GLASGOW — New cardiac innovations are being tested every day in areas of coronary stenting, pharmaceuticals, device therapies for heart failure and sudden death prevention. Even valvular heart disease is enjoying a revolution in therapy.

A cardiac stent looks very much like the wire coil that fits inside an ink pen. These coils have been utilized now for over a decade to keep blockages from returning after a vessel is ballooned open. Newer stent platforms are being released every few months and include newer and better drug coatings, strut configurations and totally absorbable stents. The goal, of course, is to improve deliverability and decrease clotting and recurrent blocking of the stent. Some of our stents have a closure rate of only 8 percent now. We've come a long way since the early 1990s when balloon-only treatment allowed the blockage to return about 50 percent of the time. Unfortunately, some of our stents require a marriage to a blood thinner called clopedigrel (Plavix). At some point, it is hopeful that we can utilize stents with a low "block-down" rate without having to consider long-term medications to go with them.

There is currently a debate as to whether or not the new clopedigrel-type drug, prasugrel will make it to the American market. There are issues with finding the correct dosage for the elderly and those with kidney failure. There are concerns about bleeding, but many are convinced that so many lives will be saved due to a lower clotting tendency that it would be beneficial. Personally, if it does come to market, I hope it doesn't come as a "one size fits all" dose like clopedigrel (Plavix). We do have to respect individual responses and characteristics when dosing oral blood thinners.

Finally, in the arena of device therapy for heart failure, biventricular pacing devices decrease mitral valve leak and cause improvement of heart muscle strength and size in certain patients with heart failure. We are grateful that Dr. Venkata Reddy has now been designated as an instructor and serves as a trainer for implantation of these devices at T.J. Samson Community Hospital. We are fortunate at T.J. Samson to be able to offer such aggressive congestive heart failure management.

Some of our patients present to us so late in their heart failure course that a biventricular device is too little too late. We have several patients who have been bridged with an LVAD (left ventricular assist device) until they could receive a heart transplant. This device is a battery driven "piggy-back" heart that helps propel blood through the native heart to the rest of the body. Dr. Jim Whiteside was the first physician in our practice to refer a patient for LVAD bridging. Since that time, we've had several patients who have benefited from this therapy. We've also begun to use this as a permanent measure for those who suffer from heart failure, but are not considered candidates for transplant. It requires a major adjustment in lifestyle, but is still compatible with a good quality of life.

Some of the most exciting innovations in heart disease include some aspects of atrial fibrillation management. Atrial fibrillation, an irregular rhythm disturbance, is a common cause of preventable stroke. Our practice is very aggressive in referring many patients for ablation procedures, which can cure atrial fibrillation around 77 percent of the time. These are nonsurgical procedures that are approached much like a heart catherization but restore normal rhythm in many patients, though some still require blood thinner and other medications. It's made the difference in quality of life for patients who tolerate this rhythm disturbance very poorly, though most patients will do well with blood thinner and rate control only.

Patients should also be aware of a few simple measures that have been made available to them that could greatly improve their quality of life who require long-term coumadin. Most patients do not know that Medicare approved a home coumadin monitoring device in March of 2008. The device is completely covered by Medicare and the patient is responsible for only 20 percent of the cost of the strips. It would certainly be a plus for someone who is driving a great distance one way to just get their finger stuck. Also, the companies who provide these devices provide great phone support and instructions for adjustment in medication and physicians' offices continue to provide support as well. If patients in general can adjust insulin based on blood sugars, adjusting coumadin dosages would certainly seem less complicated than that. I suggest if a patient is interested in home monitoring that they call their local medical equipment provider for more details.

One of the greatest innovations in cardiology surrounds the issue of aortic valvular heart disease. The aortic valve is the last door to open to allow freshly oxygenated blood to be released from the heart to the rest of the body. More than any other advent this century, the perfection of aortic valve replacement "without surgery" promises to change the quality of life of patients deemed too sick or too elderly to undergo the rigors of valve replacement. A few years ago, I was able to review one of the first implants in man and was fascinated at how simple it is. A valve is threaded in a folded configuration up the leg, over the aortic arch to the heart and then deployed right down inside of the valve itself. It's then released in the beating heart and starts to work immediately. The learning curve for implant is very steep, but becoming less complicated all of the time. The closest facility to offer this procedure is New York Columbia University and was formerly offered in Vancouver and some portions of Europe. I think this will become a fairly common procedure in time.

Finally, we all know that stroke occurs in most patients with atrial fibrillation due to a clot that forms in a small "dog-ear" like appendage that hangs from the roof of the top chamber of the heart called the atrium. Just placing a patient on coumadin, a blood thinner, reduces the risk of stroke in patients who suffer from atrial fibrillation by 65 percent. However, not everyone can take coumadin due to recurrent bleeding ulcers or lower GI bleeding, or inability to make it to the doctor's office for monitoring. For the last five years, two attempts at device development include putting a catheter up to the inside of the atrial appendage and actually occluding it or blocking it off so it can't spit out a clot that could eventually pass to the brain and cause stroke. It doesn't require surgery and for patients with normal heart pump strength, it would be an ideal way to avoid coumadin. I hope many patients can come to benefit from this type of procedure in my lifetime.

Some of the best ideas to come to this community are in the areas of primary and secondary prevention. Primary prevention means to actually prevent a first heart attack and secondary prevention means you've had a heart attack, but are aggressively trying to stop the second one. Dr. Phillip Bale has opened our first primary and secondary prevention clinic and all of the cardiologists strongly encourage many of our patients to participate. It is equally as important to ask our patients' children and siblings to be evaluated in hopes to change lifestyle to keep them from becoming ill with heart disease. Most types of artery blockage and heart damage are preventable.

Another measure in prevention includes the local Calcium Scoring program at T.J. Samson, which will cause many patients to change their lifestyle, medications and exercise regimens in order to afford an opportunity to avoid a damaging heart attack. Patients do not have to remove their clothing, require no IV and must be able to hold their breath about 20 seconds. A high calcium score indicates significant atherosclerosis and requires aggressive cholesterol-lowering medications, smoking cessation.

Finally, the best prevention measure that could impact our community would be for every single business and service area in the city of Glasgow to become totally smoke free. Secondhand smoke harms so many patients in Glasgow and Bowling Green on a daily basis. It not only causes heart attacks, cancer, lung disease and stroke, but it also costs Medicaid and Medicare dollars that we shouldn't have to apply because the effects of secondhand smoke are completely preventable by just asking the smoker to step outside. A smoke-free ordinance has been proposed already, but tabled last year by our city council. Public support of this measure is overwhelmingly positive as evidenced by the fact that the city councilman who presented the ordinance won the second-highest number of votes of the 18 candidates. Going smoke free would bring so many patrons into businesses who can't be exposed to smoke because of lung disease and other illnesses.