Senior Consultant Interventional
Cardiologist, In charge – Heart Failure
Clinic, Fortis Escorts Heart Institute
(FEHI), New Delhi
This is the Golden Era of Cardiology. No other field in medicine has seen so many advances as in this field and its just the beginning. The death rate of acute heart attacks has halved in past two decades. The focus is now shifting to prevention, early detection and minimally invasive treatment of the disease.
Trends in cardiac imaging
There is already a discernable shift from diagnosing disease at a later stage, after symptoms occur, in asymptomatic diagnosis. Patients at high risk can now be selected on the basis of risk profiles and screened in the doctors office. An important recent development is the realisation that the vast majority of heart attacks are not due to progressive atherosclerosis, but to sudden rupture of non-occlusive, vulnerable plaque. CT angiography is now widely being used in the emergency department to distinguish noncardiac chest pain from those acute heart attack patients in whom the initial ECG is non-diagnostic. Cardiac MR is also very helpful in diagnosing structural diseases of the heart with greater accuracy.
Trends in drug treatment of disease
After the publication of courage trial, which showed that in patients with stable angina, drug treatment is equally effective as angioplasty or bypass surgery, more and more patients with stable coronary artery disease (CAD) are being managed medically. Newer drugs such as ivabradine and ranolazine are very effective in control of symptoms.
Ticagrelor and prasugrel are novel anti-platelet agents, which are being used in the treatment of acute heart attack patients and in patients who undergo angioplasty. Their usage has reduced cardiovascular death, stent thrombosis and urgent target vessel revascularization. Dabigatran, apixaban and rivaroxaban are very exciting addition for stroke (paralytic attack) prevention in patients suffering from atrial fibrillation, a form of irregular heartbeat.
Trends in interventional cardiology
Today, most type of diseases can be treated by less invasive catheter based interventions obviating the need for more complex surgery. Transcatheter Aortic Valve Replacement (TAVI) has made life very comfortable for high surgical risk patients with aortic stenosis. Moreover, till now, mitral valve leakage repair was strictly a domain of surgeons. Recently, a percutaneously applied clip called MitraClip has allowed lots of patients avoid high-risk surgery. Multiple long blockages are now increasingly being treated by angioplasty because newer medicated stents have shown excellent long-term safety and efficacy. Another milestone in the treatment of coronary artery disease is the advent of Biodegradable Scaffold, also known as vanishing stent – a device that keeps the artery open till it heals and then gradually dissolves to leave behind a normal, natural artery. One of the most important innovations for management of CAD patients is cath table assessment of significance of blockage by fractional flow reserve (FFR). It is a simple and accurate guide to tell us whether a blockage needs fixing or can be left on medications.
Trends in heart failure
As the survival in patients with CAD is improving, the number of patients suffering from heart failure or weak heart is also increasing. Management of these sick patients is very difficult and these patients require frequent hospital admission. However today, along with medicines, various devices like implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT) have allowed these patients to live longer with good quality of life. Now definitive treatment such as cardiac transplant and artificial heart is also widely available.
Now the distinction between a cardiologist, a surgeon and an imaging expert is blurring and a new approach called the heart team approach is necessary to properly uate and treat the patient.
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