The Facts Karla M. Ku - The Methodist Hospital

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of coronary artery disease in women: a multivariate comparison of cardiac fluoroscopy, exercise electrocardiography, and exercise thallium myocardial perfusions scintigraphy. J Am Coll Cardiol. 1984 Jul;4(1):8-16. 24. Goodgold HM, Rehder JG, Samuels LD, Chaitman BR. Improved interpretation of exercise TI-201 myocardial perfusions scintigraphy in women: characterization of breast attenuation artifacts. Radiology. 1987 Nov;165(2):361-6. 25. Taillefer R, DePuey EG, Udelson JE, Beller GA, Latour Y, Reeves F. Comparative Diagnostic Accuracy of TI-201 and Tc-99m Sestamibi SPECT Imaging (Perfusion and ECG-Gated SPECT) in Detecting Coronary Artery Disease in Women. J Am Coll Cardiol. 1997 Jan;29(1):69-77. 26. Marwick TH, Anderson T, Williams MJ, Haluska B, Melin JA, Pashkow F, et al. Exercise echocardiography is an accurate and cost-efficient technique for detection of coronary artery disease in women. J Am Coll Cardiol. 1995 Aug;26(2):335-41. 27. Cohen JL, Cheirif J, Segar DS, Gillam LD, Gottdiener JS, Hausnerova E, et al. Improved left ventricular endocardial border delineation and opacification with OPTISON (FS069), a new echocardiographic contrast agent. Results of a phase III Multicenter Trial. J Am Coll Cardiol. 1998 Sep;32(3):746-52. 28. Hochman JS, McCabe CH, Stone PH, Becker RC, Cannon CP, DeFeo-Fraulini T, et al. Outcome and profile of women and men presenting with acute coronary syndrome: a report for TIMI IIIB. TIMI Investigators. Thrombolysis in Myocardial Infarction. J Am Coll Cardiol. 1997 Jul;30(1):141-8. 29. Glaser R, Herrmann HC, Murphy SA, Demopoulos LA, DiBattiste PM, Cannon CP, et al. Benefit of an early invasive management strategy in women with acute coronary syndromes. JAMA. 2002 Dec;288(24):3124-9. 30. Cho L, Topol EJ, Balog C, Foody JM, Booth JE, Cabot C, et al. Clinical benefit of glycoprotein IIb/IIIa blockade with Abciximab is independent of gender: pooled analysis from EPIC, EPILOG and EPISTENT trials. Evaluation of 7E3 for the Prevention of Ischemic Complications. Evaluation in Percutaneous Transluminal Coronary Angioplasty to Improve Long- Term Outcome with Abciximab GP IIb/IIIa blockade. Evaluation of Platelet IIb/IIIa Inhibitor for Stent. J Am Coll Cardiol. 2000 Aug;36(2):381-6. 31. Lansky AJ, Pietras C, Costa RA, Tsuchiya Y, Brodie BR, Cox DA, et al. Gender differences in outcomes after primary angioplasty versus primary stenting with and without abciximab for acute myocardial infarction: results of the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial. Circulation. 2005 Apr; 111(13):1611-8. 32. Abramov D, Tamariz MG, Sever JY, Christakis GT, Bhatnagar G, Heenan AL, et al. The influence of gender on the outcome of coronary artery bypass surgery. Ann Thorac Surg. 2000 Sep;70(3):800-5. 33. Weaver WD, White HD, Wilcox RG, Aylward PE, Morris D, Guerci A, et al. Comparisons of characteristics and outcomes among women and men with acute myocardial infarction treated with thrombolytic therapy. GUSTO-I Investigators. JAMA. 1996 Mar 13;275(10):777-82. 34. Weaver WD, Simes RJ, Betriu A, Grines CL, Zijlstra F, Garcia E, et al. Comparison of primary coronary angioplasty and intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review. JAMA. 1997 Dec 17;278(23):2093-8. 35. ISIS-4: a randomised factorial trial assessing early oral captopril, oral mononitrate, and intravenous magnesium sulfate in 58,050 patients with suspected acute myocardial infarction. ISIS-4 (Fourth International Study of Infarct Survival) Collaborative Group. Lancet. 1995 Mar 18;345(8951):669-85. 36. Randomised trial of intravenous atenolol among 16,027 cases of suspected acute myocardial infarction: ISIS-1. First International Study of Infarct Survival Collaborative Group. Lancet. 1986 Jul 12;2(8498):57-66. 37. Lansky AJ, Costa RA, Mooney M, Midei MG, Lui HK, Strickland W, et al. Genderbased outcomes after paclitaxel-eluting stent implantation in patients with coronary artery disease. J Am Coll Cardiol. 2005 Apr 19:45(8):1180-5. 38. Mosca L, Appel LJ, Benjamin EJ, Berra K, Chandra-Strobos N, Fabunmi RP, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation. 2004 Feb 10;109(5):672-93. Epub 2004 Feb 4. 39. Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. 2001 May 16;285(19):2486-97. Recently, the National Heart, Lung, and Blood Institute (NHLBI), the American Heart Association (AHA), the Sister to Sister: Everyone Has a Heart Foundation and the American College of Cardiology (ACC) have partnered to increase public awareness. The Red Dress — promoted by the NHLBI’s “The Heart Truth” campaign and the recognized symbol of heart disease awareness in women — cautions women to heed the threat of heart disease and take care of themselves. The AHA’s “Go Red for Women” campaign designated a National Wear Red Day to increase awareness and help stimulate donations for research and education. The Sister to Sister Foundation, dedicated to bringing free screening to women, designated February 17 as National Woman’s Heart Day and offered free screenings and counseling in Dallas, Philadelphia, Miami, San Diego and Chicago. 12 II (1) 2006 | JMDHC
S U R G E RY V E R S U S A L C O H O L S E P TA L A B L AT I O N F O R H Y P E R T R O P H I C O B S T R U C T I V E C A R d I O M YO PAT H Y: T H E C O N T R OV E R SY W i l l i a m H . S p e n c e r , I I I F r o m M e d i c a l U n i v e r s i t y o f S o u t h C a r o l i n a , C h a r l e s t o n , S o u t h C a r o l i n a I n t R o d u C t I o n Hypertrophic cardiomyopathy is a common genetic illness affecting approximately one in 500 of the general population. the disease may occur spontaneously or be inherited in an autosomal dominant pattern. 1 Initially, it was felt that most patients with this illness had severe symptoms of heart failure, angina and syncope and were at high risk for sudden death. However, population studies have revealed that many patients are asymptomatic and do not have the high risk of sudden death originally found in symptomatic patients referred to tertiary medical centers. Roughly one-third of those with hypertrophic cardiomyopathy have obstructed left ventricular outflow, and the severity of the obstruction is measured by the left ventricular outflow tract gradient. therapies that reduce the pressure gradient have been shown to improve symptoms and outcomes of patients with hypertrophic obstructive cardiomyopathy (HoCm). 2 many live with minimal symptoms while taking drugs such as beta blockers or calcium channel blockers. dual-chamber cardiac pacemakers, while originally thought to effectively reduce the left ventricular outflow tract gradient, have in reality had very limited applicability in treating HoCm. 1 for severely symptomatic patients, cardiac surgery has been a long-standing therapy. Recently, however, alcohol septal ablation (asa) has emerged as an alternative to surgery. 3 s u R G e R Y V e R s u s a s a Ventricular septal myectomy is an established treatment for symptomatic HOCM, 4 and more than 2,000 patients have received this surgery in the last 40 years. Long-term follow-up has revealed that surgery effectively reduces the left ventricular outflow tract gradient, improving symptoms and exercise tolerance. Refined surgical techniques have produced better outcomes, and a relatively low (1-2%) surgical mortality is possible in experienced centers. Recent reports show better long-term survival in patients with HOCM who undergo surgery. 4 By contrast, ASA is a catheter-based procedure that instills pure alcohol into the hypertrophied ventricular septum via a septal perforator artery. 3 This results in a therapeutic myocardial infarction. The technique has been refined since its emergence a decade ago, and the procedural mortality even in the initial experience has been quite low. Ablation therapy has been shown to effectively lower the left ventricular outflow tract gradient and improve symptoms and exercise tolerance. 5 Longer-term followup of ASA shows that mortality from sudden cardiac death, which was originally feared to be high, actually is less than what might be expected in an untreated population of severely symptomatic patients. 5 Studies also show an improvement in left ventricular diastolic function and mitral regurgitation as well as long-term regression of left ventricular hypertrophy. 6 Unlike myectomy surgery, ASA can not be applied to all patients with HOCM. Those with abnormalities of the cardiac valves or papillary muscles must be treated with myectomy surgery combined with other techniques such as valve repair or replacement. t H e d e B at e o V e R a s a The advent of ASA as an alternate treatment for severely symptomatic HOCM patients has created controversy. 7 Some say that the induced therapeutic myocardial infarction could result in an “arrhythmogenic scar.” Some also claim that this “arrhythmogenic scar” will result in an increased incidence of sudden death, ventricular dysfunction and/or heart failure during long-term follow-up. Because large numbers of patients have undergone ASA worldwide, many believe that the indications for therapy in terms of disease severity and symptoms have been lowered considerably below those for surgery. Finally, there have been reports that short-term results with ASA are inferior to surgery because they produced less gradient reduction and more mitral regurgitation on follow-up, and that a number of ASA-treated patients have required a second procedure because results from the first were inadequate. s t u d Y R e s u lt s f R o m t H e m e t H o d I s t H o s P I ta l Several studies comparing the results of ASA and surgical myectomy have been published, and all have been non randomized, uncontrolled and observational. The results of ASA performed at The Methodist Hospital in Houston, JMDHC | II (1) 2006 1
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