke. All Cardiac
patients should ask to
be vaccinated!
Vaccine lowers the
odds of having a
major event like a
heart attack or
stroke, including
death by nearly a
third over the year
following.
The annual influenza vaccine does
more than just prevent the flu. It also
prevents complications associated
with the flu such as pneumonia and
numerous other conditions that would
require hospitalization.
Meet the rest of the physicians here at CVI!
Dr. Brian Kelly, DO
Dr. Alan Rosenbaum, MD
Dr. Chandra Bomma, MD
2 | P a g e CVI Newsletter
Usefulness of Statin
Therapy in HIV
Infected Patients
HIV patients now have
a dramatic improvement
in survival rate with anti-
retroviral therapy. HIV
infected adults have 1.5-
2 times greater risk of
myocardial infarction and
atherosclerosis
compared to those who
are uninfected. The risk
increases for those
infected because of
chronic inflammation,
endothelial dysfunction,
and side effects of
medications. All of these
factors contribute to the
greater likelihood of
atherosclerosis.
Up to 80% of HIV
infected patients have
significant dyslipidemia
and only 6% are on
statin therapy. Statins
are used in the
treatment of
dyslipidemia and
prevention of
atherosclerosis. In
2015, the American
Journal of Cardiology
evaluated 18 clinical
trials addressing statin
use in HIV infected
subjects receiving anti-
retroviral therapy. This
study demonstrated
that statins are
efficacious in reducing
the lipid levels in these
patients, and the use of Pravachol,
Crestor, Lipitor, and fenofibrate are
all well tolerated. Zocor in particular
is not well tolerated, specifically
because of its effects on the
cytochrome P4 50 3A4. Further,
statins also appeared to be
efficacious in reducing the burden of
subclinical cardiovascular disease in
HIV infected patients by improving
endothelial function measured by
brachial flow mediated dilation,
carotid intima media thickness, Lp-
PLA2 levels, and soluble CD 14, but
there is no data on mortality
reduction. Because of the lack of
hard core outcomes data, the
American College of Cardiology
guidelines do not make a specific
recommendation for HIV infected
patient management with statins for
lipid management. However, in a
smaller study of 108 HIV infected
patients with known clinical
cardiovascular disease, only one
underwent CT coronary angiography.
74% of the infected subjects with
high risk morphology and had
subclinical coronary piquing would
not have received statin therapy
based on the current 2013 ACC and
AHA guidelines. Therefore, although
more studies are needed, based on
the above discussion, Dr. Jamnadas
has established his own approach to
guidelines on prevention of
atherosclerosis in HIV infected
patients.
HIV infected patients should be
counseled about cardiovascular risk
reduction and a multidisciplinary
approach should be implemented
The use of statin therapy is
encouraged for patients with an
LDL level greater than 100, and in
those who have subclinical
evidence of coronary vascular
disease, the aim should be to
reduce the LDL to around 70.
Statins are well tolerated, the
recommended statins will be used
predominantly, Pravachol and
Crestor.
Changes to Statin Therapy Guidelines for Risk Reduction of Atherosclerotic Cardiovascular Disease (ASCVD)
In November 2013, the AHA in
association with the ACC released
novel guidelines regarding the
management of hyperlipidemia.
These guidelines essentially
separate management into two
broad categories; primary, and
secondary prevention.
Primary prevention is separated
into patients with LDL-C >
190mg/dL, patients with diabetes
mellitus (type I or II) aged 40-75,
with the remainder of patients
stratified based on their estimated
10 year ASCVD risk.
In a strongly positive move, all patients with a history of ASCVD, defined as a history of MI, stable or unstable angina, any arterial
7 | P a g e CVI Newsletter
8 | P a g eCVI Newsletter
Location of Cardiovascular
Interventions
We are just North of Downtown at
1900 N. Mills Ave, Orlando, FL, 32803
Getting off Interstate 4 at exit 85
head East on Princeton Ave. Make a
Right on Mills Ave and take your next
Right. You are at CVI!
November 2015 CVI Newsletter
Oct. 2015 Vol. 1
CardioMems!
The Newest Device in
Cardiac Health
Also in this Issue
Changes to statin
therapy
guidelines to
prevent
atherosclerosis
Usefulness of
statin therapy in
HIV infected
patients
Poly-Pill
EECP
And more!!
Dr. Pradip Jamnadas MD
MBBS FACC FSCAI FCCP FACP
Founder and Director of
Cardiovascular
Interventions
Editor CVI Newsletter
Dear Patient,
We have some exciting updates to announce concerning our office and new developments in the field of cardiology! First off, a special thank you to Dr. Jamnadas for taking his staff on a Caribbean Cruise to Cozumel in September. If you'd like a behind the scenes look at our office vacation, check out our Facebook page for pictures!
Special notice: Edarbi is now accepted on Aetna insurance formulary, please speak to your provider if you are on ARB therapy. Thank you to all CVI patients for your patience in the matter.
We are Central Florida's original cardiology practice that offers walk-in urgent cardiac care and is designed to reduce unnecessary hospitalizations. We are also one of the few clinics that electronically sends our office note regarding your visit to your primary care provider on the same day you are seen.
CardioMems HF Device
CardioMems is a new device approved for implantation in patients with congestive heart failure class III. It has been clinically proven to reduce heart failure hospital admissions by 37%. The sensor is implanted during a right heart catheterization procedure. The sensory is the size of just a small paperclip. A limited pulmonary angiogram is also done at the time.
During the cath it is permanently placed in the pulmonary artery without the need of maintenance, as there is no battery in the device. The sensor monitors the pressure in the pulmonary artery and the patient takes daily readings from home using the patient electronic system, which sends the information to the provider.
CardioMems HF System, hardly bigger than a dime!
Upon analyzing the information, the provider can make changes to the patient’s medication to preempt a hospitalization. It is only contraindicated for those patients who are unable to take dual antiplatelet therapy for 1 month following the sensor implant. After one month, dual antiplatelet therapy is no longer needed. In the studies, there was a 0.2% incidence of hemoptysis, sensor malfunction, TIA, atypical chest pain, sepsis, arrhythmias, arterial embolism, or pulmonary artery embolism. Although the implantation is indicated for congestive heart failure and reduction of hospitalizations, there was a 20% relative risk reduction in mortality. This means that this is a very efficacious way to monitor and manage patients with congestive heart failure.
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