oct. 2015 vol. 1 - cardiovascular interventions0.2% incidence of hemoptysis, sensor malfunction,...

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



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.


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


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!


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


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.


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


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


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.

oct. 2015 vol. 1 - cardiovascular interventions0.2% incidence of hemoptysis, sensor malfunction,...

Documents