Katherine Leon was 38 and living in Alexandria, Va., when she gave birth to her second son in 2003. She was discharged from the hospital, but instead of getting better, she recalls, she kept feeling “worse and worse and worse.”

Five weeks after she had her child, Ms. Leon’s husband came back early from work and found her barely able to breathe. “I hate to use the word panic, because so many people say if it’s a woman she is just having a panic attack, but I was terrified,” she said.

Her husband called 911, and she was taken to the emergency room where, after a few tests, the physicians told her there was nothing wrong with her. She went home but continued to have bouts of chest pain and kept laboring to breathe.

Things came to a head several days later, she said, when she developed “that impending doom feeling.” Reluctantly, she called 911 again. Things went differently in the emergency room this time.

“There was a young woman doctor who took care of me,” said Ms. Leon. “Her reaction was totally different. She knew that there was something definitely wrong.”

A few days later, she underwent an explorative cardiac catheterization procedure and received a devastating diagnosis: She had a critical blockage in the main artery supplying her heart. She would need emergency heart bypass surgery.

She remembers thinking at the time: “Are you kidding me? I have two babies and I was going to do the whole mom thing, with playgroups and a jog stroller, and take classes. I may have tried one cigarette in my life. I didn’t have cholesterol issues. I didn’t have blood pressure issues.”

She received what at the time was considered one of the rarest possible diagnoses: spontaneous coronary artery dissection, or SCAD. The condition occurs when one of the arteries supplying the heart with oxygen spontaneously tears open, leading to a heart attack that can sometimes be fatal. It occurs most often in women, and can be exacerbated by pregnancy.

But at the time, few doctors knew that SCAD even existed, or knew much about it. “You are never going to meet anyone else who has this,” Ms. Leon remembers one doctor telling her. Another told her, “You need to move on and enjoy your children.”

Her doctors also told her that the only thing she could do to avoid SCAD in the future was to never get pregnant again. But seeking to learn more about the disease that had almost taken her life, she went online and started to find other women with similar symptoms around the world.

In 2009, Ms. Leon went to the WomenHeart Science and Leadership Symposium at the Mayo Clinic, where she met Dr. Sharonne N. Hayes, a professor of cardiovascular medicine at Mayo. At that time, the largest study on SCAD included 43 patients. “I walked up to Dr. Hayes and told her we had 70 people, and we wanted research,” Ms. Leon recalled. “She was like, ‘Wow.’”

“Everything I learned about SCAD in my medical training was wrong,” Dr. Hayes said.

By 2010, with the help of Dr. Hayes, and subsequently SCAD Research Inc., an organization founded by Bob Alico, who lost his wife to SCAD, Dr. Hayes devised an innovative way to do research, using online networks of far-flung patients and analyzing genetic and clinical data. “We never imagined there would be 1,000 female patients in our virtual registry,” Dr. Hayes said.

That fortuitous meeting between Ms. Leon and Dr. Hayes has helped transform SCAD from being an unknown, unrecognized condition to something all physicians are taught about during medical school and in later training. SCAD is now recognized as the most common cause of heart attacks in women under 40.

Why did it take so long for physicians and researchers to recognize SCAD? The most important reason might have been that the condition predominantly affects women. “We listen less well to women,” said Dr. Hayes. “We are much more likely to associate their symptoms with psychological causes.” A heart attack is more likely to be fatal in a young woman than a young man, perhaps because women’s cardiac symptoms are more often misattributed to anxiety or depression than men’s.

The bias that many women feel they face in the clinic or the emergency room has led some, like Ms. Leon, to take action and advocate for themselves and others. “People are activated by injustice, by unanswered questions,” said Dr. Hayes

She offers this advice: “Don’t walk out of a doctor’s office without answers. Find a doctor who is committed to listening to you and does not think they know everything about anything.”

The story of SCAD underscores how much we doctors still don’t understand, including about heart disease in women. Too often those in the medical profession downplay women’s complaints, telling them nothing is wrong. Women are often expected to take care of others but too often neglect themselves. Indeed, women take much longer to seek medical care for a heart attack than men. As we embrace new technologies to peer ever deeper inside the human body to find answers, perhaps the better route might be simply to attend to the patient in front of us. Often what we need to do is listen.

At Cross County Cardiology - Mount Sinai, we are leading experts in cardiovascular care, with the best resources to help you or someone you love with your heart health.  So if you think you maybe suffering from SCAD, please give us a call at 201-499-7361.  Timing is so key!

Original article published on nytimes.com on Feb 1, 2019 by Haider Warraich, M.D.

Patients with RA had one time and half the risk of cardiovascular events than other people.

Although each autoimmune disease is associated with specific tissue or organ damage, rheumatic diseases share a pro-inflammatory pattern that might increase cardiovascular risk. Retrospective and prospective studies on patients affected by systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) highlighted the concept of “accelerated atherosclerosis”. Therefore, the purpose of this systematic review and meta-analysis is the assessment of symptomatic or asymptomatic cardiovascular events among patients with rheumatic diseases as RA and SLE.

The literature research obtained all manuscripts published in the English language between 2015 and 2019 for a total of 2355 manuscripts. After selection through inclusion and exclusion criteria, four articles examined cardiovascular risk in RA patients, 8 in SLE patients, and 2 in RA and SLE patients. Patients with SLE had a RR of 1.98 (95% CI: 1.18–3.31) of symptomatic cardiovascular events compared to the unexposed cohort. The meta-regression analysis showed that younger patient (age per year increase β = −0.12 95%CI: −0.20, −0.4), belonging to studies conducted in continent different from America (β = −0.89; −95% CI: 1.67, −0.10), after 2000 (β = 0.87; 95% CI: 0.09, 1.65) and with a higher quality score 0.80 (95% CI: 0.31, 1.29) had a higher risk of cardiovascular events. In patients with RA, the RR of cardiovascular events was 1.55 (95% CI: 1.18–2.02).

These data are helpful to implement cardiovascular preventive strategies among people suffering from rheumatologic diseases to decrease the incidence of cardiovascular events. However, these implementation needs to build a higher network between rheumatologists and primary care healthcare workers to furnish the same information to patients and monitor their preventive practice compliance.

If you are affected by systemic lupus erythematosus (SLE) or rheumatoid arthritis (RA), we encourage you to setup an appointment with one of our expert CCC - Mount Sinai cardiology specialists.  Call 201-499-7361 to schedule an appointment.  We can help!

Original article published in Science Direct on August 26, 2021 by: Vincenzo Restivo, Stefania Candiloro, Mario Daidone, Rosario Norrito, Marco Cataldi, Guiseppa Minutola, Francesca Caracci, Serena Fasano, Francesco Ciccia, Alessandra Casuccio and Antonino Tuttolomondo.

Many people wear a CPAP machine at night to treat the interrupted breathing of obstructive sleep apnea, a condition that affects an estimated 22 million Americans. But CPAP machines can be noisy, cumbersome and uncomfortable, and many people stop using the devices altogether, which can have dire long-term consequences.

Mouth guards may be a more comfortable and easy-to-use alternative for many people with obstructive sleep apnea, according to a new report. The study, published in Laryngoscope, looked at 347 people with sleep apnea who were fitted with a mouth guard by an otolaryngologist. Two-thirds of patients reported they were comfortable wearing the devices, and the devices appeared to be effective in helping to relieve the disordered breathing of obstructive sleep apnea.

The lead author of the study, Dr. Guillaume Buiret, head of otolaryngology at Valence Hospital in Valence, France, said that if he had sleep apnea, he would choose an oral appliance first.

“It’s easy to tolerate, effective and it costs a lot less than CPAP,” he said. “Thirty to 40 percent of our patients can’t use CPAP, and these patients almost always find the dental appliance helpful. I would recommend it as a first-line treatment”

Loud snoring may be the most obvious consequence of sleep apnea, but the condition, if left untreated, can lead to a broad range of complications, including high blood pressure, heart disease, liver dysfunction and Type 2 diabetes.

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The problem develops when the soft tissue at the back of the throat collapses during sleep, blocking the airway. This leads to breathing cessation for brief periods, gasping for air, difficulty staying asleep, and all the problems of daytime sleepiness, from poor job performance to fatal accidents. Animals can have it too — bulldogs, for example, have a narrow airway and a soft palate that can easily block it. Their sleep apnea is almost identical to the human version.

The severity of the condition varies widely from a very mild problem that may need no treatment at all to severe or even life-threatening disease. Dr. Sara E. Benjamin, a neurologist and sleep specialist at Johns Hopkins, said that spending a night in a sleep laboratory monitored by a technician is the best way to diagnose apnea. A lab study offers the most thorough analysis, and can detect many other sleep problems besides apnea, but there are home test kits that are easy to use and cost-effective. They test breathing effort and oxygen levels, but not the brain waves, muscle tone and leg movements that a lab test records.

How can you know that you need a sleep assessment? “It’s a low standard to get evaluated, either by home testing or in a sleep lab,” Dr. Benjamin said. “If a person feels sleep problems are impacting daily activities, that’s enough to go and get evaluated. If the cause is a breathing problem, you don’t want to ignore it.”

A CPAP — continuous positive airway pressure — machine is usually the first option for treating sleep apnea. The device has a motor that delivers pressurized air through a tube attached to a mask that covers the nose, or both the nose and the mouth. This keeps the airway open. Some machines can automatically change the pressure to compensate for changes in sleep position; others require manual adjustment. Headgear varies, but all have adjustable straps to get the right fit. There are newer models that can deliver heated or humidified air, depending on the patient’s preferences, and there are small travel models as well.

But many patients find sleeping with a mouth guard less awkward or unpleasant than using a CPAP machine. The technical term for these appliances is mandibular advancement devices, so named because they work by pushing the lower jaw forward, which in most people helps keep the airway open. There are many variations of these gadgets available in drugstores, but a dentist can design a more effective personalized appliance, and modify or adjust it when necessary. The patients in the Laryngoscope study were all re-examined after the first fitting, and most needed adjustments over a two- to four-week period.

“We recommend a custom device made by a dentist,” Dr. Benjamin said. “And you should be retested to see how well it’s working. There’s subjective and objective improvement that should be tracked.”

But there are people for whom neither CPAP nor dental appliances work, either because they cannot use them consistently or correctly, or because the devices themselves do not solve the problem even when used properly. For these patients, there are various effective surgical procedures.

The most common is soft tissue surgery, which involves modifying or excising tissue at the back of the mouth. Depending on the structures and musculature of the mouth, the surgeon can trim the soft palate and the uvula, remove the tonsils, shrink tissues with a heated instrument, straighten a deviated septum, or alter the position of the tongue muscles, all with the aim of improving air flow.

There are also bone surgeries that move the jaw forward to make the entire breathing space larger, a procedure that can involve a protracted recovery period.

In 2014, the Food and Drug Administration approved a device called Inspire Upper Airway Stimulation. This is a small appliance implanted under the skin like a heart pacemaker. Using two electrical leads, it senses the breathing pattern and stimulates the nerve that controls the tongue to move it out of the way and allow air to pass freely. Implanting it is a day surgery procedure that takes about two hours.

“It doesn’t change the anatomy, and recovery is easier than with other surgeries,” said Dr. Maria V. Suurna, an associate professor of otolaryngology at Weill Cornell Medicine who specializes in surgery for sleep apnea. “It’s effective. It has the lowest complication rate of all the surgeries.

“But it’s not for everyone. It’s approved only for adults 18 and older who are not overweight and who have moderate to severe apnea.” Some people may be ineligible because of the structure of their anatomy.

“Surgery is tricky,” Dr. Suurna said. “But there’s no ideal treatment for apnea. Each has pros and cons, benefits and risks.”

At Cross County Cardiology - Mount Sinai, are experts are trained to help you navigate these type of decisions.  If you'd like to talk with us personally about your individual situation, or would like a consultation, please give us a call at 201-499-7361 today.  We can help!

Original article published 5/31 in The New York Times by Tami Chappell

Heart attack survivors could gain more than seven healthy years of life if they take the right medications and improve their lifestyle, new research estimates.

Unfortunately, studies have found, heart attack survivors rarely get optimal control over their risk factors.

The new research echoes that evidence: Of more than 3,200 patients, only 2% had their blood pressure, cholesterol and blood sugar under good control one year after their heart attack or heart procedure.

Overall, 65% still had high levels of "bad" LDL cholesterol, while 40% had high blood pressure. Things looked just as bad when it came to lifestyle -- with 79% of patients being overweight or obese, and 45% not getting enough exercise.

It all points to major missed opportunities, the researchers said.

Using a mathematical model, they estimated that if study patients' risk factors were being optimally controlled, they could gain 7.4 extra years free of a heart attack or stroke.

Why were so many patients falling short of treatment goals? It's likely a combination of things, said researcher Tinka Van Trier, of Amsterdam University Medical Center in the Netherlands.

Most patients were, in fact, on medication, including drugs to control cholesterol and blood pressure, or to prevent blood clots.

But they may not have been on the optimal doses or combinations of medication, Van Trier said.

And then there were the lifestyle factors, she said -- which can have a particular impact on blood pressure, cholesterol and blood sugar.

Van Trier presented the findings Thursday at the annual meeting of the European Society of Cardiology, being held online. Studies released at meetings are generally considered preliminary until published in a peer-reviewed journal.

Dr. Andrew Freeman, a cardiologist who was not involved in the research, said it begs an important question.

"Why aren't we being more aggressive in risk factor control?" said Freeman, who directs cardiovascular prevention and wellness at National Jewish Health in Denver.

Like Van Trier, he said that simply being on medication may not be enough: When patients' numbers are not where they should be, Freeman said, adjustments to medication doses and combinations may be necessary.

Just as important, though, is exercise, a healthy diet and weight management. Freeman encourages patients to move toward a plant-based diet, high in foods like fruits, vegetables, beans, nuts and fiber-rich grains.

Cardiac rehabilitation programs are where people can find help. Those programs can be prescribed in the aftermath of a heart attack, so that patients can have supervised exercise and, often, other services -- such as nutrition advice and help with quitting smoking and stress reduction.

"I'm an enormous fan of cardiac rehab," said Dr. Donald Lloyd-Jones, president of the American Heart Association.

After a heart attack, he explained, people can be fearful about exercise, depressed, or feel like it's "too late" to do anything about their cardiovascular health.

"Cardiac rehab gets patients into a monitored setting where they can learn to trust their bodies again," Lloyd-Jones said.

There are also resources outside of cardiac rehab. Van Trier advised patients to talk to their doctor about any help they need with quitting smoking or referral to a dietitian for help with nutrition and weight loss. Doctors may also be able to recommend community exercise programs, she said.

As for medications, Lloyd-Jones said patients should always bring any concerns to their doctor: If you're worried about a potential side effect, talk to your doctor rather than stopping a medication.

Family support is always key, all three experts said.

It's easier for patients to eat better, exercise or refrain from smoking when someone else is in it with them, Freeman said. And if the whole family is making healthy choices, he noted, everyone's heart health will benefit.

The heart experts at Cross County Cardiology - Mount Sinai are hear to discuss how getting healthy after a heart attack is key for many patients.  Call our experts today at 201-499-7361 so we can help you get on the right track to a healthy new program.

___

More Information

The American Heart Association has more onlife after a heart attack.

SOURCES: Tinka Van Trier, MD/PhD candidate, Amsterdam University Medical Center, the Netherlands; Andrew Freeman, MD, director, cardiovascular prevention and wellness, and associate professor, National Jewish Health, Denver; Donald Lloyd-Jones, MD, president, American Heart Association, Dallas, and chair, preventive medicine, Northwestern University Feinberg School of Medicine, Chicago; European Society of Cardiology Congress 2021, presentation, Aug. 26, 2021,online

Published: FRIDAY, Aug. 27, 2021 (HealthDay News).

Surgical procedures performed with the aid of a robot is sometimes marketed as the “best” form of surgery. But a recent review of 50 randomized controlled trials, testing robot-assisted surgeries against conventional methods for abdominal or pelvic procedures, suggests that while there may be some benefits to robotic surgery, any advantages over other approaches are modest.

Robotic surgery is performed by surgeons, not robots. But instead of conventional hand-held tools used in laparoscopic surgery, which involves tiny incisions, and open surgery, in which the surgeon enters the body through a large incision, the doctor uses a machine. The surgeon controls the machine’s tools remotely by using joysticks and foot controls while viewing the surgical site through a high-definition monitor that provides a three-dimensional image of the procedure.

Some surgeons believe that these robots allow more precision during the operation, shorter recovery time, and generally better clinical outcomes for patients. But the review found that in many ways, compared outcomes from the robotic and conventional procedures showed little difference.

For example, in 39 studies that reported the incidence of complications requiring further surgical interventions, up to 9 percent of conventional laparoscopies led to such problems, but so did as much as 8 percent of robotic operations. In studies of gastrointestinal surgery, life-threatening complications ranged from 0 to 2 percent for robot-assisted surgery, from 0 to 3 percent for laparoscopy and from 1 to 4 percent for open surgeries. The findings were published in Annals of Internal Medicine.

For various reasons, sometimes robot-assisted or laparoscopic surgeries do not work, and the surgeon must switch to doing an open operation. Overall, this happened up to 8 percent of the time in robotic operations and as much as 12 percent in laparoscopies. In urologic and gynecologic surgeries, there was almost no difference between robot-assisted operations and laparoscopies in the number of operations that had to be switched to open procedures.

Long-term outcomes of at least two years were reported in eight of the reviewed studies, and they found that mortality rates were similar in all three techniques. In up to 3 percent of robotic surgeries and 5 percent of open surgeries, the patient died. There were no deaths in laparoscopic procedures.

The researchers did find some time differences between the procedures, however. In short, robot-assisted surgeries generally take longer. In studies of gynecological robotic surgeries, duration ranged as high as 265 minutes, compared with maximums of 226 minutes for laparoscopy and 187 for open procedures. In both urologic and colorectal operations, robot-assisted surgeries were consistently longer than comparable laparoscopic and open operations.

The lead author, Dr. Naila H. Dhanani, a surgical resident at UT Health in Houston, said that for a patient, there is no reason to choose robotic surgery over other modes.

“Just because something’s new and fancy doesn’t mean it’s the better technique,” she said. “Yes, robotic is safe, we’ve proven that. But we haven’t proven it’s better. There were four studies that showed a benefit with robotic surgery, so that’s quite modest. Forty-six showed no difference at all.”

Dr. James A. Eastham, chief of urology at Memorial Sloan Kettering Cancer Center, who was not involved in the study, agreed.

“No one would argue with the primary conclusions,” he said. “The intra-operative complication rates and postoperative outcomes are similar regardless of surgical approach. It is far more important to select an experienced surgeon with specialization in a particular field rather than picking a technique.”

But there are certainly practical benefits for the surgeon. Operations can last for hours, and in conventional procedures the surgeon has to remain standing, bending, twisting and turning to move the tools into the right position. Not so with a robotic procedure.

“There is this ergonomic advantage,” said Dr. Gerard M. Doherty, surgeon-in-chief at Brigham and Women’s Hospital in Boston who had no part in the study. “We move the arms of the robot while sitting comfortably. I have one surgeon who told me it will extend his career by a decade.”

But robotic surgery is more expensive than other methods. The initial cost of the machines, the disposable instruments they require, the contracts for servicing the devices and the extra time spent in operating rooms make them so expensive that many hospitals cannot use them. The average initial cost of a robotic setup is about $2 million.

Even in large health care centers, robots have their limitations. “We have 64 operating rooms, and only four of them have robots in them,” Dr. Doherty said.

One company, Intuitive Surgery, which makes the da Vinci robots, has such a dominant market presence in the United States that they are essentially without competition, and this may be a factor in keeping the prices high. But more competition may be coming.

“I’ve seen robots made by other companies,” Dr. Doherty said. “Everyone’s hope is that if someone can bring a new platform in, then prices will come down. But we’ve been saying that for a decade. Intuitive has been pretty aggressive about maintaining their market.”

In any case, according to Dr. Eastham, the future of surgery is robotic. “Despite the lack of evidence that robotics is ‘better’ than true laparoscopy or open surgery,” he said, “there is no question that in the U.S., the shift to robotics has already occurred.”

Our expert doctors at Cross County Cardiology - Mount Sinai can weigh in together with you on this topic and more.  Schedule a consultation today.  Call 201-499-7361 or check out our website at www.crosscountycardiology.com.

By: Nicholas Bakalar for the NY Times; published 8/16/21

Aaron Horton, a sleep apnea sufferer, stops breathing for brief periods hundreds of times every night. To keep his oxygen levels up, he uses a device made by Royal Philips NV that is now subject to a huge recall by the Dutch healthcare conglomerate. It warned in June that the machines could be sending potentially cancer-causing particles into users’ airways.