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Newsletters May 2011 - Jefferson Cardiology Happenings

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The role of coronary bypass surgery compared to medical therapy was evaluated in the recently published STICH study. In this study of 1212 patients, persons with severely weakened heart muscle were randomized to coronary bypass plus medical therapy or medical therapy alone. The enrolled pa-tients were then observed for death from any cause as well as death from cardiovascular causes and as hospitalization for cardiovascular causes.

These patients were observed for a median follow-up of 56 months. Dur-ing this period the overall mortality rates for both groups was about the same. The incidence of hospital admission rate plus all cause mortality was less in the surgi-cal group. Seventeen percent of the group randomized to medical therapy and nine percent of the surgically ran-domized group crossed over to the other group because of change in clinical status.

In conclusion, coronary artery disease patients with weakened heart muscle may not have a definite survival benefit with bypass compared with medically treated patients. As expected, patients should be treated as individuals and patients with more angina despite medical therapy may well be benefitted by coronary bypass surgery.

A companion study evaluated the patients who were judged to have areas of live heart muscle in areas of weak-ened muscle. Traditionally such patients have been referred for bypass surgery. The companion study evaluated out-comes of patients shown to have areas of live muscle in areas of reduced pumping compared with patients with weakened muscles without demonstration of live muscle in the weakened segments. The study used nuclear and stress echo techniques traditionally used to identify appropriate surgical candidates. Contrary to current thinking, demonstra-tion of live zones of muscle in areas of reduced heart function did not demonstrate better outcomes with coronary bypass surgery. This raises the question whether severe anginal symptoms are sufficient to offer coronary patients with weakened muscle. Also the question is raised as to value of nuclear or echo techniques in these patients or whether another technique would be better.

An Alternative to Mitral Valve Surgery

In this newsletter there has been past information about new techniques to change the aortic valve without open heart surgery. Recently, results of the EVEREST II trial were published. This trial evaluated the use of a chip to seal a leaking mitral valve using a catheteriza-tion technique and avoiding surgery. In this study, 279 patients with severely leaking mitral valves were randomized to surgical valve replacement or place-ment of the valve clip by catheterization.

Results of the study revealed similar mortality and similar reduction of severe valve leakage in both groups. However, more patients treated with the clip had moderate remaining valve leakage compared to surgically treated patients. Also 23% of the clip patients were referred for surgery because of severe valve leakage after one year. Short term mortality was higher with surgery.

In short, the preliminary results of the clip procedure show promise with the lower short-term mortality compared to surgery. Yet, 23% of the clip patients needed valve surgery within 12 months and 46% were left with moderate leakage as opposed to 17% of surgical patients. Past surgical studies have demonstrated that post-surgery patients with moderate residual leakage may have long-term problems. For the time being perhaps the clip procedure may be best for persons at high risk for surgery, with symptoms not well controlled by medi-cal therapy.

Vitamin D-Fad or Reality

There has been much hype in recent years about the value of vitamin D for multiple problems. Certainly, there has been long-time evidence of benefit for bone health. There was a recent re-view by the Institute of Medicine concluding that evidence of benefit for vitamin D regarding cancer, cardiovascular disease, diabetes, and diseases of the immune system are inconsistent and inconclusive. There has been some basic research suggesting benefit as well as some observational studies. However, to date there are no conclusive large scale clinical trials demonstrating benefit apart from bone structures. Now there are clinical trials that have been launched that may provide the answer to the role of vitamin D in 5-6 years.

Tuscan Lemon Muffins

1 ¾ cup all-purpose flour ¼ cup olive oil
¾ cup granulated sugar 1 tablespoon grated lemon rind
2 ½ teaspoons baking powder 2 tablespoons fresh lemon juice
¼ teaspoon salt 1 large egg, lightly beaten
¾ cup part-skim ricotta cheese Cooking spray
½ cup water 2 tablespoons turbinado sugar

1. Preheat oven to 375 degrees
2. Weigh or lightly spoon flour into dry measuring cups; level with a knife. Combine flour and next 3 ingredients (through salt); make a well in center. Combine ricotta and next 5 ingredients (through egg). Add ricotta mixture to flour mixture, stirring just until moist.
3. Place 12 muffin-cup liners in muffin cups; coat with cooking spray. Divide batter among muffin cups. Sprinkle turbinado sugar over batter. Bake at 375 degrees for 16 minutes or until a wooden pick inserted in center comes out clean. Cool 5 minutes in pan on a wire rack.

Calories 186; Fat 6.2g (sat 1.5g, mono 3.4g, poly 0.6g) Protein 4g; Carb 29.5g; Fiber 0.6g; Cholesterol 21mg; Iron 1mg; Sodium 160mng; Calcium 81mg

A publication of Jefferson Cardiology Association
Alan D. Bramowitz, M.D. | Michael S. Nathanson, M.D. | Gennady Geskin, M.D.

Jefferson Hospital Medical Building
Suite 403, Coal Valley Road
P.O. Box 18285

Belle Vernon Office
1533 Broad Ave
Belle Vernon, Pa 15012