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Phone: (407) 894-4880
Fax: (407) 894-2364
CARDIOVASCULAR INTERVENTION | 1
Dr. Pradip Jamnadas MD
MBBS, FACC, FSCAI, FCCP, FACP
Founder and Director of Cardiovascular
ALSO IN THIS ISSUE
Dec 2015 2
Happy Holidays everyone! We hope that
everyone is staying safe and healthy going
into the end of 2015. We here at CVI are
eagerly awaiting our 2nd
Party that I am throwing. The staff at CVI
loves to have a good time, but we are also
well aware that with the holidays comes a
great deal of stress for many people.
Keeping that in mind, it is especially
important to stay on top of your health
during this part of the year! We hope
that some of the information in this
newsletter can help you stay
knowledgeable about the cardiovascular
risks that can unfortunately become very
relevant for some during the holidays.
That being said, Cardiovascular
Interventions would again like to wish
everyone an incredibly happy and safe
holiday, and we hope to see you here at
CVI next year!
- Dr Pradip Jamnadas, MD
Carotid Artery Disease:
Current Treatment Strategies
The degree of carotid stenosis increases
the risk of stroke, with an annual
incidence of about 3% for an 80 to 89%
stenosis and 5% with a 90 to 99% stenosis
in an asymptomatic patient. In
symptomatic patients, the annual stroke
risk is between 5 and 13%. However,
since this data became published,
aggressive medical therapy has changed
outcomes. Medical therapy for patients
with carotid disease includes
antiplatelets, ACE inhibitors, angiotensin
receptor blockers, and statins.
As a group, antiplatelet therapy reduces
strokes and Transient Ischemic Attacks
(TIAs) by 22%. For secondary prevention
of stroke, the use of Aspirin plus
dipyridamole was equivalent to Plavix. A
similar reduction was also noted with
aspirin plus Plavix versus Plavix alone in
patients with TIAs. In the TAIST Tiral,
anticoagulants provided similar outcomes
to antiplatelet therapy for primary as well
as secondary stroke prevention.
Treatment to control blood pressure in
stroke victims should include a diuretic. It
seems that stroke patients benefit from
diuretic therapy significantly compared to
the other patient populations. All
patients should be on a statin, ARB and
ACE inhibitor. High dose statins reduce
the stroke rate for primary and secondary
prevention (JUPITER Study).
Revascularization using carotid
endarterectomy or carotid artery
stenting, one need to have a high-volume
operator, with selective interventions
only. The relative risk reduction in
ipsilateral stroke was 53% in
asymptomatic patients in the ACAS study
Dietary Series with Julie
Results of our 2015 customer
Clinical Pearls of the
Management of GERD
DON’T FORGET TO COMPLETE A REVIEW OF
THE CARE YOU HAVE RECEIVED HERE AT
ORLANDO AT ANY OF THE WEBSITES BELOW
(Continued on page 2)
2 | CARDIOVASCULAR INTERVENTION
D R . P R A D I P J A M N A D A S , M D
Founder and Director of Cardiovascular
J I T E N K A P A D I A
C H R I S S I C K I N G E R
and 65% in symptomatic patients in the
NASCET study with carotid endarterectomy
versus medical therapy. Carotid artery
stenting however is reserved for high risk
patients who have a higher 30 day risk of
stroke and death and it was better than
carotid endarterectomy at 30 days in the
SAPPHIRE Study. In the CREST Trial, the
outcomes were similar with carotid
stenting and carotid surgery.
Take Home Points: Aggressive medical
therapy improves vascular biology.
Symptomatic patients should get
Percutaneous Intervention and
endarterectomy should both be
considered. High grade lesions should be
(Continued from page 1)
D R . B R I A N K E L L Y , D O
D R . A L A N R O S E N B A U M , M D
D R . C H A N D R A B O M M A , M D
J O N I R U T H D I G A U M
M S N , N P - C , C C R N - C M C
J U L I E W I E D M A N
M M S , P A - C
Average score in each category
Quality care is very important to us here at
Cardiovascular Interventions. Over the last
several months you may have noticed
some patient quality surveys being handed
out. Here are some of the results from our
survey on a scale of 1-5 (5 being perfectly
are very proud
to offer some
of the best
cardiac care in
If there is ever
on, please let
CARDIOVASCULAR INTERVENTION | 3DECEMBER 2015
Is there a relationship between high triglyceride
levels and increased cardiovascular risk?
DIETARY SERIES WITH JULIE WIEDMAN
Hypertriglyceridemia (HTG) is associated with low
HDL, small dense LDL particles, increased VLDL
remnants, coagulation changes and increased
fibrinogen. Both LDL increase and TG (triglyceride)
increase lead to atherosclerosis while an increase in HDL
has no proven link to ASCVD risk. The TNT Study showed
high TG and low HDL correlate with CVD risk even when
LDL is well controlled. In the study, patients on a statin
with LDL <70 who had HDL 37 and TG 186 had 39% higher
5 year risk of major CVD events than patients with HDL
>55 and TG 122. The PROVE IT Trial confirms that people
with LDL <70 and TG >150 have 6.2% higher CAD risk. HTG
strongly predicts CVD risk even with excellent LDL C
control on statin. This is because high TG are linked to
small dense LDL which have many apoB. ApoB are
atherogenic lipoproteins that carry cholesterol. On the
other hand, apoA is good protective HDL. Even when you
correct for low HDL, there is still an increased risk for CVD
with high TG.
Most forms of HTG are of secondary origin. There are
some genetic causes such as familial HTG. Familial
hypertriglyceridemia is associated with LDL >190. In the
last 10 years, LDL has dropped 11%, but TG has increased
6%. This is due to obesity and diabetes, 50% of CKD
patients have HTG also. Other causes of HTG are insulin
resistance, hypothyroidism, increased alcohol intake, high
carb diet, estrogen, thiazide diuretics, and beta blockers.
Omega 3 has been shown to be beneficial in treating HTG
with a 20-30% reduction with proper dosage. A four gram
daily dose is recommended. Make sure to inquire about
omega 3 if your triglyceride levels concern you.
There is up to a 50% reduction in TG from diet and
lifestyle. Diet should be low in sugar, carbohydrates, and
fat. Exercise 30 minutes as many days a week as you can.
TG reduction is the first and most notable effect of
exercise on lipid profile. To increase HDL requires
extensive activity, and LDL is not shown to decrease with
exercise (though weight loss helps). A guideline is to treat
by nutrition and physical activity for all. Medication is
advised if the triglyceride level is above 500. If the level is
between 200 and 500 in a high risk patient, a statin is
advised. HTG is best treated generally with statins, fibrate
(which works better if you have DM also), omega-3 (EPA
only appears better but trials are pending), and Niacin last
because there is no benefit if TG is less than 500 per
current data available.
More on Triglyceride Levels
Triglycerides are a marker for coronary artery disease
and should be treated when the fasting levels
exceed 150. The cornerstone of therapy, in levels of
triglycerides, up to 500, is intensive lifestyle changes and
weight loss. Fibrates, niacin, and fish oils are indicated for
levels greater than 500 because of the risk of pancreatitis.
The risk of pancreatitis increases as triglyceride levels
exceed 1000 with an approximate overall risk of 20%.
Weight loss and diet can reduce triglycerides by 20%,
aerobic activity 20%, decreasing carbohydrates 2%,
fibrates 20-50%, niacin 20-50%, and fish oils up to 40%.
In 2013, the ACC and AHA recommended treatment for
levels greater than 500 but no recommendations for
triglyceride lowering therapies less than 500. This does
not mean that there is no benefit in the treatment, it just
means that there are no trials.
Dr Jamnadas recommends triglyceride levels to be less
4 | CARDIOVASCULAR INTERVENTION DECEMBER 2015
Clinical Pearls for the
Management of GERD
Here is some useful information concerning
Gastroesophageal Reflux Disease (GERD) that should come
in use during the holidays!
Manifestations of GERD can be typical or atypical such as
cough, chest pain, or hoarseness of the voice. In most
cases, a 6 week trial of a Proton Pump Inhibitor (PPI) is
reasonable and cost-effective. Do not continue PPI
indefinitely. Endoscopy is not necessary in most patients.
However, if they have dysphagia, weight loss, or bleeding,
it may be necessary. Ambulatory pH monitoring should be
used in patients with symptoms that do not respond to
PPIs and those in whom antireflux surgery is being
considered. Head of bed elevation and aggressive weight
loss are the only lifestyle interventions that have proven
effective in GERD.
Lifestyle modifications are the first line of treatment which
includes weight loss, head of bed
elevation, avoidance of tobacco,
avoidance of alcohol, and abstaining
from late night meals. Coffee,
caffeine, chocolate, spicy foods,
highly acidic foods such as oranges
and tomatoes, and fatty foods
aggravate GERD. Sodium bicarbonate, calcium carbonate,
magnesium hydroxide, and aluminum hydroxide are
available over-the-counter and relieve heartburn
symptoms by neutralizing the
acid in the esophagus.
Sodium alginate acts directly
on the acid pockets that
occur and result in a change
in the pH in the stomach and
the sodium bicarbonate
releases carbon dioxide and
relieves the symptoms more
effectively than simple
antacids, H2 receptor
blockers, and more swiftly
compared to PPIs. PPIs
relieve symptoms in 70-80% of patients after a 6-8 week
course. PPI should be taken 30-60 minutes before meals.
In 2010, the US FDA issued warning regarding the
potential for wrist, hip, and spinal fractures in patients
who are using PPIs. There is also an increased risk of
community-acquired pneumonia but this link has not been
clearly established. PPI may increase the risk of C. difficile
infection, and some observational studies have
demonstrated that. The antiplatelet activity of Plavix
requires activation by the same
cytochrome system CYP as required
for metabolism of a PPI. Recent
studies demonstrate no increased
risk of adverse cardiovascular events
in patients on PPIs based on well
controlled randomized trials. The
ACC therefore stated that PPIs may be used for
appropriate indications in patients also taking Plavix. It is
of note that PPIs may decrease magnesium absorption.
GASTROESOPHAGEAL REFLUX DISEASE
CARDIOVASCULAR INTERVENTION | 5DECEMBER 2015
Non-Steroidal Anti-Inflammatory Drugs and Bleeding, Risk of
Patients with atrial fibrillation take anticoagulants to decrease the risk of
stroke. A recent study showed that the use of Non-Steroidal Anti-
Inflammatory drugs (NSAIDs) in these patients drastically increases their
risk of GI bleeding, especially if
taken for more than 14 days.
More importantly, these agents also increase the risk of thromboembolic
episodes. It is important to remember that NSAIDs decrease prostacyclius
which causes endothelial dysfunction. Thus NSAID agents should NOT be
used in patients on anticoagulant therapy.
Hormonal Therapy for Menopause; Earlier is Safer
In a recent study, patients given hormonal
replacement therapy within six years of menopause
had a decrease in the carotid intimal thickness
progression compared to patients who are 10 years
REMOVED from menopause. This is consistent with
previous studies in which Hormonal Replacement
Therapy given early, probably within 6 years of
menopause, is safer than initiating it later on.
Pradip Jamnadas,MD | | Brian Kelly, DO
Alan Rosenbaum, MD | | Chandra Bomma, MD
6 | CARDIOVASCULAR INTERVENTION DECEMBER 2015
In symptomatic patients with
suspected coronary artery disease, the
initial CTA (computed tomography
angiography) vs functional testing
pathways were evaluated. There was
no difference in outcomes at 2 years
Left atrial appendage closure is an alternative to oral
anticoagulation therapy that can be used to reduce the
risk of stroke in patients with nonvalvular atrial fibrillation.
The Lariat and Watchman are two types of devices.
The morphology of the left atrial appendage needs to be
determined by CT scan or MRI. The morphology can be
categorized as a chicken wing, cactus, windsock, or
cauliflower, the latter being the highest risk of embolic
If contraindications to anticoagulation therapy exist, this is
an alternative treatment that can be offered to patients.
Nonrandomized clinical studies demonstrate equivalency
of oral anticoagulation therapy with implantation of one of
Keep in mind that with the Watchman device, the patients
were anticoagulated for 5-7 days and then dual
antiplatelet therapy for 6 months. This means that
absolute contraindications to anticoagulation disqualifies
patients from the Watchman therapy.
Atrial fibrillation affects 1-2% of the population. It
increases the risk of stroke by 4-500%. Stroke is the fourth
most common cause of death and leading cause of
disability in the United States. Atrial fibrillation accounts
for 15% of strokes in people of all ages and 30% in those
over the age of 80. Untreated, atrial fibrillation results in
approximately 5% of patients suffering a stroke within a
year. Most of them are embolic and originated from the
left atrial appendage.
Left atrial appendage is the most common site of
thrombus formation in nonvalvular atrial fibrillation.
Ninety percent of the thrombi are discovered in this
position. In a previous study, in those patients who are
not on anticoagulants, who have atrial fibrillation for more
than 48 hours, about 15% of them have a left atrial clot.
CHADS2VASC tools are used to assess risk, and a score of 1
in a man indicates moderate risk and a score of 2 or more
indicates high risk.
Tools for assessing bleeding risk include ATRIA 2, and HAS
BLED. The HAS BLED risk factors are hypertension,
abnormal renal or liver function, stroke, bleeding, labile
INR, age over 65, and drug or alcohol use. Each of these
carry ONE point. The risk of bleeding is considered high
when the score is 3 or higher.
If the patient is undergoing cardiac surgery for another
reason, the surgeon can exercise, suture, staple, or clip the
left atrial appendage. Closure is recommended as part of
Left Atrial Appendage Closure
Promise Study; CTA vs Routine Work up
of Chest Pain
CARDIOVASCULAR INTERVENTION | 7DECEMBER 2015
Percutaneous occlusion: The PLAATO Device contains an
expandable nitinol covered cage designed to be placed in
the orifice of the left atrial
appendage. Over time, tissue
grows into the device, entirely
isolating the appendage from
the rest of the atrium. In the
original study, the annual risk
of stroke was 2.2% and
reduction in relative risk was
65%. This device was then
discontinued. The Watchman
Device, evolved from the
original PLAATO Device, and is
a self-expanding structure, was
in the PROTECT AF trial and it
was compared to long term
warfarin therapy. The device
group was treated with warfarin for 4-5 days to allow the
device to endothelialize. The warfarin was then
discontinued if the transesophageal echocardiogram
demonstrated complete closure, or there was significantly
reduced flow around the device. Patients in the device
group were then treated with aspirin and Plavix for 6
months, and then aspirin indefinitely. The results
demonstrated that the Watchman reduced the rate of
hemorrhagic stroke compared to warfarin and was not
inferior to warfarin in all cause mentality and stroke.
Most of the published data have been about efficacy of
occlusion devices compared to long term warfarin therapy.
Unfortunately the population that has not been studied
extensively is patients who have contraindications to long
term oral anticoagulation who would benefit most from an
The Lariat System Delivery
Device is approved by the FDA
and this involves a magnet
tipped wire that is passed to
the epicardial side of the left
atrial appendage by a
pericardial access to meet a
second magnet tipped wire
introduced into the appendage
by a transspetal access. Then,
a lasso is placed around the
appendage. Nothing is left
inside the heart. This could
eliminate the need for short
and long term anticoagulation
as there is no foreign body left
withing the heart. At one year, there was a 98% stroke
The trials discussed above had specific inclusion and
exclusion criteria, and therefore although they support the
percutaneous intervention, and generalization, the results
remain in question. In the PROTECT AF study, the average
CHADS score was only 2.2 and it included patients who
could tolerate aspirin as well as Plavix for a significant
period of time. This cannot therefore apply to patients
who have contraindications to anticoagulants.
In my opinion, a device that does not require
anticoagulants at all is the most desirable, but the Lasso
technique is technically challenging.
according to the PROMISE trial.
Further, there was a similar cost for
both strategies over 3 years. Greater
than 10,000 symptomatic patients
were randomized to coronary CTA or
functional testing. The endpoints
were death due to myocardial
infarction or hospitalization. The
primary endpoint was 3.3% in the CTA
group and 3% in the functional testing
group. CTA was associated with fewer
cardiac catheterizations showing no
obstructive coronary artery disease,
but more patients in the CTA group
underwent cardiac catheterization.
The difference is about 3%.
In office practice, it is still easier to do
functional testing such as Nuclear
Stress Testing. However, in the
hospital, the real advantage of CTA is
quicker availability of the test. Hence
it is more practical in the ER setting.
CARDIOVASCULAR INTERVENTION | 7DECEMBER 2015
CARDIOVASCULAR INTERVENTION | 8
Just North of Downtown at
1900 N. Mills Avenue, 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
More to come from our
Dietary Series with Julie
Blood Pressure Target
May not be what you think
What is it? And what symptoms to
looks out for.
Updates on Mitral Value
Repair and Replacement.
New classifications from The American
College of Cardiology
annual holiday party is almost upon us.
We are planning on celebrating Christmas as a
group with our families. The celebration will
be held at the Double Tree hotel, with food,
drinks, dancing, live entertainment and Santa
might stop by. Dr Jamnadas is a great host so
the party is sure to be a good time.
We really appreciate his kindness on allowing
us here at CVI to enjoy ourselves during these
special times. The staff is very hard working
and for this we are grateful for fun times.
On our cruise on September 10-14, 2015, we
voyaged to Cozumel, Mexico and that was an
amazing trip, on the way there and back we
were able to spend lots of time as a group
along with Dr Jamnadas.
In the spirit of the holidays, the giving and
receiving of gifts is at the heart of actions this
season, but we must not forgot its also a time
to give back to those less fortunate. We look
forward to celebrating more with Dr Jamnadas
and the team at CVI.
We would like to congratulate our staff and
physicians for completing their ACLS and BLS
certification last month.
04th | Courtney
05th | Becky
12th | Kinjal
24th | Half Day
25th | CLOSED
31st | Half Day
01st | CLOSED
Calender — DecemberCALENDER - DECEMBER