Coronary Artery Disease

What Is Coronary Artery Disease?

Coronary artery disease (CAD) occurs when the arteries that supply blood to the heart muscle (coronary arteries) become hardened and narrowed. The arteries harden and become narrow due to the buildup of plaque on the inner walls or lining of the arteries (atherosclerosis). Blood flow to the heart is reduced as plaque narrows the coronary arteries. This decreases the oxygen supply to the heart muscle.

Coronary artery disease (CAD) is the most common type of heart disease. It is the leading cause of death in the U.S. in both men and women.

When blood flow and oxygen supply to the heart are reduced or cut off, you can develop:

Angina. Angina is chest pain or discomfort that occurs when your heart is not getting enough blood.

Heart attack. A heart attack happens when a blood clot suddenly cuts off most or all blood supply to part of the heart. Cells in the heart muscle that do not receive enough oxygen-carrying blood begin to die. This can cause permanent damage to the heart muscle.

Over time, CAD can weaken your heart muscle and contribute to:

Heart failure. In heart failure, the heart is not able to pump blood to the rest of the body effectively. Heart failure does not mean that your heart has stopped or is about to stop working. But it does mean that your heart is failing to pump blood the way that it should.

Arrhythmias. Arrhythmias are changes in the normal rhythm of the heartbeats. Some can be quite serious.

Treatments for CAD:

Percutaneous Transluminal Coronary Angioplasty (PTCA)
Coronary Stent Placement
Directional Coronary Atherectomy (DCA)/Rotoblader procedure

There are multiple clinical research studies available for patients with coronary artery disease.

The term heart failure simply means that your heart isn't pumping blood as well as it should. Heart failure doesn't mean your heart has stopped working or that you are having a heart attack. Heart failure is also called congestive heart failure, or CHF. "Congestive" means fluid is building up in the body because the heart isn't pumping properly.

What causes heart failure?

Coronary artery disease

Problems with the heart muscle itself (cardiomyopathy)

High blood pressure (hypertension)

Problems with any of the heart valves

Abnormal heart rhythms (arrythmias)

Substance abuse

Congenital heart disease

Diabetes

Thyroid problems

What are the symptoms of heart failure?

Shortness of breath (perhaps when walking or climbing stairs)

Shortness of breath when lying down flat in bed

Waking up in the night, suddenly breathless

General tiredness or weakness

Swelling of the legs (usually just the feet or ankles)

Rapid weight gain (1 or 2 pounds a day for 3 days in a row)

Chronic cough

If you have chest pain – Call 911!!

Call your doctor if you have any of these symptoms, especially if you've had heart problems before.

What treatment will I need?
Much can be done to improve the heart's pumping and to treat the symptoms, but heart failure can't be completely cured. An important part of treatment is taking care of any underlying problems, such as high blood pressure. Treatment also includes lifestyle changes and medicine.

Here are some important things you should talk about with your doctor:

Diet--you may be told to reduce the amount of salt you eat. You doctor may also tell you to eat a diet low in fat and cholesterol.
Alcohol--you will be advised to drink less alcohol.
Exercise--most people with heart failure can still exercise, but your doctor will help you decide how much and what kind of exercise you can do.
Weight--Your doctor will tell you if you need to lose weight.
Family support--your family can be a big help to you, so involve them when possible.
Other sources of support--your doctor can give you information about support groups. It sometimes helps to talk with other people who have similar problems.

What medicines will I need to take?
Several kinds of medicines are commonly used to treat heart failure:
ACE inhibitors. ACE inhibitors help open (dilate) your arteries and lower your blood pressure, improving blood flow.
Diuretics. Diuretics are often called "water pills" because they make you urinate more often and help keep fluid from building up in your body. They can also decrease fluid that collects in your lungs, which helps you breathe easier.
Beta blockers. Beta blockers can improve blood flow and may help prevent some heart rhythm problems.
Digoxin. Digoxin (also called digitalis) helps the heart pump better. It may be combined with other medicines.
You might need to take other medicines if you have other problems or if you have side effects with any of these medicines.

You should call your doctor if you have any questions about your condition or medicine.

For more information regarding the Heart Failure programs at New York Presbyterian / Columbia University Medical Center, contact Donna Mancini, MD, Medical Director, Cardiac Transplantation at (212) 305.0000 or via email at …….@NYP.org – need contact number and email from Dr. Mancicin

Heart Valve Disease
There are four valves within your heart. They are the mitral, tricuspid, aortic and pulmonic valves. The valves make sure blood flows in only one direction through the heart.

Valve Disease
Valve disease occurs when your heart's valves do not work correctly. This can be caused by valvular stenosis or valvular insufficiency.

In valvular stenosis, the tissues forming the valve leaflets become stiffer, narrowing the valve opening and reducing the amount of blood that can flow through it. If the narrowing is mild, the overall functioning of the heart may not be reduced. However, the valve can become so narrow (stenotic) that heart function is reduced, and the rest of the body may not receive adequate blood flow.

Another condition, called valvular insufficiency (or regurgitation, incompetence, "leaky valve"), occurs when the leaflets do not close completely, letting blood leak backward across the valve. This backward flow is referred to as “regurgitant flow.”

Some patients may have both valvular stenosis and valvular insufficiency in one or more valves. Valve disease causes the heart muscle to work harder to circulate the right amount of blood through the body.

Causes of Heart Valve Disease
There are many types of valve disease .Valve disease can be congenital (present at birth) or may be acquired later in life. Sometimes the cause of valve disease may be unknown.

Congenital valve disease is an abnormality that develops before birth. It may be related to improper valve size, malformed leaflets, or an irregularity in the way the leaflets are attached. This most often affects the aortic or pulmonic valve.

If the valve disease is more serious, the symptoms can include:

Breathlessness during exertion

Waking up at night short of breath

Palpitations (irregular, fluttery heartbeat)

Angina (chest pain) because the blood vessels supplying the heart muscle are not getting enough blood

Swelling of the ankles or feet

Tiredness

Dizziness or fainting

Bicuspid aortic valve disease is a congenital valve disease that affects the aortic valve. Instead of the normal three leaflets or cusps, the bicuspid aortic valve has only two. Without the third leaflet, the valve may be:

stenotic - stiff valve leaflets that can not open or close properly

leaky - not able close tightly

This occurs more frequently in some family members. About 1/4 of patients may have some enlargement of the aorta above the valve. Bicuspid aortic valve disease affects about 2 percent of the population.

Acquired valve disease includes problems that develop with valves that were once normal. These may involve changes in the structure of your valve or infection.

Infection

Infective endocarditis and rheumatic fever are the two common infections that cause valve disease.

Rheumatic heart disease
Rheumatic fever causes a common type of valve disease, rheumatic heart disease.

It causes:

the heart valve leaflets to become inflamed

may cause the leaflets to stick together and become scarred, rigid, thickened and shortened

may cause one or more of the valves (most commonly the mitral valve) to become stenotic (narrowed) or leaky

Rheumatic fever is usually caused by an untreated streptococcal infection, such as strep throat. The use of penicillin to treat strep throat can prevent this disease. Rheumatic fever occurs most often in children aged five to fifteen, but symptoms of valve disease may not be seen for years. The valve itself is not infected in rheumatic fever. Antibodies developed by the body to fight the infection react with the heart valves, causing inflammation and eventual scarring.

Endocarditis
Endocarditis is a major infection and can be life-threatening. It occurs when germs (especially bacteria) enter your blood stream and attach to the surface of your heart valves. With endocarditis:

germs attack the heart valve, causing growths on the valve, holes in the valve or scarring of the valve tissue

may cause the valve to leak or become stenotic (narrowed)

The germs can enter your blood stream during:

dental procedures

surgery

intravenous (IV) drug use

severe infections

If you have valve disease (unless you have mild forms of mitral valve prolapse) or have had valve surgery, you are at increased risk for getting this life-threatening infection. Click here to learn more.

Stretching or tearing of chordae tendineae or papillary muscles

Other causes of valve disease include: coronary artery disease, heart attacks, cardiomyopathy (heart muscle disease), syphilis, hypertension, aortic aneurysms, connective tissue diseases, and less commonly, tumors, some types of drugs and radiation.

Changes in your valve structure can occur due to both acquired and congenital causes. These include: Stretching or tearing of chordae tendineae or papillary muscles most commonly occurs to the mitral valve.

This can be a result of:

heart attack

heart valve infection

trauma

If the chordae become torn or papillary muscles become stretched, the leaflets may flop backward when the ventricles contract (flail leaflet), causing a leaky valve.

Mitral valve prolapse (MVP) is a type of myxomatous valve disease. MVP causes the leaflets of the mitral valve to flop back into the left atrium during the heart's contraction. MVP also causes the tissues of the valve to become abnormal and stretchy, causing the valve to leak.

Is mitral valve prolapse serious?
MVP occurs in about 1 to 2 percent of the population and equally in men and women. Most often it is not a cause for concern. Only 1 in 10 patients with MVP eventually require surgery. If the prolapse becomes severe or is associated with torn chordae or flail (floppy, lacking support) leaflets, the leak may be greater, and surgery may be needed.

Fibro-calcific degeneration most commonly affects the aortic valve. It most often occurs in adults over the age of 65. This condition can be compared to atheroma in coronary artery disease. The valve leaflets become fibrotic (thickened) and calcified (hardened), producing a narrowed valve opening. Risk factors for this type of valve disease include:

increased age

low body weight

high blood pressure

Dilatation of the valve annulus is a widening or stretching of the annulus. This causes the leaflets to lack support and not close tightly.

Dilatation may occur when the heart muscle is damaged due to:

a heart attack (heart muscle injury)

cardiomyopathy (weakened heart muscle)

heart failure

advanced stages of high blood pressure

syphilis

inherited disorders (such as Marfan syndrome)

Treating Heart Valve Disease
Treatment depends on what is wrong with the valve and how serious the problem is.

Medicines may be prescribed to relieve the symptoms:

Diuretics - these help to reduce swelling by encouraging the body to get rid of   excess water in the urine

ACE-inhibitors - these help the heart work more effectively by relaxing blood vessels and so improving blood flow

Digoxin - stabilizes the heart rhythm and helps the heart pump harder

Percutaneous Valve Treatment
Mitral Valve Repair - E-valve (EVEREST I) Trial – is an FDA-approved prospective multi-center phase I clinical trial to evaluate its percutaneous repair system in the treatment of patients with moderately severe or severe MR. The primary endpoint is acute safety at thirty days, with a secondary efficacy endpoint of reduction of MR.

To be considered for the Evalve study contact Dr. William A. Gray at 212.305.7060 or at wgray@crf.org

Aortic Valve Repair
Percutaneous Balloon Valvuloplasty - A relatively noninvasive treatment for valvular heart disease. A small incision is made in the skin and a catheter is passed through a major vessel (aorta, vena cava) to the heart. By using an inflatable balloon-tipped catheter, narrowed valves may be re-opened, resulting in improved blood flow across the diseased valve.

The REVIVAL trial is a randomized study of the Percutaneous Heart Valve (PHV) compared to Aortic Balloon Valvulopoasty (ABV) for the treatment of severe aortic stenosis.  This feasibility study would be followed by a similarly structured multi-center pivotal trial.

To be considered for the REVIVAL study contact Dr. Jeffrey Moses at 212.305.7060 or at jmoses@crf.org

For more information regarding the open-heart program for repairing or replacing the heart valves at New York Presbyterian / Columbia University Medical Center contact 212.305.2500 or visit them on the web at link to www.columbiasurgery.com